MEOK 


Columbia  Slniticr^ft|> 

College  of  3^\)vsikian9i  anb  burgeons; 
ilibrarp 


i 


Dr.  Clay  Ray  Murray 


Digitized  by  tine  Internet  Arciiive 

in  2010  witii  funding  from 

Open  Knowledge  Commons  (for  the  Medical  Heritage  Library  project) 


http://www.archive.org/details/manualofoperativ1921binn 


OPERATIVE  SURGERY 
B  1  N  N  1  E 


Regional    Surgery 

A  Treatise  on  Modern  Surgical  Practice 
Prepared  by  41  Well  Known  Authori- 
ties in  Special  Fields. 

EDITED  BY 

JOHN  FAIRBAIRN  BINNIE,  A.M.,  CM. 

Illustrated  by  about  1100  Text  Figures 

and  Colored  Plates.     3  Volumes. 

Cloth,  $27.00. 

Suffice  it  to  say  that  the  monographs  are  well 
written,  interesting  and  full  of  suggestions.  As  the 
volumes  stand  they  give  to  the  reader  the  present 
status  of  each  subject  satisfactorily. 

The  authors  enter  at  once  on  the  subject  in  hand, 
without  wasting  time  and  space  with  the  usual  com- 
monplace introductory  remarks. 

Dr.  Binnie's  thoroughness  and  mastery  of  detail 
is  evidenced  in  his  own  articles  as  well  as  in  those 
of  the  men  selected  to  contribute  their  views. 


MANUAL  OF 

OPERATIVE  SURGERY 


BY 

JOHN  FAIRBAIRN  BINNIE,  A.M.,  CM.  (Aberdeen):   F.A.C.S. 

SURGEON  TO  THE  CHRISTIAN   CHURCH,   THE  RESEARCH  AND   THE   GENERAL  HOSPITALS, 

KANSAS  CITY,  MO.;  FELLOW  OF   THE   AMERICAN   SLTIGICAL  ASSOCIATION; 

MEMBRE  DE  SOCIETE  INTERNATIONALE  DE  CHIRURGIE,  MEMBER 

OF   THE    WrESTERN   SURGICAL   ASSOCIATION 


EIGHTH  EDITION,  REVISED  AND  ENLARGED 


WITH  1628   ILLUSTRATIONS 
A  NUMBER  OF  WHICH  ARE  PRINTED  IN  COLORS 


PHILADELPHIA 

P.  BLAKISTON'S  SON  &  CO. 


Copyright,  1921,  by  P.  Blakiston's  Son  &  Co. 


TBE  MAPX.K  FKR8S  VORK  PA 


CD 

O 


o  PREFACE  TO  EIGHTH  EDITION 

CD 

CO 

^         Since  the  previous  edition  of  this  work  was  published,  death  has  claimed 

^  Gwilym  G.  Davis  and  Walter  S.  Sutton  who  contributed  valuable  chapters  on 
^  "Congenital  Luxation  of  the  Hip"  and  on  "War  Surgery."  Dr.  Frank.  D. 
Dickson  (lately  Lt.  Col.  and  consultant  in  Orthopedics  to  the  3d  Army,  A.  E.  F.) 
has  kindly  revised  the  chapter  of  his  teacher  and  friend,  Davis.  Dr.  E.  H. 
Skinner  (lately  Lt.  Col.  and  associate  consultant  in  Roentgenology,  A.  E.  F.) 
has  revised  such  portions  of  Sutton's  article  as  had  to  do  with  the  localization 
of  foreign  bodies  by  roentgenological  methods.  Most  of  the  article  on  War 
Surgery  has  been  omitted. 

Probably  the  greatest  changes  in  this  new  edition  will  be  found  in  the 
chapters  on  Thoracic,  Abdominal  and  Plastic  Surgery,  which  have  been  prac- 
tically completely  rewritten.  The  author  regrets  that  Sir  Robert  Jones'  great 
book  on  "The  Orthopaedic  Surgery  of  Injuries"  appeared  so  late  that  this  mine 
of  rare  worth  could  not  be  utilized. 

Mr.  Blakiston  has  economized  space  by  some  changes  in  the  arrangement 
of  the  chapters,  otherwise  the  present  volume  would  have  contained  more 
pages  than  the  previous  edition,  instead  of  fewer  as  is  the  case.  The  author 
desires  to  express  hearty  thanks  to  his  friends  Doctors  J.  G.  Hayden,  F.  R. 
Teachenor  and  H.  S.  Valentine  for  aid  ungrudgingly  given  in  the  tedious  task 
of  proof  reading.  All  these  gentlemen  as  well  as  Dr.  Skinner  were  associated 
with  the  author  in  Base  Hospital  28  and  he  owes  much  to  them. 

J.    F.    BiNNIE. 
Kansas  City,  Mo. 


PREFACE  TO  SEVENTH  EDITION 


In  this  as  in  all  previous  editions  great  care  has  been  taken  to  avoid  the 
perspective  of  a  text-book  where  emphasis  must  be  placed  on  the  common  rather 
than  on  the  unusual  operations  of  surgery.  The  constant  endeavor  has  been 
to  give  aid  to  the  surgeon  when  he  is  in  trouble,  hence  much  greater  space  has 
been  devoted  to  some  rather  rare  operations  than  to  many  of  far  greater  every- 
day importance  but  which  ought  to  be  familiar  to  every  one.  Thus  a  chapter 
has  been  included  on  Cardiac  Surgery  even  although,  up  to  the  present,  such 
work  has  been  mostly  confined  to  the  physiological  laboratory.  Several  chap- 
ters have  been  rewritten,  many  obsolete  illustrations  discarded,  new  figures 
inserted  and  a  short  chapter  on  Retroperitoneal  Neoplasms  added.  In  spite  of 
much  new  material  careful  pruning  has  prevented  any  great  increase  in  the 
size  of  the  volume.  At  the  present  time  of  strife  it  has  been  thought  wise  to 
append  a  short  chapter  on  War  Surgery.  This  has  been  made  possible  through 
the  kindness  of  Dr.  Walter  S.  Sutton.  It  is  hoped  that  the  earnest  effort  to 
keep  the  work  up  to  date  may  have  been  successful. 

Kansas  City,  Missouri. 


Vll 


PREFACE  TO  SIXTH  EDITION 


The  original  plan  of  this  "Manual  of  Operative  Surgery"  was  to  devote 
attention  to  the  advanced  operative  surgery  of  the  day  and  to  avoid  discus- 
sion of  those  topics  which  were  sufficiently  described  in  the  text-books  on 
"The  Art  of  Surgery." 

Various  reasons  have  compelled  the  inclusion  of  subjects  such  as  were 
originally  excluded,  but  great  care  has  been  taken  to  avoid  using  the  perspec- 
tive of  a  text-book  where  emphasis  must  be  placed  on  the  common  rather 
than  on  the  unusual. 

In  this  work,  the  constant  endeavor  is  to  give  aid  and  guidance  to  the  sur- 
geon when  he  is  in  trouble,  hence  far  more  space  is  devoted  to  such  rare  and 
difficult  operations  as  hypophysectomy,  than  to  many  operations  of  much 
greater  every-day  importance,  but  which  ought  to  be  familiar  to  every  graduate. 

In  the  present  edition,  the  chapters  devoted  to  operations  on  the  stomach 
have  been  largely  rewritten,  special  attention  being  paid  to  the  anatomy  of 
the  gastro-intestinal  lymphatics. 

Many  other  chapters  have  been  rewritten  and  a  new  chapter  has  been  de- 
voted to  the  treatment  of  tumors  in  general. 

It  is  hoped  that  the  earnest  effort  to  bring  the  work  up  to  date  may  have 
been  successful. 

J.    F.    BiNNIE. 


PREFACE  TO  FIFTH  EDITION 


K.  M.  Blakiston,  Esq., 

Philadelphia, 
Dear  Sir: 

You  suggested  to  me  that  our  Manual  of  Operative  Surgery  should  be  issued 
in  one  volume  instead  of  in  two.  I  thoroughly  agreed  with  you  in  your  sugges- 
tion and  am  glad  to  say  that  several  friends,  whose  judgment  I  trust,  concurred 
in  the  wisdom  of  so  doing.  The  original  work  was  issued  in  one  rather  small 
volume  in  which,  for  various  reasons,  no  account  was  given  of  operations  on  the 
bones  and  joints,  etc.  Later  it  was  determined  to  include  these  subjects.  It 
would  have  been  manifestly  unfair  to  have  compelled  those  who  possessed  the 
original  volume  and  who  desired  the  complete  work  to  repurchase  what  they 
already  possessed — hence,  the  new  material  was  published  in  a  separate  volume. 
This  debt  to  the  above  class  of  purchasers  having  been  fulfilled,  I  think  we  are 
fully  justified  in  returning  to  the  original  idea  of  one  volume  which  is  more 
practical  so  long  as  the  book  is  not  too  large  and  clumsy. 

The  present  issue  represents  the  fifth  edition  of  Vol.  I.  and  the  second  of 
Vol.  II.  I  have  endeavored  to  bring  the  contents  up  to  date  and  hope  that  the 
book  in  its  new  dress  man  find  favor  with  the  medical  public. 

As  on  previous  occasions  I  have  to  thank  Dr.  John  G.  Hayden  and  Mrs.  C. 
M.  Bossier  for  most  valuable  assistance.  Personally,  I  desire  to  thank  you 
for  the  great  interest  taken  in  the  manual  both  by  yourself  and  by  your  very 
efficient  stafi". 

Yours  sincerely, 

J.    F.    BiNXIE. 


XI 


DEDICATORY  LETTER 


Twelfth  and  Wyandotte   Sts., 
Kansas  City,  Mo. 
Dr.  Robert  F.  Weir,  New  York: 

Dear  Dr.  Weir: — Some  considerable  time  ago  you  encouraged  me  in  a 
design  to  write  a  little  book  on  operative  surgery,  in  which  there  should  be 
omitted,  as  far  as  possible,  all  description  of  those  procedures  which  are  ordi- 
narily thoroughly  given  in  the  usual  text-books  on  general  surgery.  You  were 
good  enough  to  look  over  and  express  approval  of  the  scheme  and  of  certain 
sections  of  manuscript  submitted  to  you.  This  volume  is  the  outcome  of  your 
encouragement,  and  it  gives  me  intense  pleasure  to  have  your  permission  to 
dedicate  it  to  you. 

Following  out  the  ideas  already  expressed,  I  have  omitted  all  reference  to 
such  subjects  as  amputations  and  ligations.  Such  portions  of  genito-urinary 
and  of  rectal  surgery  as  are  fully  treated  in  the  common  text-books  have  been 
passed  over  in  silence.  It  was  my  intention  to  devote  considerable  space  to  the 
operative  surgery  of  the  bones  and  joints,  but  having  prepared  several  chapters 
on  these  subjects,  I  found  that  any  adequate  treatment  of  them  would  require 
a  second  volume.  The  exigencies  of  space  forbidding  a  satisfactory  review 
of  the  operations  on  the  bones  and  joints  of  the  extremities,  I  prefer  to  omit  such 
entirely.  My  aim  throughout  has  been  to  be  practical:  to  describe  operative 
procedures  as  they  are  done  on  the  living  subject,  instead  of  on  the  normal 
cadaver. 

For  the  bibliography  of  operative  surgery,  the  reader  is  referred  to  the 
Catalogue  of  the  Surgeon  General's  Library  in  Washington. 

In  the  preparation  of  this  volume  I  have  had  the  benefit  of  much  advice  and 
criticism  from  our  mutual  friends,  Drs.  W.  J.  and  C.  H.  Mayo  of  Rochester, 
Minn.  Drs.  Block  and  Mark  of  this  city  have  kindly  revised  the  chapters  on 
genito-urinary  surgery.  Drs.  E.  F.  Robinson  and  R.  M.  Schaufl9er  gave  me 
much  assistance  in  proof-reading,  while  my  student  assistant,  Mr.  Florian, 
helped  me  in  many  ways.  To  all  these  gentlemen  and  to  those  who  generously 
placed  plates  and  drawings  at  my  disposal,  I  beg  to  return  heartfelt  thanks. 

Hoping  that  this  work  of  mine  may  never  cause  you  to  regret  the  encourage- 
ment given  by  you, 

I  remain. 

Your  friend, 

J.  F.  Binnie. 


LIST  OF  CONTENTS 


PART  I 

Head  and  Neck 
Chapter  Page 

I.    Scalp i 

II.    The  Skull  and  the  Brain 6 

III.  Frontal  Sinus 57 

IV.  Tic  Douloureux 59 

V.    Plastic  Operations  on  the  External  Ear 76 

VI.     Empyema  of  the  Antrum  of  Highmore 82 

VII.    Osteoplastic  Exposure  of  the  Orbit     84 

VIII.    Excision  of  Upper  Jaw 85 

IX.    Lower  Jaw,    Resection     92 

X.    Odontomata loS 

XI.    Excision  of  the  Cheek 109 

XII.    Lower  Lip 115 

Xin.     Upper  Lip 129 

XIV.     Hare-lip i34 

XV.    Cleft  Palate 144 

XVI.    Tongue 158 

XVII.     Parotid  Gland 173 

XVIII.    Oper.ations  upon  the  Nose 181 

XIX.    Torticollis,  Wry-neck,  Caput  Obstipum 204 

XX.    Excision  of  Cervical  Ribs 208 

XXI.    Excision  of  Cervical  Tumors 209 

XXII.    Excision  of  the  Cervical  Sympathetic 217 

XXIII.  Retropharyngeal  Abscess  and  Tumors 222 

XXIV.  (Esophagus     224 

XXV.    Pharyngotomy,  Laryngotomy,  Partial  Laryngectomy,  and  Laryn- 
gectomy    230 

XXVI.     Tracheotomy 239 

XXVII.    Foreign  Bodies  IN  Trachea  OR  Bronchus 243 

XXVIII.     Goitre;  Bronchocele;  Strxtma      247 

XXIX.     Thymus  Gland 268 

PART  II 

The  Thorax 

XXX.     Operations  on  the  Breast 271 

XXXI.     Operations  on  the  Chest 286 

PART  III 
The  Abdomen 


XXXII.    Laparotomy;  Celiotomy;  Abdominal  Section 343 

XXXIII.    The  Stomach 355 

XV 


XVI 


CONTENTS 


Chapter  Page 

XXXIV.    Operations  on  the  Intestines 409 

XXX\'.     The  Vermiform  Appendix  and  Peritoneum 464 

XXXVI.    The  Rectum 482 

XXXVII.     Haemorrhoids  and  FisTULiC 519 

XXXVIII.     Ascites 528 

XXXIX.    Retro-peritoneal  Neoplasms 534 

XL.     The  Pancreas 536 

XLI.     The  Spleen 547 

XLII.    The  Suprarenal  Bodies 552 

XLIII.     Operations  upon  the  Liver SS3 

XLIV.     Operations  on  the  Biliary  Passages 562 

XLV.     Hernia 590 

XL VI.     Retro-peritoneal,  Large  and  Diaphragmatic  Hernia 622 

PART  IV 

The  Genito-Urinary  System 

XLVII.     Oper.\tions  upon  the  Kidney 629 

XL VIII.     Operations  on  the  Ureter 661 

XLIX.     Operations  on  the  Bladder 673 

L.     Perineal  Section     704 

LI.     Urethral  Stricture 715 

LII.     Epispadias 723 

LIII.     Hypospadias 727 

LIV.    Amputation  of  Penis 733 

LV.    Circumcision 737 

LVI.     Operations  on  the  Testicles 739 

LVII.     Hydrocele 752 

LVIII.     Varicocele 753 

PART  V 
The  Spine 


LIX.     Operations  on  the  Spine 755 

PART  VI 

LX.     Nerves 781 

LXI.     Arteriorrhaphy 812 

LXII.    Aneurysm 823 

LXIII.    Ligation  of  Arteries  in  CoNTiNmiY 834 

LXIV.    Operations  on  Veins 856 

LXV.  Operative  Treatment  of  Simple  Fractures,  Exclusive  of  Those 

Involving  Articulations  and  of  some  Special  Fractures  ....  877 

LXVI.     Compound  or  Open  Fractures 888 

LXVII.     Ununited  Fractures;  Pseudarthrosis 893 

LXVIII.     Fractures;  Malunion 9iS 

LXIX.     Special  Fractures 920 

LXX.     Osteomyelitis 94^ 

LXXI.     Tumors  of  Bone 958 

LXXII.     Chondrectomy 962 

LXXIII.     Osteotomy 962 


CONTENTS 


xvn 


Chapter  Pace 

LXXIV.     Bow-leg;  Genu  Varum 972 

LXXV.     Operations  on  the  Pelvic  Bones 974 

LXXVI.     Sacro-iliac  Disease 977 

LXXVII.     Hip 979 

LXXVIII.     Hip;  Arthritis  Deformans 989 

LXXIX.    Anchylosis  Hip 990 

LXXX     Old  Dislocations  of  the  Hip 1005 

LXXXI.     Congenital  Luxation  of  the  Hip 1009 

LXXXn.     Knee-joint 1024 

LXXXin.     Patella;  Tuberculosis 1046 

LXXXIV.     Osteotomy  for  Bony  Anchylosis  of  the  Knee 1049 

LXXXV.     Dislocation  of  the  Patella     1057 

LXXXVI.     Ankle 1061 

LXXXVII.     Dislocation  of  the  Astragalus 1067 

LXXXVin.      SUBASTRAGALOin  DISLOCATION 1068 

LXXXIX.    Os  Calcis 1069 

XC.     Bunion;  Hammer  Toe  Metatarsalgia 1070 

XCI.     Operations  on  the  Scaptjla  and  Cla\icle 1075 

XCII.     Shoulder 1084 

XCni.     Claviculo-humeral  Nearthrosis 1104 

XCIV.  Operation   for   Subacromial   Bursitis   and   for   Rupture   op  the 

SUPRA-SPINATUS  TeNDON IIO6 

XCV.    Elbow 1108 

XCVI.     Old  Dislocation  of  the  Elbow 11 15 

XCVII.     Anchylosis  Elbow 1117 

XCVin.     Wrist 1122 

XCIX.    Wrist  Anchylosis 1125 

C.     Metacarpo-phalanxeal  dislocations 1127 

CI.     Syndactylism;  Webbed  Fingers 1127 

Cn.     Operations  on  the  Tendons  of  the  Fingers 1128 

CHI.     Operations  for  lNF£CTr\-E  Lesions  of  THE  Hand 1132 

CIV.    Indications.    Joints 114c 

CV.    Amputation  or  Disarticulation 1143 

CVI.     Flat-foot 1189 

CVII.     Tendon  Sheaths  and  Tenorrhaphy 1192 

CVIII.     Tenotomy 1221 

CIX.     Contractures 1238 

ex.     Princlples  of  Plastic  Surgery 1241 

CXI.     Methods  of  Drainage 1256 

CXII.    Acute  Abscess 1259 

CXIII.     Operative  Treatment  of  Neoplasms 1261 

CXIV.    Ligatures  and  Sutures 1263 

CXV.     Wounds 1268 

CXVI.    Localization  of  Foreign  Bodies 1271 


Index 1279 


MANUAL  OF  OPERATIVE  SURGERY 


PART  l.-HEAD  AND  NECK 


CHAPTER  I 

SCALP 

REMOVAL  OF   SEBACEOUS    CYSTS    (WENS) 

Method  A. — Make  an  incision  through  the  skin  into  the  cyst.  The  incision 
must  be  nearly  as  long  as  the  diameter  of  the  tumor.  Do  not  squeeze  out  the 
contents  of  the  cyst.  Seize  the  divided  cyst  wall  with  a  strong  forceps  (hemo- 
stat).  With  a  twisting  motion  it  is  easy  to  pull  out  the  whole  sac.  Apply 
pressure  to  the  wound  for  a  few  seconds.  Close  the  wound  with  one  or  more 
sutures.     Dress. 

Method  B. — Make  a  free  incision  through  the  skin  (which  is  thin  over  the 
tumor)  down  to,  but  not  into  the  cyst.  Dissect  out  the  cyst  unbroken.  Close 
the  wound.     Dress. 

Method  C. — If  the  cyst  is  infected  and  suppurating,  treat  it  either  as  an 
abscess  or  better  excise  it  plus  the  infected  portion  of  the  skin. 

In  cases  where  the  cyst  is  not  adherent  and  not  inflamed,  method  A  is  ex- 
tremely easy  and  gives  perfect  results;  opening  the  cyst  permits  removal  through 
a  comparatively  small  cut,  and  the  author  has  never  seen  harm  result  from 
escape  of  cyst  contents.  Remember  that  sebaceous  cysts  occasionally  become 
malignant,  hence  look  with  suspicion  on  such  as  do  not  shell  out  readily. 

ANGIOMA   OF   SCALP 

When  simple  nevi  of  the  scalp  require  removal  by  operation,  the  incision 
must  be  made  sufficiently  far  from  the  disease  so  that  hemostasis  may  be  easily 
effected;  the  wound,  if  extensive,  may  tax  the  resources  of  plastic  surgery. 
Rapidly  growing  angiomata,  those  which  penetrate  the  subcutaneous  tissues  or 
are  large  and  tumor-Hke  and  those  which  bleed  or  threaten  severe  hemorrhage, 
all  call  for  operation. 

Angiomata  over  the  fontanelles  often  communicate  with  the  longitudinal 
sinus,  hence  in  these,  radical  operation  should,  if  possible,  give  way  to  less 
vigorous  measures  such  as  ignipuncture.  The  same  is  true  in  the  case  of  cav- 
ernous angiomata,  which  evidently  penetrate  the  skull. 


SCALP 


(A)  strangulation. — Pass  a  stout  pin  or  needle  under  the  middle  of  the 
nevus  from  side  to  side.  Pass  a  stout  thread  around  the  base  of  the  nevus,  under 
the  pin  (which  keeps  the  thread  from  slipping).  Tie  the  thread  very  tightly. 
Instead  of  one,  two  pins  may  be  introduced  at  right  angles  to  each  other.  In 
time  the  strangulated  tissues  die,  slough  off  and  leave  an  ulcer.  In  the  twentieth 
century  this  treatment  savors  of  barbarism. 

(B)  Subcutaneous  Ligation.- — Many  methods  of  subcutaneous  ligation  have 
been  used;  most  of  them  are  exceedingly  simple. 

I.  At  the  points  A,  B,  C,  D  (Fig.  i)  puncture  the 
scalp  with  a  knife.  These  points  must  be  well  away 
from  the  disease.  With  a  needle  introduce  a  stout 
chromicized  catgut  or  a  silk  suture  through  A  and  bring 
it  out  at  B,  reintroduce  at  B  and  bring  out  at  C;  in  the 
same  manner  carry  the  suture  from  C  to  D  and  from  D 
to  A.  Both  ends  of  the  suture  now  emerge  at  A.  Tie 
the  suture  tightly  and  let  its  knot  retract  under  the 
skin  through  the  puncture  at  A.    Apply  dressings. 

II.  Krogius  ("Centralblatt  fur  Chir.,"  Sept.  30,  1905) 
found  that  compression  and  ligation  even,  of  the  afferent 

vessels  was  inefficient  in  cases  of  large  racemose  (cirsoid)  angiomata  of  the 
scalp;  that  ignipuncture,  injections  and  excision  were  dangerous.      He  therefore 


B// 


ID 


Fig.    I. — Subcutaneous 
ligation  angioma. 


i  VWVA^fc^ 


Fig.   2. — Krogius'  operation  angioma. 

devised  the  following  method  of  subcutaneous  ligation:    Arm  a  full  curved 
needle  with  catgut.     Pass  the  needle  from  .4  to  B  (Fig.  2),  hugging  the  bone. 


Fig.  3. — Krogius'   operation  angioma. 


Remove  the  full  curved  and  substitute  a  less  curved  needle.  With  this  pass 
the  suture  from  B  to  A  immediately  under  the  skin  (Fig  3).  Both  ends  of  the 
suture  now  emerge  at  A.    Tie  the  suture  tightly. 


ANGIOMA  3 

Repeat  the  process  all  round  ihe  nevus  unlil  practically  every  vessel  entering 
or  leaving  the  tumor  is  controlled.  Each  suture  or  ligature  should  to  some 
extent  overlap  into  the  territory  controlled  by  the  next  one. 

(C)  Bryant's  Operation. — Suitable  in  cases  of  cirsoid  growth.  Make  an 
incision  outside  and  nearly  round  the  growth,  down  to  the  periosteum.  Leave 
undisturbed  that  portion  of  growth  containing  the  largest  vessels.  Raise  the 
flap  and  attend  to  hemostasis.  Apply  dressings  under  as  well  as  over  the  flap. 
When  the  wound  is  covered  with  granulations,  replace  and  suture  the  flap. 
If  after  elevation  of  the  flap  for  a  few  days  pulsations  continue  in  the  flap  (the 
tumor  is  in  the  flap),  ligate  at  a  distance  the  main  vessel  entering  it.  This 
method  has  given  J,  D,  Bryant  much  satisfaction. 

In  a  case  of  angioma  of  the  lower  frontal  region 
the  author  operated  as  follows: 

1.  Shave  the  anterior  portion  of  the  scalp. 
Make  a  tranverse  incision  over  the  head  practically 
from  ear  to  ear  but  inside  the  line  of  the  hair. 

2.  Reflect  the  skin  flap  thus  formed  downwards 
and  forwards  until  the  angioma  is  almost  reached 
(Fig.  4).  At  this  point,  if  necessary,  cut  through 
the  deeper  structures  until  a  layer  of  tissue  is  found 
beneath  the  angioma  and  continue  the  reflection  of 
the  flap  downwards  in  this  plane  until  the  lower 
limits  of  the  angioma  are  passed.  Working  from  Fig.  4, 
the  under  side  of  the  flap  pass  sutures  or  ligatures 

around  the  main  vessels  entering  the  angioma  from  the  base  of  the  flap. 

3.  Treat  the  flap  as  in  Bryant's  operation  and  a  few  days  later  excise  the 
tumor.  Replace  the  flap  and  close  the  wound  with  sutures.  The  object  of  this 
method  is  of  course  to  avoid  making  any  visible  scar. 

Clairmont  reports  from  v.  Eiselsberg's  clinic  ("  Archiv.  ftir  klin.  chir.,"  Ixxxv, 
549)  an  operation  which  combined  the  principles  of  Bryant's  operation  and 
excision.  Following  Krause,  the  operation  was  completed  in  two  sittings. 
Figs.  5  and  6  show  the  extent  of  the  disease.  A  skiagram  showed  that  the 
middle  meningeal  arteries  were  much  enlarged.  The  occipital  limits  of  the 
tumor  were  clearly  defined;  elsewhere  it  was  not  well  delimited.  The  use  of 
temporary  hemostasis  by  an  elastic  band  was  impossible.  Preliminary  ligation 
would  have  called  for  the  tying  of  both  occipital  arteries,  the  frontal  artery  (the 
size  of  the  little  finger),  and  both  external  carotids  near  their  origin,  which 
might  cause  danger  of  embolism.  Communicating  vessels  between  the  scalp 
and  the  inside  of  the  skull  were  so  numerous  as  to  make  the  gain  from  pre- 
liminary ligations  very  doubtful.  The  operation  performed  may  be  taken  as 
a  guide  for  the  treatment  of  extremely  extensive  cirsoid  aneurysm  of  the  scalp. 

Place  the  patient  almost  in  a  sitting  posture.     Anesthetize. 

Step  I. — Make  an  incision  through  the  skin  and  epicranial  aponeurosis 
skirting  the  growth  anteriorly  and  laterally.  Make  the  cut  inch  by  inch, 
using  compression  on  each  side  of  the  cut  against  the  bone  until  the  vessels  are 
secured  by  forceps  and  ligatures.     Isolate  and  doubly  ligate  the  main  vessels 


4  SCALP 

before  dividing  them.  This  incision  outlines  a  horseshoe-shaped  flap  having 
its  base  at  the  occiput. 

Step  2. — Reflect  the  flap  from  the  cranium.  This  step  requires  the  use  of 
many  hemostats  and  ligatures  because  of  the  free  anastomosis  with  the  deep 
vessels. 

Step  3. — As  in  Bryant's  operation,  place  gauze  between  the  flap  and  the  bone. 
Replace  the  flap  over  the  gauze.     Apply  dressings  and  bandage. 

Step  4. — After  three  or  four  days  remove  the  dressings  and  excise  the  tumor 
from  the  under  surface  of  the  flap.  Thrombosis  of  the  vessels  in  the  tumor, 
and  loosening  of  the  surrounding  connective  tissue  due  to  the  edema,  make  the 
excision  of  the  growth  easier  than  it  would  have  been  at  the  first  sitting. 

Step  5. — Replace  the  flap.     Suture.     Dress  the  wound. 


V? 

ifpMH 

p ' 

-'"'■'"^f^H 

1 

'  i  ^ii 

\ 

Fig.  5.  Fio.  0. 

Figs.  5  and  6. — Cirsoid  aneurysm.     {Clalrmonl.) 


(D)  Excision.^ — It  is  very  easy  to  excise  small  nevi  and  to  close  the  wound 
with  sutures.  When  large  nevi  are  being  excised  hemorrhage  during  the  excision 
may  be  avoided  by  tying  an  elastic  constrictor  tightly  round  the  head  as  in 
trephining  or  by  having  a  rubber-covered  ring  (ring  pessary)  pressed  firmly 
against  the  scalp  surrounding  the  nevus.  The  operation  consists  in  excising  the 
disease  by  cutting  through  healthy  tissue,  in  securing  hemostasis  and  in  closing 
the  wound  either  directly  or  by  some  plastic  procedure. 

The  freezing  treatment  of  nevi  threatens  to  displace  all  other  methods. 

Liquid  Air. — First  get  the  liquid  air.  Make  a  very  firm  pad  of  cotton  on  the 
end  of  a  stick.  Dip  the  pad  in  liquid  air.  Shake  off  any  loose  drop  of  the  liquid. 
Press  the  charged  pad  with  moderate  firmness  on  to  the  nevus  for  a  few  seconds. 
Repeat  the  process  on  every  part  of  the  lesion.  The  treatment  is  usually  pain- 
less. Apply  no  dressings.  If  any  raw  surfaces  are  present  on  the  lesion  they 
must  be  covered  with  thin  gauze  before  being  treated,  otherwise  the  applicator 
would  freeze  to  them  (Whitehouse) ;  all  scabs  must  be  removed  prior  to 
treatment. 


MALIGNANT   TUMORS    OF   SCALP  5 

The  applications  may  require  to  be  repeated  two  to  three  times  at  intervals 
of  about  one  week. 

Carbon-dioxide  Snow. — Instead  of  liquid  air,  carbon-dioxide  snow  may  be 
used  and  is  easily  obtained  in  tanks  such  as  are  used  in  commerce.  Permit  a 
spray  of  the  gas  to  play  into  a  bag  of  chamois  leather.  Snow  is  immediately 
formed.  Put  the  snow  into  a  cylindrical  mould  of  wood  or  metal  and  tamp  it 
down  firmly  with  a  stick  or  pestle.  Remove  the  firm  candle  of  snow  from  the 
mould  and  trim  it  to  the  desired  shape  with  a  knife.  Apply  the  point  of  the 
snow-candle,  with  moderate  firmness  for  a  few  seconds,  to  the  part  to  be  treated. 

MALIGNANT  TUMORS   OF   THE   SCALP 

The  principles  of  operation  are  the  same  as  obtain  in  other  situations,  viz., 
free  excision  and,  especially  in  the  case  of  epitheUoma,  removal  of  the  lymphatics 
which  drain  the  site  of  disease,  when  this  is  possible.  The  main  features  of  the 
anatomy  of  the  lymphatics  of  the  scalp  are  as  follows: 

(A)  The  lymphatics  of  the  frontal,  and  the  anterior  part  of  the  parieto- 
occipital regions,  drain  into  the  parotid  lymph  glands.  These  glands  for  the 
most  part  lie  in  the  parotid,  and  their  removal  means  removal  of  the  parotid. 
A  cancer  of  the  scalp,  with  secondary  nodes  in  the  parotid,  is  practically 
inoperable. 

(B)  The  lymphatics  of  the  posterior  part  of  the  parieto-occipital  region  drain 
into  the  mastoid  group  of  glands  lying  on  the  mastoid  portion  of  the  sterno- 
mastoid  muscle.    These  are  easily  extirpated. 

(C)  The  occipital  region  is^rained  by  two  routes.  From  the  outer  part,  the 
lymphatics  join  to  form  a  single  trunk  which  runs  downwards  to  a  point  under 
the  sterno-mastoid  muscle,  where  it  enters  one  of  the  external  glands  of  the 
sterno-mastoid  group.  From  the  inner  part  of  the  region,  the  lymphatics  go  to 
the  occipital  glands. 

From  the  foregoing  it  is  clear  that  only  in  case  of  frontal  and  anterior  tem- 
poro-parietal  cancer,  are  the  lymphatic  nodes  "next  in  order"  really  inaccessi- 
ble. When  a  cancer  of  the  scalp  is  freely  movable — excise  it  thoroughly  but 
leave  the  skull  intact;  the  wound  may  be  closed  by  sutures,  by  flaps  of  skin,  or  by 
skin  grafts.  When  the  cancer  is  adherent  to  the  bone,  make  an  incision  down  to 
the  bone  all  round  the  disease,  but  in  healthy  tissue.  With  the  chisel  introduced 
through  the  incision,  cut  away  all  the  external  table  of  the  skull  corresponding  to 
the  diseased  area.  If  for  any  reason  it  is  thought  that  the  disease  has  penetrated 
the  diploe  it  becomes  necessary  to  remove  the  whole  thickness  of  the  skull. 
The  cranial  defect  should  be  closed  at  once  by  some  plastic  method,  v. 
Bergmann  writes,  "when  the  disease  affects  the  frontal  or  occipital  regions  we  do 
not  hesitate  to  penetrate  the  dura  and  remove  portions  of  the  cerebral  cortex." 


THK    SKULL    AND    THE    BRAIN 


CHAPTER    II 
THE   SKULL  AND   THE  BRAIN 

EXPOSURE   OF  THE   SKULL 

Many  means  of  exposing  the  skull  may  be  employed,  all  of  which  must  be 
preceded  by  the  shaving  of  a  large  part,  or,  still  better,  of  all  the  scalp.  In  cases 
of  open  fracture,  one  may  expose  the  bone  sufficiently  by  enlarging  the  wound 
already  existing.  When  the  operation  is  for  the  removal  of  a  foreign  body 
lodged  in  the  bone,  a  linear  incision  may  be  employed.  The  same  incision  may 
suffice  to  lay  bare  enough  bone  for  the  application  of  Doyen's  perforator  or  a 
very  small  trephine.  When  a  moderate  sized  trephine  is  to  be  used  or  one  de- 
sires to  explore  the  surface  of  the  skull,  the  best  incision  is  one  curved  in  the  form 
of  a  U  or  horseshoe.  Unless  specially  contraindicated  the  open  end  of  the  U 
should  face  downwards  in  the  direction  of  the  blood-supply  of  the  scalp.  The 
knife  penetrates  to  the  bone  at  the  first  cut  and  the  flap  is  rapidly  and  readily  re- 
flected downwards.     Hemostasis  must  be  attended  to  at  once.     Before  incising 


Fig.  7. — Alakkas'   pin,   and  forceps  for  introducing  it. 

the  scalp  some  surgeons  tie  an  elastic  constrictor  round  the  head  immediately 
above  the  ears  so  that  hemorrhage  may  be  controlled.  Lanphear  attains  the 
same  ends  by  surrounding  the  site  of  operation  with  a  continuous  chain  suture, 
each  stitch  of  which  includes  the  whole  thickness  of  the  scalp.  Makkas  sur- 
rounds the  area  of  operation  with  clamps,  either  straight  or  slightly  curved, 
which  assure  a  bloodless  field.  Fig.  7.  When  operating  in  a  region  supplied 
by  the  temporal  artery,  it  is  convenient  to  have  an  assistant  exert  pressure 
thereon.  The  best  methods  of  securing  hemostasis  are  those  described  in 
Cushing's  decompression  operation  (p.  25)  and  in  the  osteoplastic  opening  of 
the  skull  (p.  14). 

METHODS   OF  OPENING  THE   SKULL 

(A)  The  Trephine. — There  are  two  species  of  trephine,  but  of  these  there  are 
many  modifications: 

I.  The  ordinary  trephine  is,  in  principle,  merely  a  hollow  steel  cylinder 


TREPHINING 


Fig.  8. — Trephine  and 

"brace." 
B.  Trephine:  i,  Centre 
pin;  2,  movable  guard;  3, 
stem  to  fit  into  brace.  C. 
Extra  stem  by  which  burs 
or  drills  may  be  attached 
to  brace.  {Monod  and 
Vanverts.) 


whose  lower  end  is  provided  with  a  saw-edge.  To  keep  the  saw-edge  in  position 
on  the  skull,  a  pin  projects  through  the  centre  of  the  cylinder.  The  pin  is  with- 
drawn as  soon  as  the  trephine  has  cut  a  groove  in  the 
bone  sufl&ciently  deep  to  prevent  it  from  slipping. 
Power  is  applied  to  the  instrument  through  a  T-shaped 
handle  or  a  "brace"  similar  to  those  used  by  carpenters. 
To  prevent  any  sudden  onward  movement  of  the  instru- 
ment into  the  brain  after  the  inner  table  of  the  skull  is 
penetrated,  movable  guards  may  be  fixed  to  the  outside 
of  the  trephine.     (See  Fig.  8.) 

2.  The  Gait  Trephine. — The  principle  of  this  trephine 
is  identical  with  the  preceding  except  that  the  cutting 
part  of  the  instrument  is  shaped  like  a  truncated  cone 
(Fig.  9).  The  conical  shape  prevents  any  sudden  onward 
movement  when  the  inner  table  of  the  skull  is  penetrated. 
The  Gait  trephine  is  most  commonly  used  in  America. 
The  only  disadvantage  of  this  instrument  is  that  on 
account  of  its  shape  it  necessarily  makes  the  button  of 
bone  removed  much  smaller  than  the  hole  left  in  the 
skull,  a  matter  of  some  importance  if  one  intends  reim- 
planting  the  bone  removed. 

Trephining. — Place  the  patient  with  his  head  resting 
on  a  sand-bag  and  held  steady  by  the  hands  of  an  assistant  (Fig.  10).  Expose 
the  skull  as  already  described.  Make  the  centre  pin  of  the  trephine  protrude 
about  one-sixteenth  of  an  inch  beyond  the  cutting-edge  and  bore  it  into  the 
skull  at  the  selected  site.  By  steady  movements  of  the  wrist,  twist 
the  trephine  from  left  to  right  and  right  to  left  until  it  has  cut  a 
groove  in  the  skull.  Withdraw  the  centre  pin  and  proceed  with  the 
trephining.  As  soon  as  the  outer  table  of  the  skull  is  penetrated 
there  will  be  less  resistance  to  the  operation  and  more  escape  of 
blood.  As  soon  as  hard  bone  is  again  met,  proceed  with  increased 
caution.  The  inner  table  is  often  very  thin.  After  every  few  move- 
ments of  the  instrument  probe  the  groove  in  the  skull  with  the  blunt 
end  of  a  straight  needle.  If  probing  shows  greater  penetration  at 
one  part  of  the  groove  than  another,  lessen  the  pressure  of  the 
trephine  at  that  point.  The  inner  table  is  usually  found  divided  at 
one  place  before  another;  when  this  is  the  case,  by  slightly  tilting  the 
trephine  the  place  where  penetration  has  already  taken  place  is 
avoided  while  the  rest  of  the  skull  is  being  divided.  As  soon  as  the 
bone  is  divided  the  resulting  button  is  easily  removed  and  the  dura 
mater  exposed.  Along  the  edges  of  the  osseous  hole  there  will 
always  be  found  projecting  spicules;  these  must  be  cut  away  with 
rongeur  forceps.  If  bleeding  from  the  cut  bone  is  severe,  it  may  be 
stopped  by  sponge  pressure,  or,  if  necessary,  by  slightly  crushing  the  bone  be- 
tween the  jaws  of  a  rongeur  forceps.  In  the  author's  practice  this  last  procedure 
has  almost  never  failed  to  give  satisfaction  and  to  have  no  subsequent  ill  results. 
Horsley's  wax  (beeswax  7,  almond  oil  i,  salicylic  acid  i)  applied  to  the  bleed- 


tre- 


FlG 

Gait 
phine. 

(Tiemann.) 


8  THE    SKULL    AND    THE   BRAIN 

ing  bone  is  an  efficient  hemostatic  agent.  Leonard  Freeman  finds  sterilized 
chewing  gum  most  convenient  for  this  purpose,  but  outside  of  the  United  States 
this  material  will  never  be  within  reach.  Should  there  be  any  intention  to 
reimplant  the  button  of  bone  removed,  it  must,  at  once,  be  placed  in  sterile 
water  and  kept  at  a  temperature  of  about  ioo°  F. 


Fig.  io. 


i-iG.  II. — Use  of  Keen's  forceps. 
Appearance  of  trap-door  opening  in  skull. 

The  most  convenient  size  of  trephine  for  ordinary  purposes  is  one  three- 
fourths  of  an  inch  in  diameter.  Smaller  instruments  are  often  useful.  Tre- 
phines having  a  diameter  much  greater  than  one  inch  are  useless  owing  to  the 
curvature  of  the  cranial  vault. 

Should  it  be  desired  to  enlarge  the  trephine  opening,  this  is  easily  accom- 
plished by  biting  away  the  surrounding  bone  with  rongeur  forceps.  Keen's 
forceps  are  excellent  for  this  purpose  (Figs,  ii  and  12). 


OPENING    OF   THE    SKULL  9 

Occasionally  the  dura  is  accidentally  injured  by  the  trephine  and  bleeding 
occurs.  When  this  is  the  case,  enlarge  the  hole  in  the  skull  so  that  free  access  is 
obtained  to  the  dural  wound,  surround  any  bleeding  vessel  by  a  fine  suture, 
and  close  the  rent  in  the  dura. 


Keen's  forceps. 

Fig.  12. 

(B)  Chisel  and  Mallet. — Especially  on  the  continent  of  Europe,  the  skull 
is  frequently  opened  by  means  of  a  chisel.  In  America  and  England  the  method 
is  not  a  general  favorite.  The  writer  has  more  than  once  observed  severe 
shock  result  from  it.  Either  the  ordinary  chisel  or  a  gouge  with  a  V-shaped 
cutting-edge  may  be  employed.  Support  the  patient's  head  on  a  sand-bag. 
Expose  the  skull  as  already  described.  Apply  the  chisel  nearly  parallel  to  the 
plane  of  the  skull,  and  by  careful  use  of  the  mallet  make  it  cut  a  narrow  groove 
in  the  bone.  The  groove  is  gradually  deepened  until  the  inner  table  is  divided. 
Those  skilled  in  the  use  of  the  chisel  for  this  purpose  can  remove  or  reflect  a  large 
piece  of  skull  in  a  surprisingly  short  space  of  time.  The  chisel  is  very  useful  in 
operating  in  cases  of  fracture,  especially  of  fissured  fractures,  where  it  is  desired 
to  shave  away  jagged  and  injured  portions  of  bone.  In  the  formation  of  trap- 
door openings  through  the  skull,  the  chisel  was  the  original  instrument  employed. 

(C)  Gigli  Wire  Saw.— It  is  desired  to  remove  a  large  area  of  skull  in  one 
piece.  Expose  the  skull  by  a  U-shaped  incision  of  appropriate  size.  At  each  of 
the  four  corners  of  the  area  to  be  removed  perforate  the  skull  with  a  small  trephine 
or  a  Doyen's  burr.  Doyen's  burr  is  a  very  efficient  and  safe  instrument,  most 
conveniently  operated  by  a  brace  or  Stille's  apparatus  (Fig.  13).  Before  apply- 
ing the  perforator  the  outer  table  of  the  skull  ought  to  be  drilled  so  as  to  permit 
the  rounded  perforator  to  bite.     Hudson's  drill  is  powerful  and  safe.     With  a 


lO 


THE  SKULL  AND  THE  BRAIN 


dural  separator,  separate  the  dura  from  the  skull  along  a  line  stretching  from 
one  trephine  opening  to  another.  Introduce  an  appropriately  shaped  grooved 
du-ector  to  take  the  place  of  the  dural  separator.  Pass  a  Gigli  wire  saw 
along  the  grooved  director  and  leave  the  director  in  place  to  protect  the 
dura.  With  the  wire  saw  divide  the  skull  from  within  outwards.  Remove 
the  director.  Repeat  the  procedure  until  the  desired  area  of  bone  is  entirely 
detached.  The  Gigli  wire  saw  is  an  excellent  instrument  for  use  in  the  forma- 
tion of  trap-door  openings  through  the  skull. 

(D)  Forceps.— After  perforating  the  skull  as  described  in  the  preceding 
paragraph,  one  may  divide  the  bone  between  the  perforations  with  bone-cutting 
forceps,  e.g.,  Keen's  or  DeVilbiss'  (Fig.  12),  and  attain  the  same  result  as  when 
the  Gigli  wire  saw  is  employed. 


I 


Fig.   13. — Stille's  drills  and  burrs. 


(E)  Electric  Saws,  Etc.- — Circular  saws  and  drills  driven  by  the  surgical 
engine  are  used  by  some  busy  hospital  surgeons  as  a  means  of  quickly  opening 
the  cranium.  They  are  rarely  used  in  private  practice,  are  useful  but  expensive 
luxuries,  and  any  full  description  of  their  application  would  be  out  of  place  in  a 
work  such  as  this. 

In  all  the  methods  of  opening  the  cranial  vault  which  have  thus  far  been 
described  the  bone  is  removed  over  a  greater  or  less  area.  Is  it  necessary  to 
close  this  defect  by  anything  more  than  replacement  of  the  reflected  scalp? 
When  the  scalp  is  replaced,  in  time  the  bone  defect  becomes  filled  with  exceed- 
ingly hard  and  strong  fibrous  tissue  sufficient  to  protect  the  cerebral  contents 
from  injury  by  ordinary  violence.  To  prevent  the  formation  of  adhesions  be- 
tween the  scalp  and  the  cerebral  contents  many  surgeons  are  in  the  habit  of 
interposing  between  them  divers  smooth  aseptic  materials  cut  to  such  a  shape 
that  they  will  fit  into  the  cranial  defect.     Of  these  materials,  mention  may  be 


{'LOSIKE    OF    CRANIAL    DEFECTS 


II 


made  of  gold-foil,  celluloid,  ihin  rubber  tissue,  the  membrane  which  lies  be- 
tween the  shell  and  white  of  a  hen's  egg,  etc.  If  the  wound  remains  aseptic, 
these  foreign  bodies  will  lie  in  place  indefmitely.  Their  use  is  particularly  in- 
dicated after  operations  for  epilepsy,  but  in  the  ordinary  routine  of  cerebral 
surgery  the  author  has  distinct  doubts  as  to  their  value. 

Carl  Beck's  method  of  using  the  temporal  fascia  may  be  employed  (see 
p.  50).     As  well  as  free  transplants  of  fascia  or  of  fat. 

Macewen  fills  up  the  osseous  defect  with  the  fragments  of  bone  removed. 
These  he  arranges  all  over  the  exposed  dura  like  a  tesselated  pavement.  The 
larger  fragments  or  buttons  of  bone  he  breaks  into  small  pieces  before  im- 
planting them.  Excellent  results  have 
attended  this  procedure. 

Instead  of  fragments  of  bone  removed, 
decalcified  bone  chips  or  particles  of  bone 
obtained  from  other  patients  or  animals 
have  been  successfully  implanted. 

Osteoplastic  measures  have  been  devised 
to  close  defects  in  the  skull  with  bone. 
Miiller,  Konig  and  others  have  formed  flaps 
consisting  of  the  scalp  and  the  outer  table  of 
the  skull,  and  with  these  have  covered  the 
defect. 

MULLER-KONIG   OPERATION 

Step  I. — Expose  the  cranial  defect  (O, 
Fig.  14)  by  reflecting  the  skin-periosteal  flap 
ABC.  Excise  all  scar  tissue  from  the 
cranial  defect  and  freshen  the  edges  of  the 
bone. 

Step  2.- — Outline  and  reflect  the  flap 
DFE.  In  forming  this  flap  cut  away  with 
the  chisel  a  portion  of  the  outer  table  of  the 
skull  (G).  The  portion  of  bone  G  is  an  in- 
tegral part  of  the  flap  DEF,  and  is  of  size 
and  shape  suitable  to  be  inserted  into  the 
cranial  defect  (0). 

Step    3. — ^Insert    the    graft    G    into    the 
defect  O,  and  suture  the  edges  of  flap  DEF  to  the  bed  from  which  flap  ABC 
was  raised. 

Step  4. — Implant  flap  ABC  in  the  bed  from  which  flap  DFE  was  raised. 

The  operation  may  be  modified  by  exposing  the  whole  area  ACDE  by  raising 
a  flap  of  scalp  without  periosteum  and  then  filling  the  defect  O  by  bone  taken 
from  the  area  H  attached  to  the  periosteum  and  not  to  the  scalp. 

Criticism. — During  the  necessary  manipulations,  it  is  difl&cult  to  keep  the 
flap  of  bone  from  becoming  detached  from  the  pericranium.  The  pericra- 
nium normally  has  little  or  nothing  to  do  with  the  nutrition  of  the  bone.  The 
scar  in  the  Miiller-Konig  operation  is  extremely  uncouth.     While  the  author 


Miiller-Konig  operation. 


12  THE  SKULL  AND  THE  BRAIN 

has  successfully  used  the  method,  yet  he  considers  free  transplantation  of  bone 
far  easier,  at  least  as  successful  and  theoretically  much  preferable. 

Ropke  ("Zent.  fur  Chir.,"  No.  35,  1912)  has  used  a  part  of  the  scapula  in  the 
following  manner: 

1.  After  exposing  the  cranial  defect  by  reflecting  a  flap  of  scalp,  excise  the 
scar  tissue  over  the  brain  and  vivify  the  edges  of  the  bone.  Temporarily  pack 
the  wound  with  gauze  wrung  out  of  hot  water.     Apply  dressings. 

2.  Place  the  patient  on  his  right  side  and  pull  the  left  arm  forwards.  Make 
an  incision  about  3^  inch  to  the  outer  side  of  the  vertebral  border  of  the  scapula, 
exposing  the  fascia  covering  the  infra-spinatus.  Divide  the  fascia  and  infra- 
spinatus just  external  to  the  vertebral  border  but  do  not  divide  the  periosteum. 
With  a  sharp  knife  dissect  outwards,  cutting  the  infra-spinatus  from  the  body 
of  the  scapula  until  an  area  of  the  bone  is  exposed  fully  as  large  or  larger  than 
the  cranial  defect. 

With  surgical  engine,  sharp  chisel  or  suitable  forceps,  e.g.,  DeVilbiss', 
divide  the  bone  all  round  the  desired  area,  being  careful  to  leave  the  vertebral 
border  of  the  bone  intact. 

Dissect  the  isolated  plate  of  bone  from  the  subscapular  muscle.  Place 
the  fragment  of  bone  in  warm  salt  solution. 

3.  Attend  to  hemostasis.  Suture  the  divided  infra-spinatus  muscle  and 
fascia  to  the  vertebral  border  of  the  scapula.     Close  the  wound.     Dress. 

4.  With  scissors  carefully  remove  all  muscle  attached  to  the  bone  implant, 
and  place  the  bone  plate  in  the  cranial  defect.  Replace  the  scalp.  Close  the 
wound.     Dress. 

Macewen  has  long  recognized  the  importance  of  closing  cranial  defects; 
most  other  surgeons  were  later  in  doing  so,  and  many  to-day  are  skeptical 
or  disbelieve  in  its  necessity.  The  later  results  in  cases  of  skull  fractures 
treated  in  Korte's  clinic  support  Macewen's  ideas  forcibly  (p.  17).  Stieda 
("Archiv   fur   klin.  Chir.,"  Ixxvii,  532)  formulates  the  following  rules: 

1.  If  the  wound  can  be  rendered  and  kept  aseptic,  close  the  defect  at  once  by 
implantation  of  the  fragments  removed  (Macewen's  method). 

2.  If  the  wound  is  healed — do  not  wait  for  the  appearance  of  epilepsy  but 
excise  the  scar  tissue  from  the  cranial  defect  and  repair  it  by  the  Miiller-Konig 
osteoplastic  method. 

Macewen's  method  is  only  applicable  for  closing  the  skull  at  the  time  the 
skull  is  opened,  i.e.,  when  the  bone  removed  is  available  for  reimplanting. 

In  the  Miiller-Konig  operation  the  fragment  of  bone  transplanted  is  supposed 
to  gain  its  nourishment  from  the  pericranium.  In  the  author's  experience, 
such  great  gentleness  has  to  be  exercised  to  prevent  the  fragment  of  bone  from 
actually  falling  off  the  pericranium  that  it  is  difficult  to  imagine  any  useful 
amount  of  nutriment  passing  from  the  pericranium  to  the  bone.  If  this  is  true, 
then  in  view  of  the  success  of  bone  transplantation  the  complicated  Miiller- 
Konig  operation  should  be  discarded  and  the  cranial  defect  closed  by  the  free 
(non-pedunculated)  transplantation  of  bone. 

This  might  be  accomplished  in  several  ways:  v.  Eiselsberg  did  it  by  using  a 
portion  of  the  tibia  covered  with  periosteum.     Undoubtedly  the  same  end  could 


TKAP-DOUK    CRANIOTOMY 


13 


be  attained  by  implanting  fragments  of  the  outer  table  of  the  skull  obtained  in 
the  neighborhood  of  the  defect  to  be  filled. 

C.  C.  Coleman  (Surg.  Gyn.  and  Obst.,  July,  1920)  has  had  large  and  favor- 
able experience  with  this  method,  using  a  technique  which  he  credits  to  C.  H. 
Frazier. 

1.  Excise  the  scar  tissue  of  the  scalp  and  cranial  defect  but  do  not  injure  the 
dura.  (If  the  scalp  scar  is  so  extensive  that  after  its  excision  closure  of  the 
resulting  scalp  wound  is  impossible  without  undue  tension,  cover  the  defect 
with  healthy  skin  and  defer  the  cranioplasty  until  later). 

2.  Make  an  incision  through  the  pericranium  around  the  defect  and  about 
yi  inch  from  its  margin.  With  an  elevator  separate  the  pericranium  along  with 
any  remnants  of  scar  tissue  from  the  edge  of  the  defect  and  with  it  separate  the 
dura  from  the  bone  at  the  edge  of  the  defect. 

3.  With  a  chisel  pare  the  edge  of  the  defect  and  bevel  it.  While  doing  this 
protect  the  dura  by  a  thin  spatula.  Cut  a  rubber  dam  pattern  of  the  size  and 
shape  of  the  defect.     Pack  the  wound  with  gauze  wrung  out  of  hot  water. 

4.  Over  one  parietal  eminence  make  an  incision  down  to  but  not  through  the 
pericranium.  Retract  the  scalp.  Apply  the  rubber  dam  model  to  the  skull. 
With  knife  and  chisel  cut  a  graft  of  pericranium  and  a  thin  layer  of  the  outer 
table  of  the  skull  the  size  of  the  model. 

5.  Suture  this  graft  (pericranium  to  pericranium)  into  the  defect,  the  bony 
surface  being  next  to  the  dura. 

6.  Close  the  wounds.  Dress.  It  is  wise  to  keep  the  patient  flat  in  bed  for 
two  weeks  as  the  intracranial  pressure  favored  by  the  horizontal  posture,  gives 
the  thin  transplant  the  proper  curve  in  relation  to  the  surrounding  skull. 

Primrose  uses  not  only  bone  but  cartilage  for  the  closure  of  cranial  defects. 
Fascial  grafts  (fatty  surface  next  the  brain)  are  of  much  value  to  fill  dural 
defects. 

Primrose  (Annals  Surg.,  July,  1919)  in  34  cases  of  cranial  defects  from  war  wounds  where 
satisfactory  closure  was  accomplished  by  a  firm  graft  of  bone  or  cartilage  obtained  the  following 
results. 

Cases  completely  relieved  of  distressing  symptoms 19 

Cases  rendered  worse  by  the  operation 2 

Cases  improved  but  not  wholly  relieved 8 

Cases  with  no  change  in  the  svTnptoms 5 

The  relief  of  such  symptoms  as  headache,  dizziness,  the  fear  of  injury  and  the  sense  of 
insecurity,  occasionally  the  worry  and  mental  depression  dependent  upon  the  possession  of  an 
ugly  deformity  is  as  a  rule  immediate  and  complete.  The  value  of  the  operation  in  cases  of 
epilepsy  is  less  e\adent.  In  one  of  Primrose's  cases  the  graft  became  a  source  of  irritation  and 
had  to  be  removed  and  a  fascial  graft  substituted  with  relief  from  the  convulsions. 

Temporary  Osteoplastic  Opening  of  the  Skull.  Opening  of  the  Skull  by 
Means  of  a  "Trap-door." — This  method  is  often  of  great  value  and  the  flap 
reflected  may  be  very  large.  The  base  of  the  flap  should  be  in  the  direction 
of  the  main  blood  supply,  e.g.,  the  temporal  region  where  there  is  the  added 
advantage  of  having  thin  bone  at  the  place  where  the  bone  pedicle  must  be 
fractured. 


14  THE    SKULL    AXD    THE    BRAIN 

Step  I. — By  scratchinj?  the  skin,  outline  the  desired  flap.  On  each  side  of 
the  future  pedicle  penetrate  to  the  bone.  From  one  of  these  openings  to  the 
other,  pass  a  suitable  elevator  between  the  scalp  and  the  bone.  Pull  a  rubber 
tube  through  the  tunnel  thus  formed  and  put  it  on  the  stretch.  Grasp  the  two 
ends  of  the  tube  m  the  jaws  of  a  long  bladed  clamp  (Fig  15).  A  pad  of 
gauze  placed  between  the  clamp  and  skin  protects  the  latter.     Divide  the 

scalp  along  the    line   of   scratches.     The 

.  -  -    •     ^    >  tube   and    clamp    prevents    all    bleeding 

f  ^  from   the  flap    side   of    the    incision.     A 

♦  Makkas'  pin  can  be  used   instead  of  the 

*  tube  and  clamp. 

^  Step  2. — At    several   points  along  the 

line  of   proposed   bone  section    perforate 

the    skull   with  a    burr.     Between    these 

openings  separate  the  dura  from  the  skull. 

Divide  the  skull  between  these  openings 

"  y  J  "        V  i  by  means  of  a  Gigli  saw.     While  sawing 

(^;^/  -^        the   bone,  protect  the  dura  by  means  of 

Fig.  15.  ^^  elevator  or  thin  strip  of  metal.     The 

bone  is  thus   cut  from   within   outward. 

It  is  well  to  cut  so  as  to  make  a  broad  beveled  edge.     Much  of  the  limbs  of 

the  bone  flap  may  be  cut  with  the  De  Vilbiss  forceps  or  their  equivalent. 

Many  surgeons  use  a  surgical  engine. 

Step  3. — Raise  the  flap  with  blunt  instruments,  fracture  its  base.  At  this 
stage  the  middle  meningeal  artery  may  be  injured  and  bleed,  especially  if  it 
tunnels  the  bone.  A  small  pack  of  cotton  pressed  between  the  dura  and  the 
bone  will  control  this  heeding. 

Step  4. — Open  the  dura  by  a  flap  leaving  enough  margin  for  suturing. 


CLOSURE   OF  THE   SCALP   WOUND 

The  scalp  wound  is  closed  by  sutures.  The  author  always  prefers  to  intro- 
duce as  few  sutures  as  possible,  because  there  is  little  tendency  to  retraction, 
and  in  this  locality  especially,  any  fluids  which  may  be  thrown  out  in  the 
wound  are  very  much  better  soaked  up  in  the  dressings  than  retained  beneath 
the  scalp.  If  few  stitches  are  used,  drainage  is  unnecessary  even  when  thorough 
cleansing  of  the  wound  has  been  impossible,  except  in  the  presence  of  pus,  or 
when  a  large  cavity  has  been  left  after  removal  of  tumor,  etc.  Drainage  of  the 
wound  by  a  strip  or  wick  of  iodoform  gauze  has  proved  e.xtremely  unsatisfactory 
to  the  author;  the  gauze  has  almost  always  acted  as  a  plug  instead  of  a  drain. 
Of  course,  where  more  extensive  drainage  or  packing  is  indicated,  gauze  properly 
introduced  acts  ideally.  In  suitable  cases  drainage-tubes  of  rubber,  glass  or 
decalcified  bone  (chromicized  )are  to  be  employed. 

After  closing  the  wound  apply  the  usual  dressings.     These  are  most  con- 
veniently held  in  place  by  a  starch  bandage. 


CRANIAL    TOPOGRAPHY. 


15 


HEMORRHAGE   FROM   THE    MIDDLE   MENINGE.AL    VESSELS 

The  middle  meningeal  artery  enters  the  cranium  through  the  foramen  spino- 
sum,  usually  accompanied  by  two  veins.  It  divides  into  an  anterior  and  a 
posterior  branch,  which  ramify  in  all  directions  over  the  dura.  Meningeal 
hemorrhage  is  usually  accompanied  by  fracture  of  the  skull,  but  as  it  sometimes 
is  caused  by  violence  which  does  not  injure  the  bone,  and  even  by  contrecoup, 
the  operative  treatment  of  the  latter  class  of  cases  must  be  considered  separately. 

I.  When  focal  symptoms  permit  the  determination  of  the  site  of  the  bleed- 
ing, the  indications  for  treatment  are  exceedingly  simple.  Trephine  the  skull 
at  the  site  of  the  hemorrhage.  A  tough,  dark-colored  clot  will  be  found.  This 
must  be  removed  with  forceps,  probe,  spoon,  and  stream  of  hot  water.  Prob- 
ably the  trephine  opening  will  require  enlargement;  possibly,  a  second  opening 
may  be  required,  as  extradural  clots  are  frequently  very  extensive.     If  active 


Fig.  16. — Exposure  of  middle  meningeal  artery.     {Esmarch  and  Kowalzig.) 


bleeding  continues,  search  for  its  source  by  enlarging  the  trephine  opening  with 
forceps  or  making  another  opening  as  may  be  required.  Ligate  the  vessel. 
Examine  the  dura  carefully  for  signs  of  injury.  If  that  structure  is  torn,  cleanse 
the  wound  from  blood-clots  and  close  it  with  fine  sutures.  For  suturing  the 
author  prefers  fine  silk  or  celluloid  hemp  to  catgut,  merely  because  the  former 
are  so  thin  that  they  can  be  readily  threaded  on  very  small  needles.  If  the  dura 
be  found  distended  and  discolored,  or  pulsation  is  absent  showing  that  subdural 
hemorrhage  is  probably  present,  carefully  incise  that  membrane,  remove  blood- 
clot,  stop  bleeding,  and  close  the  dural  wound.  After  the  removal  of  extradural 
clots  the  dura  soon  becomes  pushed  up  against  the  skull  in  its  normal  position, 
and  the  external  wound  may  be  closed  without  drainage. 

II.  In  the  absence  of  distinct  focal  symptoms  the  trephine  must  be  applied 
somewhere  along  the  course  of  the  artery  so  that  further  bleeding  may  be 
stopped  and,  what  is  of  greater  importance,  an  opportunity  may  be  obtained  to 
explore  for  and  remove  the  blood-clot.  Roswell  Park  writes:  "Vogt  and  Beck 
have  suggested  trephining  at  a  point  one  and  a  half  inches  above  the  zygoma 
and  the  same  distance  behind  the  angle  of  the  orbit.  An  inch  trephine  at  this 
point  is  sure  to  expose  the  anterior  branch  of  the  middle  meningeal  artery. 


i6 


THE    SKILL   AND    THE   BRAIN 


Nevertheless,  the  removal  of  the  clot  which  causes  the  compression  is  much 
more  important  than  merely  finding  the  artery.  Kronlein  has  made  the  sug- 
gestion of  trephining  twice,  if  necessary,  in  those  cases  in  which  the  chance  of 
finding  the  clot  is  good.  He  divides  these  hematomata  generally  into  three 
classes:  (i)  fronto-temporal;  (2)  temporo-parietal;  (3)  parieto-occipital.  He 
suggests  trephining  over  the  artery  first,  and  then,  if  no  hematoma  be  found 
and  the  indications  still  point  to  meningeal  hemorrhage,  to  trephine  again  just 
below  the  parietal  eminence,  because  an  opening  in  this  position  would  expose 
either  of  the  latter  classes  of  blood  tumors."  (See  Cushing's  decompressive 
operation.) 

Figures  16  and  17  are  self-explanatory. 


Fig.  17. — Exposure  of  middle  meningeal  artery, 
a,  b.     Base  line  from  lower  margin  orbit  through  external  auditory  meatus,     c,  d.  Parallel  to  a,  b. 
from  upper  margin  orbit,  backwards,    e,  f.  Perpendicular  to  a,b,  and  about  i  l^i  inches  posterior  to  external 
angular  process,     g,  h.  Perpendicular  to  a,  b,   and  immediately  posterior  to  mastoid.     (Esmarch  and 
Kowalzig.) 


Steiner  has  made  a  careful  study  of  the  surgical  anatomy  of  the  middle 
meningeal  artery,  and  as  a  result  has  worked  out  the  following  method  of 
reaching  the  vessel. 

(A)  (i)  Draw  a  line  from  the  middle  of  the  root  of  the  nose  to  the  apex  of 
the  mastoid  process.  (2)  From  the  root  of  the  nose  draw  a  line  backwards 
parallel  to  a  line  drawn  from  the  lower  margin  of  the  orbit  through  the  middle 
of  the  external  auditory  meatus.  (3)  Bisect  the  first  line  by  one  drawn  at 
right  angles  to  it. 

Where  the  third  or  vertical  line  crosses  the  second  {i.e.,  that  parallel  to  the 
base  line  of  the  skull)  is  the  point  to  trephine  when  searching  for  the  anterior 
branch  of  the  artery. 

(B)  To  reach  the  posterior  branch  of  the  middle  meningeal  artery,  trephine 
at  the  point  where  a  line  drawn  directly  backwards  from  the  root  of  the  nose  is 
crossed  by  a  line  drawn  at  right  angles  to  it  from  the  apex  of  the  mastoid 
process. 


FRACTURES    OF    SKULL  1 7 

OPERATION    FOR   FRACTURES   OF  THE  CRANIAL   VAIXT 

In  cases  of  compound  or  open  fracture,  the  wound  in  the  scalp  may  be  en- 
larged, so  as  to  expose  the  skull,  or,  if  more  convenient,  the  scalp  may  be  re- 
flected by  the  usual  U-shaped  incision,  as  is  done  in  simple  fractures. 

I.  Depressed  Fracture. — The  principle  to  be  followed  is  to  elevate  the 
depressed  bone,  remove  all  dirt,  remove  all  sharp  spicules,  stop  bleeding,  and 
leave  everything  in  the  best  possible  condition  for  healing. 

If  beside  the  depression  there  is  a  sufficiently  large  hole  in  the  skull,  the  de- 
pressed bone,  may  be  elevated  or  removed  by  means  of  periosteal  elevators, 
necrosis  forceps,  or  rongeurs.  It  is  imperative,  especially  in  compound  frac- 
tures, to  make  an  opening  in  the  skull  large  enough  to  demonstrate  the  absence 
of  dirt  and  hemorrhage.  Failure  to  attend  to  this  may  be  disastrous;  the  extra 
work  involved  in  doing  it  does  no  harm.  If  no  opening  of  sufficient  size  exists 
in  the  skull  beside  the  depression,  it  is  necessary  to  make  one.  This  is  usually 
done  with  the  trephine.  Apply  the  centre  pin  of  the  trephine  to  the  solid 
skull  beside  the  depression.  Part  of  the  cutting-edge  of  the  instrument  overlaps 
the  fracture,  but  most  of  it  lies  on  the  unfractured  bone.  Remove  a  button  of 
bone.  In  operating  do  not  exert  any  pressure  on  the  fractured  fragments  of 
bone  lest  injury  to  the  cranial  contents  result.  Remove  or  elevate  the  de- 
pressed bone.  Remove  blood-clot  and  foreign  material.  Stop  bleeding. 
If  desired,  the  fragments  of  bone  may  be  cleansed  and  returned  if  conditions 
are  favorable.*  If  the  dura  mater  is  torn,  it  must  be  cleansed  and  sutured.  In 
severe  injuries  the  brain  itself  is  often  much  lacerated.  The  cerebral  wound 
must  be  cleaned  by  gentle  irrigation  with  hot  water  and  loose  fragments  of 
brain  removed.  Bleeding  must  be  stopped  by  ligature,  application  of  hot 
water,  or  packing  with  gauze.  The  divided  dura  must  be  sutured,  leaving  an 
opening  for  drainage  or  for  the  gauze  packing,  and  the  external  wound  partially 
closed.  When  the  dura  is  destroyed  to  an  extent  that  its  closure  becomes  im- 
possible, it  is  wise  to  cover  it  with  some  smooth  aseptic  material,  such  as  gold- 
foil,  rubber  tissue,  or  the  like,  unless  drainage  is  necessary.  Possibly  the  im- 
plantation of  a  free  mass  of  fat  might  be  of  value  (see  p.  52).  Schulze-Berge 
has  covered  the  dural  defect  by  splitting  the  neighboring  dura  into  two  layers 
from  the  outer  of  which  he  formed  a  flap  sufl&cient  to  fill  the  defect.  When  a 
drain  is  required,  the  part  of  the  brain  bereft  of  dura  must  be  left  largely  to  it- 
self. In  one  case  of  the  writer's  where  there  was  much  destruction  of  brain  and 
dura  and  the  wound  was  infected  the  patient  recovered  perfectly  in  spite  of  the 
appearance  of  a  hernia  cerebri.  The  patient  was  seen  several  years  after  the 
accident  and  enjoyed  perfect  health.     Twelve  years  later  epilepsy  developed. 

When  the  fracture  is  situated  over  the  longitudinal  sinus  the  sinus  is  liable 
to  be  wounded.     Bleeding  can  commonly  be  controlled  by  means  of  packing. 

*  Brewitt  ("Archiv  fur  klin.  Chir.,"  Ixxix)  studied  the  late  results  of  Korte's  cases  of 
complicated  fracture  of  the  skull.  Of  thirty-eight  patients  treated  by  reimplantation  of  the 
bone  twenty-four  remained  in  good  health,  two  had  slight  and  two  such  severe  disturbances 
that  they  were  unable  to  work.  None  were  epileptic.  Three  out  of  four  cases  treated  by  a 
secondary  plastic  operation  were  in  good  health,  one  had  considerable  trouble.  Out  of  thirty 
cases  where  the  skull  was  left  open  only  nine  remained  in  good  health;  two  had  slight,  one 
severe  disturbances;  one  had  epilepsy;  eight  died  from  the  injury;  nine  cases  could  not  be 
traced. 


THE    SKULL   AND    THE   BRAIN 


Wounds  of  the  sinus  have  been  sutured  but  its  stiff  hard  walls  do  not  lend 
themselves  easily  to  direct  suture. 

Revenstorf  ("  Centralblatt  fiir  Chir.,"  Sept.  21,  1907)  recommends  the  in- 
sertion of  a  suture  such  as  is  sufficiently  shown  in  Fig.  18.  The  stitch  seems  as 
if  it  would  be  inefficient  but  the  blood  pressure  in  the  sinus  is  so  low  that  the 
pressure  exerted  by  the  suture  suffices. 

2.  Fissured  Fractures.^ — When  the  fracture  consists  of  a  fissure  involving 
both  tables  of  the  skull,  the  dangers  to  be  combated  are:  (a)  In  compound  frac- 
tures, dirt,     (b)  Intracranial  hemorrhage. 
(c)  Separation  of  spicules  from  the  internal 
table  and  injury  to  the  brain  from  them. 

These  dangers  are  met  as  follows:  In 
compound  fracture,  that  portion  of  the 
fissure  near  the  scalp  wound  must  be 
treated  on  the  lines  laid  down  for  depressed 
fracture,  and  the  rest  of  the  fissure  treated 
as  if  the  fracture  was  of  the  simple  variety. 
In  simple  fracture  the  fissure  should  be 
exposed,  and  with  a  small  trephine, 
rongeurs,  or  chisel  the  skull  removed  at 
various  points  along  the  line  of  fissure 
sufficiently  to  permit  the  surgeon  to  satisfy 
himself  as  to  the  absence  of  hemorrhage  or 
of  the  penetration  of  the  brain  by  spicules 
of  bone. 
WTien  the  fissure  does  not  involve  the  inner  table  of  the  skull,  as  demon- 
strated by  probing  with  the  blunt  end  of  the  needle,  it  is  to  be  left  undisturbed, 
unless  in  the  neighborhood  of  a  wound  of  the  scalp.  When  exposed  to  dirt, 
as  is  always  the  case  in  compound  fractures,  the  fissure  should  be  cleaned  by 
shaving  its  edges  with  a  sharp  chisel.  Fissured  fractures  are  usually  met  with 
radiating  from  other  fractures  of  the  cranial  vault. 

All  fractures  of  the  cranial  vault  ought  to  be  subjected  to  exploratory  opera- 
tion whether  they  are  depressed  or  not.  J.  Abadie  (La  Pr.  Med.,  Sept.  25,  1916) 
gives  the  following  advice. 

1.  Unless  entirely  and  certainly  superficial  every  wound  of  the  scalp  ought 
to  be  explored  by  incision. 

2.  Every  injury  (even  superficial)  to  the  skull  ought  to  be  explored.  In 
cases  where  there  is  a  mere  shallow  grooving  like  a  scratch  made  by  a  nail  it  is 
wise  to  cut  into  the  bone  with  a  saw  to  demonstrate  the  intactness  of  the  diploe 
and  that  the  probe  cannot  depress  the  inner  table. 

3.  In  all  other  cases  the  skull  should  be  opened,  fragments  removed  and 
edges  smoothed. 

4.  The  general  condition  of  the  patient  can  present  no  contraindication  as, 
in  the  apparently  dying,  coma  may  disappear  after  operation  and  operation 
cannot  increase  the  dangers  inherent  to  the  wound. 

5.  A  saw  or  trephine  is  preferable  to  chisel  and  mallet  in  operating.  The 
rongeur  is  excellent  but  should  cut  and  not  crush  the  bone. 


Fig.  18. 

-Y,  Longitudinal  sinus  with  rent  in  it;  5,  5, 
sutures;  D,  D,  dura. 


FRACTURES    OF    SKULL  IQ 

6.  If  the  dura  has  l)een  pciu-traU-d,  hone  ou<i;ht  to  he  removed  for  at  least 
1-2  cm.  heyond  the  dural  wound  toi)ermit  certain  removal  of  splinters  of  the 
inner  table.  It  is  not  necessary  to  remove  the  ui\injured  outer  table  from  over 
the  site  of  the  removed  sjilinters  of  inner  table. 

7.  If  the  dura  has  not  been  opened  by  the  injury  ought  it  to  be  left  intact? 
Abadie  finds  incision  of  the  dura  does  not  increase  the  danger  and  has  seen  foci 
of  infection  form  under  the  unopened  dura  which  might  have  been  avoided  by 
timely  opening.  If  there  is  blood  under  the  dura  or  a  focus  of  attrition  (evi- 
denced by  depressability)  open  the  dura  and  after  evacuating,  let  the  edges  of 
the  wound  fall  together. 

8.  If  the  dura  is  torn,  explore  with  the  finger  and  remove  any  splinters. 

9.  Drain  with  a  gauze  wick  kept  wet  with  hypertonic  salt  solution. 

10.  Unless  drainage  is  to  be  used,  place  gauze  soaked  in  4  per  cent.  Collargol 
in  contact  with  the  dura  (or  brain)  temporarily. 

11.  In  non-infected  cases  without  dural  wound,  close  the  wound  completely. 
Generally  part  of  the  wound  should  be  left  open  for  drainage. 

12.  Progressive  headache,  a  rising  temperature  or  marked  slowing  of  the 
pulse  call  for  lumbar  puncture. 

13.  Portions  of  projectiles  not  directly  accessible  at  the  primary  operation 
should  be  removed  two  or  three  days  later  under  guidance  of  radioscopy. 

14.  The  after  history  is  either  entirely  good  or  entirely  bad.  If  there  is  any 
'upset'  even  on  one  day,  the  prognosis  is  bad.  "This  rule  is  not  absolute,  we 
have  personal  experience  to  the  contrary,  but  it  is  the  general  clinical  impres- 
sion." 

Fractures  of  the  base  of  the  skull  when  they  demand  operation  do  so  on 
account  of  secondary  complications  such  as  hemorrhage  and  more  especially 
infection.  The  operation  consists  in  exposure  (and  if  necessary  incision)  of 
the  meninges  low  down.  The  middle  fossa  is  the  one  most  commonly  affected 
and  may  be  reached  by  Cushing's  decompression  operation.  In  an  exhaustive 
paper  ("Annals  of  Surg.,"  June,  19 10)  Ransohoff  comes  to  the  following 
conclusions: 

"i.  There  will  always  be  a  large  mortality  connected  with  basal  fractures — 
death  resulting  from  primary  shock,  brain  laceration  or  hemorrhage.  Thirty- 
seven  per  cent,  of  the  fatal  cases  die  within  six  hours  or  less,  and  56  per  cent, 
die  within  twelve  hours.  It  is  not  probable  that  the  mortality  of  this  class  of 
cases  can  ever  be  reduced  with  or  without  operation.     They  are  primarily  fatal. 

"2.  Twenty-three  per  cent,  of  the  fatal  cases  die  during  the  second  twelve 
hours  of  the  first  day  and  6  per  cent,  die  during  the  second  day.  They  are  the 
cases  in  which  the  coma  is  not  profound,  in  which  the  pupils  are  not  fixed, 
in  which  the  breathing  is  not  stertorous,  and  in  which  there  is  not  complete 
muscular  relaxation.  With  a  slow  full  pulse  and  lumbar  puncture  indicating 
hemorrhage  and  increase  of  intracranial  pressure,  a  trephining  operation  is 
indicated.     In  the  doubtful  cases,  an  operation  is  indicated. 

"3.  In  this  class  of  cases,  where  facilities  for  the  major  operation  of  tre- 
phining are  not  at  hand,  repeated  lumbar  punctures  should  be  essayed.  This 
procedure  may  be  destined  to  take  the  place  of  decompressive  operations. 

"4.  There  is  a  large  group  of  cases  in  which  there  is  complete  consciousness 


20  THE    SKULL    AND    THE    BKAIN 

or  in  which  there  is  a  somnolence  or  milder  degree  of  coma,  and  in  which  the 
concomitant  symptoms  do  not  indicate  a  grave  intracranial  trauma  either  to 
the  brain  or  its  vessels.  The  pupils  though  uneven,  react;  involvement  of  one 
or  more  cranial  nerves  may  be  evident.  The  symptoms  singly  or  collectively 
are  not  ominous  at  any  time.  Eighty  per  cent,  of  this  class  of  cases  have  a 
tendency  to  get  well  with  or  without  operation.  They  should  not  be  operated 
on  unless  the  symptoms  indicate  an  increase  of  intracranial  pressure  from 
hemorrhage  or  beginning  cerebral  edema,  or  distinct  localizing  (cortical) 
symptoms. 

"5.  There  is  a  distinct  class  of  cases  in  which  operation  is  indicated.  They 
are  cases  which  seemingly  not  severe  in  the  beginning  grow  progressively  or 
suddenly  worse,  showing  signs  of  increased  intracranial  pressure.  Decom- 
pressive operation  may  save  a  considerable  proportion  of  them. 

"6.  It  has  yet  to  be  determined  where  the  trephining  should  be  done  to 
obtain  the  best  results.  Since  most  fractures  involve  the  anterior  or  the  middle 
fossa,  subtemporal  trephining  is  doubtless  the  procedure  oftenest  indicated. 
When,  however,  a  hematoma  in  the  mastoid  or  occipital  region  indicates  an 
involvement  of  the  posterior  fossa,  the  operation  should  be  subtentorial.  To 
relieve  the  subtentorial  tension  by  an  opening  made  in  the  temporal  region  is 
illogical  and  may  be  dangerous.  I  attempted  it  recently  in  a  cerebellar  tumor 
the  site  of  which  could  not  be  determined.  The  patient  succumbed  within 
two  weeks  with  symptoms  of  bulbar  paralysis." 

During  1920  the  subject  of  trephining  in  basal  fractures  was  discussed  at 
length  in  the  Paris  Surgical  Society  ("Bui.  et  Mem.  de  la  Soc.  de.  Chir.  de  Paris, 
1920).  The  general  opinion  was  in  favor  of  spinal  puncture  as  opposed  to 
decompressive  operation.  De  Martel  however  declared  that  when  a  patient 
with  cranial  fracture  was  comatose,  lumbar  puncture  should  be  done.  "If 
the  puncture  gave  passage  to  a  bloody  liquid,  flowed  freely  and  was  followed  by 
a  slight  amelioration,  it  was  proper  to  make  a  series  of  such  punctures.  If  the 
puncture  did  not  give  the  above  results  bilateral  subtemporal  trephining  should 
be  practiced  as  by  this  means  alone  could  rupture  of  the  meningeal  be  recognized, 
lumbar  puncture  facilitated  and  rendered  inoffensive  and  effective  decompres- 
sion of  the  brain  realized.'' 

REMOVAL   OF   TUMORS   FROM   THE    BRAIN 

Description  of  the  methods  of  diagnosing  and  locating  tumors  of  the  brain 
would  be  out  of  place  in  this  work.  The  diagram  (Fig.  19)  here  presented  is 
merely  meant  to  act  as  a  graphic  reminder  of  the  generally  accepted  position 
of  some  of  the  chief  centres.  Sherrington  and  Griinbaum  find  that  in  monkeys 
all  the  motor  centres  are  anterior  to  the  fissure  of  Rolando.  F.  Krause  ("Die 
deutsche  Klinik,"  viii,  961)  has  substantiated  these  findings  in  man.  Fig.  20 
represents,  on  the  left  hemisphere,  the  results  of  Krause's  investigations  in 
twelve  operations.  J.  C.  DaCosta  and  others  agree  with  Sherrington's  views. 
It  is  necessary,  however,  to  study  the  relations  which  the  sulci  and  convolutions 
of  the  brain  bear  to  certain  landmarks  on  the  skull,  so  that  it  may  be  possible 
to  expose  the  brain  at  the  desired  spot. 


CEREBRAL   TOPOGRAPHY 


21 


Fig.  10- 


£xlcn3ion  and 
Inward  Rotation 
Foot 


Eltvation,  Abduction 
Arm 


Extension    ) 
flexion  J 


c.nAe4  \Flexion 
Uil  finders  (Extenjion 


,      i  Extension 
•"•'"{Flexion 

Extension  little  finfer 


L'pperiLowr  Eyelids 
Anfle  of  Mouth 

Zygomatic  Muscles  and 
levator  labii  sup. 

Masseter 


Ulnar  flexion  \ 
-Volarflexion  1 1^„-., 
^ladiatflexionX'^"^ 
fforsaUlexion) 
'.Strong  tlexlon'\ 
Extensioit        ( jf,umh 
~  Opposition     \ 
5pasm        ) 


ExI.  pterygoid 


Fig.  21.— Bennefs  method  shown  on  the  right;  Thane's*  on  the  left.     {Esmarch  and  Kowalzig.) 

*  Thanes  Method.— Dr^sv  the  line  a-h  (Fig.  21)  from  the  root  of  the  nose  to  the  external 
occipital  protuberance.  Take  the  point  e,  three-fourths  of  an  inch  posterior  to  the  middle 
point  of  a-h.  A  line  drawn  forwards  and  outwards  from  e,  at  an  angle  of  67  degrees  to  a-b, 
corresponds  to  the  fissure  of  Rolando. 


22 


THE    SKULL    AM)    TIIK    I5RAL\ 


The  .simplcsl  and  most  easily  rcmcmhered  means  of  finding  the  fissure  of 
Rolando  is  that  devised  by  Bennet  (Fig.  21).  At  right  angles  to  the  sagittal 
suture  draw  two  parallel  lines,  the  anterior  of  which  (c-d)  runs  along  the  anterior 
margin  of  the  external  auditory  meatus;  the  posterior  (e-f)  touches  the  posterior 
margin  of  the  mastoid  process.  These  two  lines  will  be  about  two  inches  apart. 
On  the  anterior  line  take  a  point  (g)  two  inches  above  the  external  auditory 
meatus,  and  from  it  draw  a  line  (g-e)  upwards  and  backwards  to  the  point  where 
the  posterior  line  meets  the  sagittal  suture.  This  oblique  line  is  about  three 
and  three-quarter  inches  in  length  and  corresponds  to  the  Rolandic  fissure. 

The  simplest  means  to  find  the  point  of  bifurcation  of  the  Sylvian  fissure  is 
the  following  (Esmarch):  Draw  a  line  one  and  one-half  inches  above  and 
parallel  to  the  zygoma.  Draw  a  vertical  line  three-quarters  of  an  inch  posterior 
to  the  frontal  process  of  the  malar.     These  two  lines  cross  at  a  point  correspond- 


FiG.  22. 


ing  to  the  bifurcation  of  the  Sylvian  fissure.  Vogt's  method  of  finding  the  same 
spot  is  more  easily  remembered.  The  desired  position  is  two  finger-breadths 
above  the  zygoma  and  one  thumb's  width  behind  the  frontal  process  of  the 
malar  (Fig.  16). 

A  more  elaborate  system  for  finding  the  cortical  centres  is  that  of  Chiene 
("Sajous'  Annual,"  1895)  (Fig.  22):  "Shave  the  head  and  find,  in  the  median 
line  of  the  skull,  between  the  glabella  (G)  and  the  external  occipital  protuber- 
ance (0),  the  following  points:  The  mid-point  (M),  the  three-fourths  point  (T), 
and  the  seven-eighths  point  (S).  Find  also  the  external  angular  process  (E) 
and  the  root  of  the  zygoma  (P)  immediately  above  and  in  front  of  the  external 
auditory  meatus.  Having  found  these  five  points,  join  EP,  PS,  and  ET. 
Bisect  EP  and  PS  at  N  and  R;  also  bisect  AB  at  C  and  draw  CD  parallel  to 
AM.  The  pentagon  (ACBRPN)  corresponds  to  the  temporo-sphenoidal  lobe, 
with  the  exception  of  its  apex,  which  is  a  little  in  front  of  N.  MDCA  corre- 
sponds to  the  Rolandic  area  containing  the  fissure  of  Rolando,  the  ascending 
frontal  and  the  ascending  parietal  convolutions.     A  is  over  the  anterior  branch  of 


CEREBRAL   TOPOGRAPHY 


■^0 


the  middle  meningeal  artery  and  the  bifurcation  of  the  Sylvian  fissure;  AC  fol- 
lows its  horizontal  limb.  The  lateral  sinus  at  its  highest  point  touches  the  line 
PS  at  R.  MA  corresponds  to  the  precentral  sulcus,  and,  if  it  be  trisected  at 
K  and  L,  these  points  will  correspond  to  the  origins  of  the  superior  and  inferior 
frontal  sulci.  The  supramarginal  convolution  lies  in  the  triangle  HBC.  The 
angular  gyrus  is  at  B." 


9 


n        1        Z        3        4       St 


Fig.  23. — Osteoplastic  exposure  of  cerebral  tumor.     {Krause,  Die  Deutsche  Klinik.) 


Having  determined  by  measurement,  etc.,  the  point  at  which  removal  of 
bone  will  expose  the  tumor,  mark  that  point  on  the  scalp  with  iodine,  nitrate  of 
silver,  the  point  of  a  cautery,  or,  what  is  far  better,  puncture  the  scalp  with  a 
small  drill  which  at  the  same  time  marks  the  outer  table  of  the  skull.  If  it 
seems  proper,  any  desired  areas  of  the  skull  may  be  mapped  out  by  a  series  of 
drill  marks. 

Step  I. — Reflect  the  scalp  and  open  the  skull  as  already  described.  Gener- 
ally one  of  the  osteoplastic  or  trap-door  openings  is  best.     If  the  patient  is  weak 


24  THE  SKULL  AND  THE  HKAIN 

or  if  there  has  been  much  loss  of  blood  and  shock  sustained  during  this  step 
of  the  operation,  attend  to  hemostasis,  apply  dressings,  and  defer  further 
proceedings  for  a  few  days.  If  the  tumor  cannot  be  removed,  the  mere  opening 
of  the  skull  often  relieves  distressing  symptoms,  e.g.,  agonizing  headache. 

Step  2. — Examine  the  exposed  cranial  contents  both  by  inspection  and 
palpation.  In  cases  of  tumor  and  blood-clot  it  is  usual  to  notice  an  absence  of 
cerebral  pulsation  and  the  dura  often  bulges  into  the  trephine  opening.  By 
palpation  tumors  have  been  correctly  located  at  a  depth  of  one  inch  from  the 
surface.  Fig.  23  shows  the  appearance  of  a  subcortical  gliosarcoma  in  the  arm 
centre,  before  and  after  incision  of  the  meninges.  Having  recognized  and  de- 
termined the  superficial  boundaries  of  the  growth,  reflect  the  dura  mater  as  a 
U-shaped  flap.  If  the  dura  is  involved  in  the  growth,  part  of  it  must  be  sacri- 
ficed. When  encapsulated,  the  tumor  itself  is  removed  by  careful  dissection 
with  blunt  instruments;  a  plain  silver  teaspoon  is  very  useful  for  this  purpose. 
Infiltrating  tumors  are  unsuited  for  operation.  Hemorrhage  is  arrested  by 
gentle  ligation  of  vessels  when  this  is  possible;  by  the  application  of  gauze  pads 
wrung  out  of  hot  water  and  by  packing  with  iodoform  gauze.  The  cavity  left 
in  the  brain  may  require  drainage  by  means  of  gauze,  but  the  brain  soon  ex- 
pands and  fills  up  the  space.  After  the  active  operation  is  completed,  close  the 
wound  in  the  dura  and  scalp,  leaving  of  course,  an  opening  for  the  emergence  of 
the  gauze.  If  the  skull  has  been  opened  by  the  trap-door  method,  enough  bone 
must  be  removed  from  the  flap  to  permit  of  proper  drainage.  When  a  portion 
of  the  dura  mater  has  been  excised,  it  is  well  to  protect  the  brain  by  the  applica- 
tion of  a  layer  of  rubber  tissue  or  celluloid.  This  measure  is  only  feasible  if 
drainage  is  not  required.  If  the  tumor  is  cystic,  drainage  of  the  cyst  is  often 
recommended  as  sufficient,  but  in  the  author's  experience  this  has  proved  futile, 
and  he  has  been  compelled  to  operate  again  and  remove  the  cyst-walls. 

Hemorrhage  and  shock  are  not  the  only  dangers  to  be  feared  in  cranial 
operations.  It  is  well  known  that  when  the  ventricles  have  been  opened  a 
dangerous  condition  of  hyperpyrexia  may  develop.  (Bergmann,  de  Verco, 
Parry  Davenport:  quoted  by  A.  Broca,  "Precis  de  Chirurgie  Cerebrale,"  p. 
323.)  Sir  Victor  Horsley  is  of  the  opinion  that  a  thermo-taxic  centre  exists  in 
the  cortex  and  that  w^hen  this  centre  is  injured  a  condition  of  hyperpyrexia  pre- 
vails independently  of  any  injury  to  the  ventricles.  One  case  seen  by  the  author, 
in  which  the  skull  was  opened  with  chisel  and  mallet  but  the  dura  was  undis- 
turbed, died  in  a  state  of  marked  hyperpyrexia  before  sufficient  time  had  elapsed 
for  septic  changes  to  have  developed.  Another  case  reported  to  the  author  by 
H.  E.  Pearse  supports  Horsley's  contention.  This  case  was  one  of  depressed 
fracture.  At  the  operation  a  rubber  drainage-tube  was  inserted.  Immediately 
the  temperature  rose  to  a  high  degree.  The  dressings  were  removed  and  the 
drain  was  found  to  have  slipped  between  the  skull  and  brain.  On  removal 
of  the  drain  the  temperature  returned  to  normal  and  the  patient  made  an 
uninterrupted  recovery. 

DECOMPRESSIVE   OPERATIONS   ON   CRANIUM 

Macewen,  Horsley  and  others  have  found  much  good  follow  exploratory 
opening  of  the  cranium  in  cases  where  tumor  was  present  but  could  not  be 


DECOMPRESSION  ^5 

removed.  The  opening  in  the  skull  permits  the  tumor  to  grow  without  exercis- 
ing so  much  pressure  on  the  cranial  contents.  Under  such  circumstances  the 
non-elastic  dura  is  capable  of  keeping  up  injurious  pressure,  hence  when  de- 
compression is  desired  the  dura  should  be  incised  or  a  portion  of  it  be  excised. 

Operations  of  the  class  referred  to  are  known  as  "decompressive  operations." 

Whenever  feasible,  tumors  of  the  brain  should  be  removed,  but  frequently 
it  is  impossible  to  find  the  location  of  the  tumor  or  to  remove  the  tumor  if  its 
precise  situation  is  known.  Under  the  above  circumstances  a  decompressive 
operation  at  the  site  of  election  is  indicated  not  as  treatment  of  the  tumor  but 
as  treatment  of  the  distressing  symptoms,  vomiting,  headache,  choked  disc,  etc. 

If  the  tumor  is  believed  to  be  in  the  cerebrum,  Harvey  Gushing  has  shown 
that  it  is  advantageous  to  open  the  skull  under  the  temporal  muscle.  In  this 
situation  the  bone  is  thin  and  non-vascular,  while  the  temporal  muscle  and 
fascia,  if  properly  preserved,  form  an  efficient  covering  for  the  brain  and  pre- 
vent an  undue  hernial  protrusion  in  case  there  is  a  great  increase  of  intracranial 
tension.  If  the  tumor  is  below  the  tentorium  cerebelli  the  skull  may  be  opened 
through  the  occipital  bone. 

Method  A. — Cushing's  Subtemporal  Decompression  Operation. 

Step  I. — From  a  point  immediately  in  front  of  the  attachment  of  the  ear 
make  an  incision  upwards  and  slightly  backwards  for  about  three  inches  (Fig. 
24).  Do  not  employ  a  curvilinear  incision  in 
the  scalp.  The  cut  penetrates  the  skin  and 
galea  but  not  the  temporal  fascia.  While  making 
the  incision  the  surgeon  controls  bleeding  from 
one  side  of  the  wound  by  pressing  the  scalp 
against  the  skull,  the  assistant  exercising  similar 
pressure  on  the  other  side,  and  at  the  same 
time  controlling  the  temporal  artery  by  pressure 
with  one  finger. 

Before    releasing    the   finger  pressure,    clamp 
the   galea  with  hemostats  about  3^^  inch  apart.  I 

When  these  hemostats  are  laid  flat  on  the  scalp 
the  galea  will  cover  the  edge  of  the  skin  wound,  and  control  bleeding  (Fig.  25). 

Step  2. — Cut  through  the  temporal  fascia  and  muscle  to  the  bone.  At  the 
upper  end  of  the  incision  never  separate  the  fascia  from  its  bony  attachments. 
If  there  is  bleeding  from  the  lower  end  of  the  wound  pack  a  strip  of  gauze 
between  the  muscle  and  bone. 

Step  3. — Free  the  muscle  from  the  squamous  portion  of  the  temporal  bone 
over  an  area  about  3  inches  in  diameter.  To  gain  access  to  the  denuded  area 
Gushing  raises  and  retracts  the  soft  parts  by  double  angled  retractors. 

Step  4. — Penetrate  the  skull  by  means  of  a  suitable  burr.  Separate  the 
dura  from  the  bone.  Do  this  with  particular  care,  downwards  and  forwards 
because  of  the  middle  meningeal  vessels.  If  the  operation  is  performed  for 
purposes  of  drainage  as  in  fracture,  a  small  opening  suffices,  if  for  decompression 
as  in  cerebral  tumor,  the  opening  must  be  as  large  as  the  temporal  muscle 
permits. 

Step   5. — The  large  cortical  vessels  are  visible  through  the  dura.     Gut 


26 


THE    SKULL    AND    THE    BRAIN 


through  the  dura  at  a  spot  free  from  these  vessels  but  do  not  injure  the  pia- 
arachpoid.  Enlarge  the  opening  by  cutting  on  a  grooved  director.  In  case 
of  a  fracture  explore  toward  the  base  beneath  the  temporal  lobe  and  remove 
clots,  etc.  The  object  of  the  operation  in  tumor  cases  is  to  relieve  tension  and 
preserve  vision  when  the  growth  is  unlocalizable  or  irremovable.  If  a  tumor 
is  unexpectedly  encountered,  unless  a  cyst  which  may  be  emptied,  it  should  be 
left  in  situ  until  later  when  an  osteoplastic  procedure  can  be  carried  out  to 
expose  it,  temporar}-  dependence  being  placed  on  the  relief  of  tension  to  ameli- 
orate symptoms. 


iriG. 


■{Cushing  Manual  .\curo.  :>ur^.  Med.  Depart.,  U.  i>.  A.) 


Step  6. — Close  the  temporal  muscle  with  interrupted  sutures  of  fine  silk 
(Gushing).  In  the  same  way  close  the  temporal  fascia.  These  two  structures 
will  prevent  undue  cerebral  herniation. 

Step  7. — Suture  the  galea  very  carefully,  the  stitches  being  placed  fairly 
close  together  and  cut  close  to  the  knot. 

Step  8. — Introduce  fine  silk  skin  sutures  on  straight  seamstress  needles, 
leaving  the  needles  in  situ  until  the  last  one  is  in  place.  This  everts  the  skin 
margin  and  brings  a  broad  area  of  the  cut  surface  into  approximation.  The 
skin  sutures  may  be  removed  in  48  hours. 

William  Sharpe  (Am.  Journ.  Med.  Sc,  June,  1916)  advised  unilateral  or 
even  bilateral  subtemporal  decompression  in  cases  of  'Steeple  Skull'  (Thurm- 
schadel)  or  oxycephaly  ic  which  there  is  optic  atrophy  beginning  from  intra- 
cranial pressure.  The  cranial  deformity  consists  essentially  of  a  ver\-  high 
forehead  towering  over  the  face,  of  poorly  marked  supracilian*"  and  temporal 
ridges  and  in  severe  cases  of  a  protrusion  at  the  anterior  fontanelle.     There  is 


EXPOSURE    OF    CEREBELLUM 


27 


Fig.   26. — Showing  outrigger   for  head   and  adjustable  shoulder  supports:  before   padding: 
also  hoop  to  support  sheets.     (Cushing,  "Tumors  of  Nervus  Acusticus.") 


Fig.  2: 


-Patient  in  position  before    anesthetization. 
Acusticus.") 


(Cushing,  "Tumors  of  Nervus 


28  THE    SKULL    AND    THE    URAIX 

present  exophthalmos,  divergent  (rarely  convergent)  strabismus  and  impair- 
ment of  vision.  Without  operation,  once  symptoms  have  arisen  they  tend  to 
progress  and  few,  if  any,  of  the  patients  reach  maturity.  The  few  cases  reported 
by  Sharpe  are  encouraging. 

Bilateral  Exposure  of  the  Cerebellum.  (Gushing.  Tumors  of  the  Nervus 
Acusticus,  1917.) — This  operation  may  be  used  as  a  means  of  decompression 
in  cases  of  unlocalized  subtentorial  lesions  or  for  the  exposure  and  removal  of 
tumors  of  the  cerebellum  or  of  the  acoustic  nerve.  In  Cushing's  hands  the 
operation,  when  it  includes  the  removal  of  a  tumor^  may  be  extremely  long 
(three  hours  or  more)  but  reasonably  safe,  the  operative  mortality  in  the 
acoustic  cases  having  fallen  to  about  11  per  cent.,  whereas  it  was  formerly  over 
50  per  cent. 

Preparation  oj  Patient. — Omit  breakfast.  Give  an  enema  if  necessary. 
Shave  the  back  of  the  head  (Fig.  27)  on  the  mornmg  of  the  operation. 

The  operating  table  is  shown  in  (Figs,  26-27).  The  patient  lies  prone 
on  a  thick  mattress.  The  shoulders  are  supported  on  well-padded  crutches, 
the  forehead  is  carried  by  a  padded  outrigger. 

The  anesthetic,  ether,  is  administered  by  means  of  Connell's  apparatus. 

Preparation  of  the  Field. — Wash  with  green  soap  on  a  gauze  sponge.  Wash 
with  alcohol  and  then  with  bichloride  solution  as  the  patient  is  getting  well  under 
the  anesthetic.  Mark  the  proposed  lines  of  incision  by  a  knife  scratch.  The 
transverse  curvilinear  incision  runs  from  mastoid  to  mastoid  arching  about 
4  cm.  (13^^  inches)  above  the  occipital  protuberance.  The  vertical  incision 
runs  downwards  9  or  10  cm.  (33^^  inches)  exactly  in  the  middle  line. 

Cover  the  whole  field  with  a  large  layer  of  bichloride  gauze.  Drape  every- 
thing, except  the  exact  field  of  operation,  with  sheets  which  form  a  tent  for 
the  anesthetist.  Sheets  should  be  pinned  or  clipped  to  the  skin  around  the 
field  of  operation.  No  towel  should  slip  or  be  changed  during  the  operation, 
hence  the  importance  of  marking  the  proposed  lines  of  incision  prior  to  draping 
and  hiding  anatomical  landmarks. 

Step  I. — With  finger  pressure  control  hemorrhage  while  making  the  curvi- 
linear incision  which  divides  the  scalp  and  galea  (epicranial  aponeurosis). 
Before  releasing  the  finger  pressure,  pick  up  the  galea  and  the  principal  sub- 
occipital vessels  with  hemostats.  Lay  the  hemostats  flat  on  the  skin,  thus 
folding  the  galea  over  the  edge  of  the  scalp  wound  (Fig.  28)  and  so  preventing 
subsequent  bleeding.  Reflect  the  curved  flap  downwards  to  slightly  below 
the  occipital  protuberance  and  the  muscular  attachment  of  the  superior  curved 
line.  Make  the  vertical  incision  (Fig.  29)  exactly  in  the  midline  through  the 
intermuscular  spaces  to  the  skull  and  the  spines  of  the  upper  vertebrae.  Apply 
clamps  symmetrically  on  the  two  sides  as  guides  for  future  closure.  The  ver- 
tical incision  shows  the  exact  level  at  which  the  transverse  cut  should  be  made 
along  the  line  of  muscular  attachment.  Apply  a  distinctive  forceps  on  each 
side  to  the  two  upper  edges  of  the  vertical  incision  in  the  fascia  (Fig.  29). 
Divide  the  fascia  along  the  superior  curved  line  and  reflect  it  downwards. 
Treat  the  muscle  similarly.  Leave  enough  of  the  fascia  and  muscle  attached 
to  the  bone  to  serve  for  subsequent  suture.  With  an  elevator  separate  the 
muscle  from  the  bone  on  each  side  far  enough  to  expose  the  margin  of  the  fora- 


EXPOSURE    OF   CEREBELLUM 


29 


men  magnum,  the  edge  of  each  mastoid  and  well  down  under  the  occipital 
bone  on  either  side.  Bleeding  from  emissary  vessels  may  be  controlled  by 
plugging  with  Horsley's  wax  or  a  fragment  of  muscle.  With  a  burr  open  the 
skull.  Enlarge  the  openings  with  rongeurs  (Fig.  30)  to  the  full  extent  of  the 
denuded  area.     The  lower  margin  of  each  lateral  sinus  is  usually  exposed. 


3B«pa»Wfcf)W^«i»  II    I    111  ■■ 


Fig.  28. — Showing  control  of  incision  for  completion  of  incision.     (Gushing,  "Tumors  of 

Nervus  Acusticus.") 


Bone  wax  may  occasionally  be  required  to  stop  bleeding.  Often  it  must  be 
applied  after  each  bite  of  the  forceps  during  the  removal  of  the  thicker  bone 
in  the  mid-line. 

Opening  of  the  Dura. — Should  an  opening  be  made  over  one  of  the  hemi- 
spheres the  cortex  would  protrude  and  be  damaged  because  of  increased  intra- 


30 


THE    SKULL    AND    TilK    BRAIN 


dural  Icnsion.  To  avoid  this  make  a  niiiuilc  opening  through  the  dura  near 
the  foramen  magnum  so  as  to  withdraw  iluid  from  the  posterior  cistern.  If 
this  fails  to  lessen  tension  do  not  enlarge  the  opening  but  at  once  tap  the  lateral 
ventricle.  To  do  this  retract  the  scalp  in  the  subaponeurotic  layer  and  burr  a 
hole  through  the  skull  about  3-4  cm.  {iji  inches)  above  the  superior  curved 


Fig.  29. — Mid-cervical  incision  carried  to  spine.     Placement  of  identifying  clamps  on  corners 
before  lateral  incisions  are  made  through.     {Gushing,  "Tumors  of  Nervus  Acusticus.") 

line  and  2  cm.  {%  inch)  from  the  midline.  Through  this  hole  pass  a  blunt 
cerebral  aspirating  needle  slightly  upward  and  outward  to  a  depth  of  4-5  cm. 
(i%-2  inches).  Usually  the  first  tap  succeeds.  Leave  the  needle  in  place 
during  the  rest  of  the  exploration. 

It  is  now  safe  to  open  the  dura.     "Care  must  be  taken  in  crossing  the 
median  line,  for  the  sagittal  cerebellar  sinus  may  be  of  considerable  size  and 


EXPOSURE    OF    CEREBELLUM 


31 


the  cerebellar  falx  may  penetrale  in  some  cases  for  a  considerable  distance.  As 
the  midline  is  crossed  the  cerebellum  should  be  held  away  with  a  spoon  spatula, 
and  the  sinus  may  be  caught,  before  division,  with  silver  clips.  Stellate  inci- 
sions of  the  membrane  to  the  margin  of  the  bone  defect  are  then  made  and  the 
hemispheres  fully  exposed." 


11 


{'     4 


Fig.  30. — Showing  denudation  of  suboccipital  region:  exposure  of  foraminal  field  by  reflection 
of  flaps:  primary  bone  openings.     {Cushing,  "Tumors  of  Nervus  Acusticus.") 


When  decompression  is  alone  the  object  sought,  the  wound  may  now  be 
closed.  If  there  is  any  doubt  of  the  diagnosis,  compare  the  two  hemispheres 
for  dijBferences  of  tension,  of  form,  or  of  vascularity.  "An  intracerebellar  cyst 
can  usually  be  detected  by  palpation;  an  involvement  of  one  hemisphere  rather 
than  the  other  by  displacement  of  midline  structures."  If  it  is  believed  that  a 
cerebello-pontile  angle  lesion  is  present,  slight  pressure  with  a  spoon  spatula 


32 


THE    SKULL    AND    THE    BRAIN 


on  the  cerebellar  hemisphere  (Fig.  31)   gives  access  to  the  region,  provided 
that  the  margin  of  the  mastoid  has  been  included  in  the  cranial  defect. 

The  sigmoid  sinus  is  first  brought  into  view  and  at  a  varying  distance 
beyond  it,  the  arachnoid  attachment  or  an  encysted  collection  of  fluid  within 
the  arachnoid,  is  ecountered.     On  opening  the  cyst  the  surface  of  the  tumor 


IlG.  31. — Showing  exposure  of  encysted  fluid  within  the  arachnoid  overl\-ing  a  tumor,  from  a 
sketch  during  operation.     {Gushing,  "Tumors  of  Nervus  Acusticus.") 


will  usually  be  seen.  The  best  line  of  approach  is  toward  the  jugular  foramen 
rather  than  directly  toward  the  porus.  With  wet  cotton  pledgets  wipe  the 
arachnoid  and  the  margin  of  the  cerebellum  from  the  tumor.  The  cerebellum 
must  be  protected  continuously  by  a  covering  of  wet  cotton.  Do  not  endeavor 
to  extirpate  the  tumor,  incise  it  bluntly  and  enucleate  as  much  els  possible  intra- 
capsularly  with  a  spoon  like  a  gall-stone  scoop.     If  there  is  much  bleeding 


CALLOSAL    PUNCTURE  ^^ 

insert  pledgets  of  cotton  wet  with  Zenker's  solution.  When  the  deep  cavity 
is  absolutely  dry,  allow  the  dislocated  cerebellar  lobe  to  settle  back,  in  place. 

Closure  of  the  Wound. — Close  the  vertical  wound  accurately  with  many 
interrupted  sutures  of  fine  silk.  The  four  guiding  clamps  apj)lied  early  in  the 
operation  aid  much  in  assuring  accuracy.  This  closure  is  made  in  several 
layers.  Close  the  transverse  wound  by  suturing  the  muscle,  the  fascia,  the 
galea  and  the  skin  each  separately.  Apply  temporary  dressings  and  leave  the 
patient  on  the  table  until  conscious.  Then  put  on  voluminous  dressings  held 
in  place  by  a  starch  bandage  (wet  crinoline  bandage).  Leave  the  dressing  in 
place  about  lo  days. 

Anton  suggested  that  in  cases  of  inoperable  or  unlocalized  brain  lesions 
(tumors,  internal  hydrocephalus,  etc.)  intracranial  pressure  might  be  lowered 
by  perforating  the  corpus  callosum,  whereby  a  free  communication  would  be 
established  between  the  ventricles  and  the  subdural  space.  If  the  intra- 
ventricular pressure  is  above  normal  the  fluid  must  flow  out  into  the  subdural 
space  and  in  doing  so  keep  the  perforation  patent.  Experiments  made  by 
Rehn  show  that  such  a  flow  does  take  place.  The  anterior  and  middle  thirds 
of  the  corpus  callosum  form  the  best  site  for  puncture  as  it  is  thinnest  here 
and  one  or  other  of  the  lateral  ventricles  is  sure  to  be  penetrated.  A  careful 
study  of  callosal  puncture  has  been  made  by  v.  Bramann  ("Archiv  fur  klin. 
Chir.,"  xc,  68g),  who  operates    in  the  following  manner: 

1.  Choose  a  spot  about  one  finger-breadth  behind  the  bregma  (i  to  i}^  cm, 
behind  the  coronary  suture)  and  expose  the  skull  here  by  any  suitable  incision. 

2.  With  a  bur  make  an  opening  i  cm.  by  i}'2  to  2  cm.  through  the  skull 
at  right  angles  to  the  sagittal  suture. 

3.  Note  the  longitudinal  sinus  and  at  its  margin  make  a  small  opening 
through  the  dura  mater. 

4.  Pass  a  sinus  forceps  (v.  Bramann  uses  a  special  pliable  silver  cannula  with 
a  mandrin)  alongside  the  sinus  into  the  longitudinal  fissure  where  it  meets  the 
falx.  Guided  by  the  falx,  pass  the  instrument  vertically  downwards  until  it 
penetrates  the  corpus  callosum. 

5.  Open  the  blades  of  the  forceps  (or  remove  the  mandrin  from  the  cannula) 
and  permit  the  ventricular  fluid  to  escape.  Enlarge  the  callosal  opening  by 
moving  the  instrument  gently  backwards  and  forwards  (not  laterally). 

6.  Remove  the  instrument  and  close  the  wound  in  the  scalp. 

V.  Bramann  has  performed  callosal  puncture  in  twenty-two  patients  without 
a  death  attributed  to  the  operation  (cerebral  tumors  thirteen;  hydrocephalus 
eight;  epilepsy  one). 

Anton  and  v.  Bramann  believe  callosal  puncture  indicated:  i.  In  all  cases  of 
hydrocephalus  where  internal  treatment  has  failed. 

2.  In  all  cases  of  tumors  and  pseudo  tumors  of  the  brain  accompanied  by 
internal  hydrocephalus  and  choked  disc  which  threatens  blindness. 

3.  When  intracranial  pressure  is  so  great  as  to  interfere  with  palpation 
of  the  brain  or  with  the  removal  of  tumors,  preliminary  callosal  puncture  may 
aid. 


34  THE  SKULL  AND  THE  BRAIN 

OPERATIONS    FOR    INFECTIVE    DISEASE   OF   THE  MIDDLE  EAR 
AND   CRANIAL   CONTENTS 

Cerebral  abscess  is  almost  always  the  result  of  chronic  otitis  media.  Proper 
treatment  of  the  cerebral  abscess  requires  removal  of  the  original  focus  of  dis- 
ease. In  the  following  pages  the  author  makes  free  use  of  Macewen's  classical 
work  on  the  "Pyogenic  Infective  Diseases  of  the  Brain  and  Spinal  Cord."  The 
reader  is  advised  to  carefully  study  the  above  book  before  attempting  any 
operation  for  cerebral  abscess.  The  present  chapter  is  only  written  in  the  hope 
of  aiding  some  parctitioner  who  is  forced  to  operate  without  the  advantage  of 
such  study. 

Suppurative  disease  of  the  middle  ear  unrelieved  by  treatment  administered 
through  the  external  meatus  is  always  complicated  by  disease  of  the  mastoid. 
The  chief  indications  demanding  operation  on  the  mastoid  cells  are: 

1.  Repeated  inflammations  of  the  mastoid  antrum  and  cells  with  swelling 
over  or  fistulae  leading  into  the  bone. 

2.  Acute  inflammation  with  retention  of  pus  in  the  antrum  or  cells. 

3.  The  occurrence  of  initial  symptoms  of  intracranial  involvement  asso- 
ciated with  chronic  purulent  otorrhoea. 

4.  Persistent  chronic  otorrhoea,  not  principally  due  to  the  condition  of  the 
tympanum  or  Eustachian  tube,  and  which  is  considered  by  the  aurist  otherwise 
incurable,  even  although  there  are  no  clear  indications  of  mastoid  involvement. 

5.  If  the  discharge  contain  virulent  organisms,  if  it  be  highly  offensive,  mixed 
with  osseous  debris  or  cholesteatomatous  masses,  operation  is  indicated,  as 
most  serious  intracranial  mischief  is  often  present  without  marked  mastoid 
swelling. 

The  Operation. — I.  Cleanse  the  external  and  middle  ear  as  thoroughly  as 
possible.     Shave  the  scalp  above  and  behind  the  mastoid.     Cleanse  the  skin. 

Step  I. — Place  the  patient  on  his  side  with  the  affected  mastoid  uppermost. 
Have  the  parts  well  lighted.  Pull  forward  the  external  ear.  Palpate  the  mas- 
toid and  the  posterior  root  of  the  zygoma.  Make  a  perpendicular  cut  about 
one-quarter  inch  behind  the  posterior  border  of  the  external  bony  meatus  from 
the  posterior  root  of  the  zygoma  to  a  point  about  one-third  of  an  inch  from  the 
tip  of  the  mastoid.  The  knife  penetrates  to  the  bone.  With  the  elevator 
separate  the  periosteum  and  soft  structures  from  the  bone  in  front  of  the  cut 
and  thus  fully  expose  the  posterior  aspect  of  the  external  audority  meatus. 
Attend  to  hemostasis.  Hold  the  reflected  tissues  and  auricle  forward  with  a 
sharp  retractor. 

Step  2. — Observe  the  limits  of  the  suprameatal  triangle,  viz.,  the  posterior 
root  of  the  zygoma  above,  the  upper  and  posterior  segment  of  the  bony  external 
meatus  below,  and  an  imaginary  vertical  line  (EF,  Fig.  32),  extending  from  the 
most  posterior  portion  of  the  external  osseous  meatus  to  the  zygomatic  root, 
behind.  This  vertical  imaginary  line  is  the  base  of  the  triangle.  Observe 
the  degree  of  obliquity  of  the  posterior  wall  of  the  external  auditory  meatus  as  it 
leads  inwards  and  forwards  to  the  middle  ear.  By  the  aid  of  a  probe  observe 
the  depth  of  the  inner  wall  of  the  tympanic  cavity  from  the  level  of  the  skull. 

The  best  instrument  for  use  in  penetrating  the  bone  is  a  bur  rapidly  rotated 


EXPOSURE    OF   MASTOID    ANTRUM 


35 


by  a  surgical  engine.  One  may  conveniently  use  a  bur  operated  by  the  "  brace" 
shown  in  Fig.  13.  Apply  the  bur  to  the  bone  at  a  point  inside  and  beside  the 
base  of  the  suprameatal  triangle.  Penetrate  the  outer  shell  of  hard  bone.  In 
some  cases  the  whole  mastoid  is  thickened  and  sclerosed  by  disease.  With  the 
bur,  slowly  and  cautiously  advance  through  the  bone  in  a  direction  inwards  and 
a  little  forwards,  parallel  to  the  posterior  wall  of  the  external  auditory  meatus. 
Do  not  use  the  bur  as  if  it  were  a  drill,  making  a  uniform  cylindrical  perforation 
the  same  size  as  the  instrument;  this  would  be  dangerous  and  nearly  useless. 
Use  it  to  make  a  hole  in  the  mastoid  very  much  larger  than  the  instrument — 
large  enough  to  permit  of  the  continuance  of  the  work  under  the  guidance  of  the 
eye  as  well  as  of  touch.  The  external  opening  may  safely  be  made  the  whole 
size  of  the  suprameatal  triangle.     Whenever  a  dark  spot  is  seen  on  the  cut 


Fig.  32. — C,  F,  E  (X^     Suprameatal  or  Alacewen  s  triangle. 

A.  B.  Upper  two-thirds  of  this  line  overlies  the  sigmoid  sinus.     C,  D.  Overlies  sigmoid  sinus 
from   knee   to   commencement. 

surface  of  bone,  examine  it  at  once  with  a  fine  probe  or  searcher  (a  dental  probe 
is  good).  The  dark  spot  is  probably  an  opening  into  one  of  the  mastoid  cells 
or  even  the  antrum;  if  the  latter,  the  probe  will  find  a  large  cavity  communicat- 
ing with  the  middle  ear.  The  depth  of  the  antrum  from  the  surface  varies  from 
/'i  to  ^  inch.  A  small  opening  having  been  made  in  the  antrum  and  its 
cavity  explored  with  a  probe,  bur  away  all  its  external  wall,  remove  all  pus, 
granulation  tissue,  or  other  disease  products. 

II.  Observe  the  position  of  the  opening  between  the  antrum  and  the  middle 
ear,  the  position  of  the  facial  nerve  traversing  the  inner  half  of  the  floor  of  the 
antral  passage  obliquely  from  without  inwards,  as  it  passes  into  the  inner  wall 
and  roof  of  the  tympanum  above  the  foramen  ovale.  The  nerve  route  is  often 
indicated  by  a  cylindrical  ridge  of  bone  smoother  and  denser  than  that  in  the 
neighborhood.  If  the  position  of  the  nerve  is  not  positively  made  out,  have 
an  assistant  observe  the  patient's  face  for  the  occurrence  of  twitchings  if  the 
nerve  is  endangered  in  the  subsequent  proceedings.  In  observing  the  condition 
of  the  tissues  deep  down  in  the  wound  light  should  be  thrown  in,  either  by  means 


36  THE    SKULL   AND   THE    BRAIN 

of  a  head  mirror  or  of  an  electric  lamp  (with  reflector)  held  by  an  aid.  Ex- 
amine the  roof  of  the  antrum  for  evidences  of  bone  disease.  If  buds  of  granu- 
lation tissue  sprout  from  the  roof,  examine  them;  they  may  come  from  inside 
the  skull  and  show  the  presence  and  location  of  intracranial  involvement. 

Step  3. — Examine  the  mastoid  cells  opened  during  exposure  of  the  antrum; 
if  they  are  diseased,  as  evidenced  by  the  presence  of  granulation  tissue,  pus.  etc., 
destroy  their  walls  wuth  the  bur,  so  that  instead  of  numerous,  irregular,  small 
cells,  one  large  cavity  with  smooth  walls  is  formed.  Remember  the  location  of 
the  sigmoid  groove  and  sinus  (Figs.  32  and  34).  Because  of  the  sinus  it  is  wise 
to  open  the  mastoid  cells  by  working  from  the  antrum  downwards  and  back- 
wards. Never  attack  an  exposed  cell  before  thoroughly  exploring  it  with  a 
probe.  Remember  that  granulation  tissue  and  other  disease  products  may  be 
continuous  from  the  middle  ear  through  the  antrum,  mastoid  cells,  sigmoid 
groove,  and  sinus  to  the  cerebellum.  If  granulations  are  found  sprouting  out 
from  the  sigmoid  groove  or  other  evidences  show  disease  in  that  locality,  do  not 
yet  attack  it.  Complete  the  thorough  cleansing  of  the  antrum  and  mastoid, 
bur  away  all  partitions,  and  leave  them  as  one  cavity  with  smooth  walls. 

Step  4. — The  middle  ear  is  diseased  and  requires  to  be  opened.  Apply  a 
small  bur  at  the  junction  of  its  roof  with  the  outer  wall  of  the  antral  passage. 
Do  7iot  touch  the  floor  or  inner  wall  of  the  passage  for  fear  of  injury  to  the  facial 
nerve  or  semicircular  canal.  Freely  expose  the  tympanic  attic  and  examine  its 
roof  in  the  same  way  as  the  roof  of  the  antrum  was  examined.  Examine  the 
malleus  and  incus ;  if  diseased,  remove  them.  It  is  important  to  leave  the  stapes, 
if  possible;  but  if  diseased,  it  also  must  be  removed.  If  the  mastoid  antrum, 
and  middle  ear  are  the  only  seats  of  disease,  the  active  operation  is  ended;  the 
cavity  is  packed  with  iodoform  and  boracic  acid  (1:4)  and  with  iodoform  gauze. 
Closure  of  the  wound  is  facilitated  by  removal  of  a  portion  of  the  posterior 
bony  wall  of  the  external  auditory  meatus.     Dressings  are  applied. 

Step  5. — If  on  examination  of  the  roof  of  the  antrum  or  tympanic  cavity 
erosions  of  the  bone  exist  and  granulations  sprout  out  from  the  cranial  cavity, 
or  if  there  are  symptoms  of  intracranial  involvement,  active  operation  is  con- 
tinued. With  the  bur  remove  the  eroded  bone  of  the  antral  or  tympanic  roof  in 
a  direction  outwards  from  the  perforation.  If  pus  and  granulation  tissue  pre- 
sent, there  is  an  extradural  focus  which  must  be  carefully  cleansed.  Do  not 
inject  any  fluids  until  the  whole  space  between  the  dura  and  bone  has  been 
explored  and  the  presence  or  absence  of  openings  through  the  dura  made  certain. 
If  there  is  no  dural  opening,  gentle  washing  is  safe,  and  the  extradural  space 
may  be  dressed  with  iodoform  and  boracic  acid  and  iodoform  gauze.  If  there 
is  evidence  of  disease  under  the  dura,  clean  the  extradural  space  and  freely 
open  the  dura. 

Step  6. — Pus  in  the  arachnoid  or  pia  or  on  the  surface  of  the  brain  must  be 
gently  washed  away,  and  iodoform  and  boracic  acid  powder  must  be  applied. 
If  an  abscess  exists  in  the  temporo-sphenoidal  lobe,  enlarge  the  opening  through 
the  roof  of  the  antrum  and  tympanic  cavity,  apply  iodoform  and  boracic  acid 
to  the  wound,  and  proceed  to  Step  7. 

Step  7. — Extend  the  cut  through  the  soft  parts  upwards  and  expose  the 
skull  above  the  ear.     Open  the  skull  with  a  small  trephine  whose  centre  pin  is 


INFECTIONS    OF    MASTOID  37 

applied  at  a  point  three-fourths  of  an  inch  above  the  posterior  root  of  the  zygoma 
and  in  line  with  the  posterior  osseous  wall  of  the  external  auditory  meatus. 
Rub  iodoform  into  the  cut  surface  of  the  bone.  Incise  the  dura.  If  necessary, 
make  a  crucial  incision.  Stop  bleeding.  If  the  abscess  is  large,  the  brain  will 
probably  bulge  and  fail  to  pulsate;  if  smaller,  neither  of  these  signs  may  be 
present.  To  explore  for  pus  use  a  trocar  and  cannula  or  a  sinus  forceps.  A 
hollow  needle  is  liable  to  become  plugged.  Introduce  the  instruments  inwards, 
downwards,  and  slightly  forwards,  so  as  to  impinge,  if  pushed  far  enough,  against 
the  cranial  aspect  of  the  roof  of  the  tympanum.  If  a  trocar  and  cannula  are 
used,  the  trocar  should  be  removed  at  every  quarter  inch  of  progress  to  see  if  pus 
escapes;  if  a  sinus  forceps,  the  blades  should  be  slightly  opened  for  the  same 
purpose.  After  pus  is  found,  remember  that  the  abscess  probably  contains 
sloughs  and  shreds  of  tissue  too  large  to  escape  through  the  cannula  and  which 
must  be  removed.  Alongside  the  cannula  introduce  closed,  narrow-bladed 
hemostatic  or  sinus  forceps;  open  the  blades  gently  and  permit  the  sloughs  to 
flow  out  between  the  blades.  If  the  sloughs  cannot  escape  by  themselves,  they 
may  be  assisted  out  by  forceps  or  spoon;  their  removal  is  of  prime  importance. 
After  removal  of  the  sloughs  replace  the  hemostatic  forceps  by  a  small  cannula. 
Through  the  mastoid  wound  and  the  opening  through  the  antral  roof  introduce 
into  the  abscess  cavity  a  cannula  at  least  one-half  as  large  again  as  that  already 
in  situ.  Be  sure  that  the  end  of  this  tube  is  in  the  cavity.  It  is  wise  to  let  the 
two  cannulas  come  in  contact.  Gently  introduce  a  stream  of  hot  water  or  mild 
antiseptic  solution  through  the  smaller  tube  and  see  that  it  all  escapes  through 
the  larger.  Lest  fluid  should  enter  the  Eustachian  tube,  fill  the  middle  ear  with 
the  iodoform  and  boracic  powder.  In  an  acute  abscess  which  has  been 
thoroughly  cleansed  of  infective  matter,  a  drainage-tube  is  of  little  value  and 
may  do  harm.  If  there  is  doubt  as  to  the  thoroughness  of  the  evacuation,  intro- 
duce a  decalcified  bone  drain  so  that  its  opening  is  just  within  the  abscess. 
Stitch  the  drain  to  the  skin.  If  the  abscess  cannot  be  properly  drained,  in  the 
above  manner,  use  a  rubber  or  glass  tube  for  from  twenty-four  to  forty-eight 
hours.  Treat  the  mastoid  opening  as  already  described.  Close  the  temporal 
opening  with  or  without  drainage  on  ordinary  surgical  principles. 

[If  abscess  of  the  temporo-sphenoidal  lobe  exists,  without  indication  of  dis- 
ease requiring  the  mastoid  to  be  opened,  the  operation  is  carried  out  practically 
as  described  in  Step  7;  but  in  washing  out  the  abscess  an  escape  for  the  fluid 
must  be  provided  by  means  of  a  cannula,  at  least  half  as  large  again  as  that 
through  which  it  enters.     The  two  cannulae  lie  side  by  side.] 

Step  8. — It  has  already  (Step  3)  been  shown  that  disease  of  the  sigmoid 
groove  may  be  discovered  while  the  mastoid  cells  are  being  obliterated. 
Examination  with  the  fine  probe  or  searcher  shows  that  buds  of  granulation 
tissue  coming  through  osseous  openings  are  continuous  with  the  same  tissue  in 
the  sigmoid  groove.  Apply  the  bur  to  the  posterior  wall  of  the  antrum  and 
with  it  remove  the  bone  horizontally  backwards  for  half  an  inch.  In  a  majority 
of  cases  this  will  open  the  greater  part  of  the  diameter  of  the  sigmoid  groove 
after  which  it  may  be  opened  above  and  below  that  point  as  may  be  indi- 
cated. The  anterior  knee  of  the  sinus  is  situated  from  one-eighth  to  a  quarter  of 
an  inch  behind  the  base  line  of  the  suprameatal  triangle  (Fig.  7,2).     If  it  seems 


38  THE  SKULL  AND  THE  BRAIN 

necessary  to  open  the  sigmoid  sinus  to  remove  septic  blood-clot,  fully  one  inch  of 
the  sinus  ought  to  be  exposed,  vertically,  by  removal  of  bone.  Remove  any 
diseased  tissue  lying  between  the  groove  and  the  sinus.  If,  on  examination  by 
the  eye  and  the  probe,  the  disease  is  found  to  extend  through  the  bone  into  the 
cerebellum,  this  disease  route  must  be  followed  and  cleansed  and  any  cerebellar 
abscess  attended  to  in  the  manner  to  be  described.  If  there  is  septic  sinus 
thrombosis,  open  the  sinus  and  remove  the  filth  within  it.  After  cleansing  the 
sinus,  introduce  into  it  a  quantity  of  iodoform  and  boracic  acid  powder,  make 
the  walls  of  the  sinus  collapse,  gently  pack  the  sigmoid  groove  with  the  same 
powder,  and  loosely  pack  the  whole  cavity  with  iodoform  gauze.  If  during  the 
operation  hemorrhage  take  place  from  a  non-thrombosed  sinus,  it  may  be 
stopped,  if  slight,  by  temporary  pressure;  if  more  severe,  by  separating  the  wall 
of  the  sinus  from  the  bone  and  pushing  the  loosened  wall  inwards  by  means  of 
iodoform  gauze  packing.  In  certain  cases  Horsley  has  found  it  valuable  to 
doubly  ligate  and  divide  the  internal  jugular  vein.  This  is  intended  to  prevent 
dissemination  of  the  infective  material  throughout  the  body. 

Step  9. — In  the  preceding  step  it  has  been  shown  how  extension  of  disease 
through  the  sigmoid  sinus  to  the  cerebellum  may  be  discovered.  If  this  is 
the  case,  the  disease  is  followed  and  the  bone  between  the  sigmoid  groove  (outer 
aspect  of  the  groove)  and  the  cerebellum  is  removed  by  the  bur.  The  mem- 
branes covering  the  cerebellum  are  treated  in  the  same  manner  as  were  those 
covering  the  temporo-sphenoidal  lobe.  If  a  cerebellar  abscess  exist,  enlarge- 
ment of  the  osseous  opening  already  made  permits  of  its  evacuation  and  treat- 
ment on  the  principles  already  described. 

After-treatment. — If  there  is  no  evidence  of  petrous  or  internal  ear  disease, 
the  wounds  must  be  packed  with  iodoform  gauze  to  compel  healing  to  take  place 
from  the  bottom.  The  whole  cavity  ultimately  becomes  a  solid  mass  of  scar 
tissue.  In  the  presence  of  petrous  or  internal  ear  disease  a  seton  of  iodoform 
gauze  must  be  passed  from  the  middle  ear,  through  the  antrum  out  by  the  mas- 
toid opening.  This  gauze  seton  is  frequently  renewed  and  its  route  kept  clean, 
until  epithelium  from  the  mucous  membrane  and  the  skin  has  so  covered  the 
track  that  a  permanent  fistula  is  assured  through  which  any  discharge  from  the 
internal  ear  or  petrous  bone  may  escape.  The  formation  of  the  permanent 
sinus  may  be  hastened  by  lining  it  with  skin  grafts. 

After  the  dressings  are  applied  put  the  patient  to  bed,  and  keep  him  there 
until  the  wounds  are  completely  healed.  A  low  liquid  diet  is  recommended  for 
a  fortnight  after  cerebral  abscesses  have  been  evacuated.  The  only  peculiarity 
of  the  after-treatment  is  the  necessity  of  a  little  extra  insistence  on  quiet,  and  on 
the  observance  of  the  usual  rules  adopted  after  major  surgical  operations.  It 
is  well  to  have  the  room  darkened. 

Abscesses  in  other  localities  of  the  brain,  after  being  diagnosed  and  located, 
are  operated  upon  on  the  same  principles  as  have  been  described  in  the  pre- 
ceding pages. 

OPENING  THE  MASTOID  WITH  THE  CHISEL  AND  RONGEURS 

Undoubtedly  the  bur  operated  by  a  surgical  engine  is  the  most  elegant  instru- 
ment with  which  to  open  the  mastoid  antrum,  and  it  possesses  many  advan- 


OPENING    THE    MASTOID  39 

tages  over  the  chisel;  but  comparatively  few  surgeons  possess  the  necessary 
instruments  nor  are  they  convenient  to  carry  to  a  patient's  home  when  the 
patient  cannot  or  will  not  enter  a  hospital.  Most  surgeons  possess  some  dex- 
terity in  the  use  of  the  chisel  but  are  not  educated  to  the  bur,  hence  the 
chisel  and  its  relative,  the  rongeur  forceps,  are  the  instruments  commonly  used 
in  the  mastoid  operation. 

The  operation  often  ends  immediately  after  the  mastoid  antrum  is  opened. 
This  is  improper,  as  the  antrum  is  only  one  of  many  mastoid  spaces,  any  or  all 
of  which  may  be  diseased. 

Whiting  ("The  Modern  Mastoid  Operation"),  in  his  superbly  illustrated 
book,  shows  how  the  "air-cells"  may  extend  above  and  over  the  bony  meatus, 
and  unless  these  are  obliterated,  the  suppurative  process  is  sure  to  continue. 
The  principle  of  the  complete  operation  on  the  mastoid  is  the  obliteration  of  all 
the  mastoid  cells  and  the  removal  of  all  disease  wherever  situated,  as  described 
in  the  preceding  pages.  The  method  of  operating  usually  adopted  by  the 
author  is  much  as  follows: 

Clean  the  ear  as  well  as  possible.  Shave  and  clean  the  skin  over  and  around 
the  mastoid. 

Step  I. — ^Make  an  incision  parallel  to  the  insertion  of  the  auricle  and  about 
34  inch  posterior  to  the  external  auditory  meatus.  The  incision  stretches  from 
just  above  the  root  of  the  zygoma  to  a  little  below  the  tip  of  the  mastoid.  Ex- 
pose the  whole  surface  of  the  mastoid  by  reflecting  the  soft  parts  along  with 
the  periosteum.  A  second  incision  at  right  angles  to  the  first  may  be  necessary 
to  insure  exposure.  Examine  the  bone  for  points  of  necrosis  or  for  the  escape 
of  pus  at  the  vascular  orifices. 

It  is  especially  important  to  examine  the  mastoid  vein  at  its  outlet,  which  is 
usually  near  the  posterior  margin  of  the  bone.  The  vein  varies  in  size  and  may 
divide  into  several  branches  as  it  passes  through  the  skull.  As  the  vein  com- 
municates directly  with  the  sigmoid  sinus,  when  the  latter  is  thrombosed  the 
former  is  likely  to  be  in  the  same  state.  Thrombosis  of  the  mastoid  vein  is 
positive  evidence  of  sinus  thrombosis;  apparent  patency  of  the  vein  is  of  no  sig- 
nificance. Pus  oozing  from  the  mastoid  foramen  signifies  pus  situated  outside 
the  dura  in  the  cerebellar  fossa,  about  the  sigmoid  groove. 

Step  2. — Pull  the  external  ear  well  forwards  with  a  retractor.  Observe  the 
depth  and  direction  of  the  external  auditory  canal.  Beginning  at  the  upper  part 
of  the  suprameatal  triangle,  shave  off  thin  slices  of  bone  downwards  and  forwards 
towards  the  tip  of  the  mastoid,  always  hugging  the  posterior  margin  of  the  bony 
meatus.  This  shaving  is  to  be  done  with  a  chisel  or  gouge  about  34  inch  in 
width,  propelled  by  a  mallet.  The  chisel  must  be  held  almost  parallel  to  the 
surface  of  the  bone,  and  must  always  be  directed  downwards  and  forwards. 

The  usual  chisels  and  gouges  supplied  for  mastoid  work  are  short  and  have  thin  shanks 
and  handles.  Such  may  be  safe  and  convenient  in  the  hands  of  aurists,  but  to  the  general 
surgeon  a  chisel  with  a  handle  like  a  Macewen  osteotome,  or  even  a  carpenter's  tool,  is  much 
safer  and  more  practical.     It  is  well  to  have  a  number  of  chisels  or  gouges  of  different  sizes. 

After  several  exceedingly  thin  slices  of  bone  have  been  removed,  the  diploe 
will  be  reached,  unless  there  is  much  sclerosis. 


40  THE  SKULL  AND  THE  BRAIN 

With  a  narrow  curette  scrape  away  the  superficial  portion  of  the  diploe.  If 
pus  or  fluid  appears,  note  its  quantity,  as  this  gives  some  index  to  the  size  of  the 
cavity  from  which  it  comes;  note  also  if  the  pus  is  thrown  out  in  jets  or  pulsating 
fashion,  because  such  pulsation  is  communicated  from  the  brain  and  is  almost 
absolute  proof  that  the  disease  has  penetrated  at  least  to  the  meninges.  With  a 
probe  gently  explore  the  pus-cavity  and  enlarge  the  opening  with  curette,  gouge, 
or  rongeur,  as  may  be  convenient.  Never  endeavor  to  clean  out  a  pus-cavity 
in  the  mastoid  with  the  curette  through  a  narrow  external  opening — it  is  too 
dangerous.  If  no  pus  or  fluid  appears,  deepen  the  groove  already  cut  in  the 
bone  to  the  extent  of  3-3  inch.  If  the  sigmoid  sinus  is  abnormally  far  forwards, 
it  ought  now  to  be  visible  as  "a  soft,  bluish-looking  structure,  very  fluctuant  to 
palpation  and  perhaps  pulsating  demonstrably,  which 
upon  gentle  pressure  of  a  probe  yields  readily  but  does 
not  bleed"  (Whiting).  When  the  sinus  is  found  in  this 
abnormal  position,  the  rest  of  the  operation  consists  in 
exposing  all  the  diseased  cavities  and  evacuating  all 
infective  material,  without  injuring  the  sinus,  unless 
that  structure  is  involved  in  the  process.  When  the 
sinus  is  not  abnormally  placed,  proceed  with  the  re- 
moval of  all  the  outer  wall  of  the  mastoid  process. 

Step  3. — With  the  chisel  repeat  the  manoeuvres  by 
which  the  mastoid  was  originally  opened,  and  so  widen 
the  existing  opening  that  the  blade  of  a  rongeur  (Fig.  t,;^) 
can  easily  enter  it  and  pass  under  the  bone.  With  a 
rongeur  carefully  bite  away  the  whole  bony  outer  wall  of 
the  mastoid  process.  Never  attack  any  part  of  the  bone 
before  making  sure  that  the  sigmoid  sinus  will  not  be 
injured. 

Instead  of  widening  the  original  opening  in  the  bone 
with  the  chisel,  the  author  usually  inserts  into  it,  par- 
FiG.  Z2>. — Narrow-bladed  tially,  one  blade  of  a  heavy  rongeur,  the  other  blade  of 
rongeur  forceps.  ^^,j^.^j^  ^^^^^  against  the  mastoid  farther  back.  By  ex- 
erting a  twisting  force  it  is  easy  to  use  the  posterior  blade  of  the  forceps  as  a 
fulcrum,  and  with  the  anterior  blade  (the  blade  engaged  in  the  bony  opening) 
to  scrape  off  a  thin  layer  of  the  cortical  bone.  This  method  of  using  the  ron- 
geur is  difi&cult  to  describe,  easy  and  safe  to  practice,  and  aids  materially  in 
the  operation.  When  the  mastoid  has  once  been  opened  to  such  an  extent 
that  the  ronguer  can  be  used  efficiently,  either  as  a  biting  or  as  a  scraping  in- 
strument, put  the  chisel  and  mallet  aside  as  of  no  further  use.  If  much 
sclerosis  is  present,  this  rule  does  not  apply. 

Step  4. — No  attempt  has  been  made,  as  yet,  to  find  the  antrum  or  systemat- 
ically to  obliterate  the  mastoid  cells;  the  cortical  bone  has  been  removed,  at  least 
to  a  large  extent;  the  diploe  has  been  but  little  disturbed.  Remember  that  the 
antrum  in  99  per  cent,  of  cases  (Macewen)  lies  in  whole  or  in  part  within  the 
suprameatal  triangle;  that  in  the  adult  its  depth  beneath  the  cortical  bone  varies 
from  one-eighth  to  three-fourths  of  an  inch. 

With  a  probe,  once  more  observe  the  direction  and  depth  of  the  bony  meatus. 


INFECTIONS    OF    MASTOID 


41 


With  the  curette,  cautiously  remove  the  cancellous  bone  from  the  suprameatal 
triangle  in  a  direction  parallel  to  the  posterior  wall  of  the  bony  meatus.  This 
will  almost  inevitably  open  the  antrum.  If  the  bone  is  much  sclerosed,  a  small 
gouge  must  be  used  instead  of  the  curette.  Having  opened  the  antrum,  explore 
it  thoroughly  with  a  probe.  With  the  curette,  aided,  if  necessary,  by  rongeur 
forceps,  remove  all  the  external  wall  of  the  antrum.  In  the  same  manner 
remove  all  the  mastoid  air-spaces.  Every  step  in  the  removal  of  bone  must  be 
preceded  by  careful  examination  of  the  tissues  to  be  removed;  remember  par- 
ticularly the  normal  site  of  the  facial  nerve  (Fig.  34)  and  the  normal,  and 
particularly  the  abnormal,  course  of  the  sigmoid  sinus. 


Fig.  34. — ^Left  temporal  bone. 

Antrum  and  most  of  the  mastoid  cells  obliterated.     I.  Semicircular  canals.    2.  Location  of  facial  nerve 
in  aqueduct  of  Fallopius,  which  has  been  opened.     3.  Location  of  sigmoid  sinus. 


The  mastoid  has  now  been  converted  into  a  comparatively  shallow  pit. 
Examine  the  walls  of  the  pit  carefully  to  see  whether  the  disease  process  does  or 
does  not  penetrate  the  cranial  cavity.  If  the  disease  involves  the  sigmoid  sinus 
or  the  meninges  elsewhere,  it  must  be  attacked  according  to  the  principles 
already  enunciated. 

In  acute  mastoiditis,  after  the  antrum,  etc.,  have  been  cleaned  out,  the  in- 
flammation of  the  tympanum  will  promptly  recede;  hence  it  is  unnecessary  to  use 
the  curette  in  the  tympanic  cavity  (Whiting).  This  is  fortunate,  as  otherwise 
much  damage  to  hearing  might  easily  be  inflicted.  In  cases  of  chronic  mastoid- 
itis and  otitis  the  tympanum  must  be  thoroughly  opened  and  appropriately 
treated  along  the  lines  laid  down  on  page  36  et  seq. 

Step  5. — With  rongeur  forceps  and  curette  make  smooth  the  floor  and  sides 
of  the  bony  defect  Partially  close  the  wound  in  the  soft  parts  with  sutures. 
Pack  the  remainder  of  the  wound  with  iodoform  gauze.  It  is  comforting  to  the 
patient  to  have  the  gauze  separated  from  the  wound  by  a  layer  of  perforated 


42  THE  SKULL  AND  THE  BRAIN 

oiled  silk  or  rubber  tissue.  After  granulations  have  formed  along  the  course  of 
the  pack  they  may  be  covered  by  Thiersch's  skin-grafts.  This  is  usually  two 
or  three  weeks  after  the  operation. 

It  must  be  remembered  that  in  children  under  three  years  of  age  the  mastoid 
process  is  either  absent  or  its  presence  is  merely  indicated,  while  the  antrum  is  to 
be  sought  rather  higher  than  in  the  adult.  In  these  young  children  the  bone  is 
so  soft  that  the  antrum  may  be  opened  with  a  curette. 

In  cases  of  acute  (not  chronic)  mastoiditis  Stenger  makes  a  short  incision 
over  the  mastoid,  reflects  the  periosteum  and,  if  no  fistula  is  present,  chisels  or 
bores  a  narrow  passage  towards  the  antrum.  He  curettes  this  passage  (which 
need  not  penetrate  the  antrum)  or  the  fistula,  if  such  is  present,  and  loosely  packs 
with  gauze,  dries  the  surrounding  skin  and  applies  a  cupping  glass  provided 
with  some  form  of  pump  for  suction.  A  sterile  ointment  spread  on  the  skin 
makes  the  cupping  glass  act  better.  The  suction  is  kept  up  not  longer  than  three 
hours  at  a  time.  The  suction  causes  pain  while  it  acts,  but  the  relief  is  great 
during  the  intervals.  Stenger  and  Hasslauer  report  excellent  results  and  a 
shortening  of  convalescence.     ("Muenchner  med.  Wochensch.,"  Aug.  21,  1906.) 

The  use  of  suction  by  means  of  the  cup  undoubtedly  may  help  drainage,  but 
its  main  object  is  to  obtain  hyperemia  and  the  whole  procedure  is  based  on  the 
ideas  of  Bier. 


OPERATIVE  TREATMENT  OF  MENINGOCELE  AND 
ENCEPHALOCELE 

Operation  should  not  be  undertaken  in  cases  of  the  above  tumors  when  there 
are  serious  concomitant  malformations  or  when  it  is  believed  that  portions  of 
brain,  necessary  to  life,  are  present  in  the  growth.  Horsley  has  suggested  the 
application  of  the  induced  current  to  the  tumor  in  order  to  diagnose  if  impor- 
tant cerebral  tissue  is  involved.  Some  surgeons — e.g.,  Berger — believe,  and  act 
on  the  belief,  that  any  cerebral  material  present  in  a  meningocele  is  neoplastic 
in  nature  and  possesses  no  physiological  function  and  may  safely  be  disregarded. 
With  the  exceptions  mentioned  above,  Chipault  considers  all  cases  of  menin- 
gocele suitable  for  operation.  [Meningoceles  of  the  cranial  vault  are  alone 
referred  to  at  present.] 

The  Operation. — Trace  out  two  flaps  of  skin  alone,  over  the  tumor.  The 
base  of  each  flap  corresponds  to  the  pedicle  of  the  tumor.  Reflect  the  flaps. 
Expose  the  pedicle  of  the  tumor  at  its  exit  from  the  skull.  Transfix  the  pedicle, 
with  a  blunt  needle,  close  to  the  skull,  in  one  or  more  places,  and  apply  two  or 
more  interlocked  catgut  ligatures.  Tie  the  ligatures.  Cut  away  the  tumor 
distal  to  the  ligatures.  Replace  the  skin-flaps.  Suture.  Dress.  Instead  of 
ligating  the  pedicle  as  above  described,  it  is  better  to  open  and  explore  the  sac. 
If  brain  tissue  is  present,  looks  normal  in  character,  and  is  reducible  without 
giving  rise  to  symptoms  of  compression,  reduce  such  brain  tissue,  excise  the 
rest  of  the  tumor,  and  close  the  opening  in  the  cerebral  membranes  with  suture. 
If  no  brain  tissue  is  present,  excise  the  sac.  If  brain  tissue  is  present  but  is 
either  abnormal  in  appearance  or  irreducible,  it  must  be  excised.     From  the 


HYDROCEPHALUS  43 

literature  of  nine  years  Chipault  collected  fifty  cases  of  meningocele  subjected 
to  operation  with  only  nine  deaths. 

Meningoceles  protruding  through  the  base  of  the  skull  are  rarely  in  situa- 
tions accessible  to  the  surgeon.  In  one  case  Fenger  gained  access  to  the  tumor 
by  temporarily  resecting  the  superior  maxilla,  and  saved  his  patient.  When  it 
is  possible  to  expose  a  basal  meningocele  the  principles  of  operation  are  the  same 
as  those  already  described. 

MICROCEPHALUS.     IDIOCY 

Lane,  Fuller,  and  Lannelongue  advised  removal  of  portions  of  the  skull  in 
cases  of  microcephalus,  on  the  supposition  that  the  early  closure  of  the  skull  and 
consequent  defective  bone  cavity,  impeded  cerebral  development.  Variously 
shaped  portions  or  strips  of  skull  have  been  removed  by  many  surgeons  and  the 
primary  results  seemed  promising.  The  author  in  several  cases  was  astounded 
to  find,  even  on  the  day  following  operation,  marked  improvement  in  the  con- 
dition of  such  patients.  The  improvements  in  speech  and  mentality  were  truly 
incredible,  but  in  not  one  of  the  cases  observed  by  him  were  these  improvements 
retained,  and  he  is  forced  to  conclude  that  such  operations  are  worthless.  They 
will  not  be  described  here. 

HYDROCEPHALUS 

The  earliest  attempts  to  treat  hydrocephalus  by  surgical  means  consisted 
in  the  application  of  strapping  to  the  head  in  the  endeavor  to  prevent  its  in- 
crease in  size  or  to  diminish  its  size.  Such  means  were  doomed  to  failure. 
Later,  paracentesis  was  resorted  to,  and  cerebrospinal  fluid  was  removed  in 
greater  or  less  quantity,  but  though  repeated  paracentesis  occasionally  gave 
relief  yet  sooner  or  later  meningitis  generally  developed  and  death  ensued. 

Mikulicz  suggested  draining  the  cerebrospinal  fluid  into  the  tissues  under  the 
scalp  and  this  procedure  was  carried  out  in  several  different  ways.  Metal  tubes 
were  inserted  so  as  to  conduct  fluids  from  the  ventricles  to  the  subcutaneous 
tissues.  Silk  threads,  formalinized  arteries  or  veins  were  used  for  the  same 
purpose  but,  as  is  noted  elsewhere,  while  temporary  success  was  not  infrequent, 
the  subcutaneous  tissues  refused  to  continue  acting  as  absorbents  and  per- 
manent good  results  were  notable  because  of  their  absence. 

Leonard  Hill  (quoted  by  Cheyne  and  Burghard)  has  shown  that  the  amount 
of  cerebrospinal  fluid  is  regulated  by  absorption  and  exudation  from  the  veins  or 
lymphatics  of  the  brain,  more  especially  towards  the  base;  ahd  if  any  cause 
interferes  with  the  normal  regulation  of  this  cerebrospinal  fluid  the  result  on 
the  brain  will  be  very  serious.  Meningitis  interferes  with  this  regulation,  so  that 
the  fluid  collects  in  the  ventricles  and  causes  hydrocephalus.  See  also  W.  E. 
Dandy,  Diagn.  &  Treatment  Hydrocephaly  resulting  from  Stricture  of  Aque- 
duct of  Sylvius,  Surg.  Gyn.  and  Obst.,  Oct.  1920.)  The  meningitis  at  fault  is 
specially  present  at  the  base  of  the  brain  near  the  fourth  ventricle,  obstructing 
the  exit  of  fluid  from  the  ventricles,  and  hence  its  proper  absorption.     Based 


44 


THE    SKULL   AXD    THE   BRAIN 


on  the  above,  G.  A.  Sutherland  and  one  of  the  authors  referred  to,  attempted 
to  establish  the  natural  absorption  by  the  following  operation: 

Reflect  a  flap  of  scalp  and  open  the  skull  near  and  posterior  to  the  anterior 
fontanelle  (occasionally  the  lower  angle  of  the  fontanelle  itself  has  been  opened). 
Incise  the  dura.  Take  about  twelve  strands  of  thin  catgut  2  to  3  inches  in 
length  and  tie  the  ends  together.  Pass  one  end  of  this  bunch  of  catgut  down- 
wards and  backwards  between  the  brain  and  the  dura  until  about  ^-^  inch  is  left 
projecting  from  the  opening  in  the  dura.  Seize  the  free  end  of  this  projecting 
portion  in  a  forceps  and  push  it  through  the  brain  into  the  lateral  ventricle. 
Thus  a  catgut  drain  is  made  to  stretch  from  the  ventricle  into  the  subdural  space. 
Close  the  wound  in  the  dura  and  the  scalp.  As  a  rule,  the  temperature  runs  up 
to  104°  or  io5°F.,  but  falls  again  in  the  course  of  a  week  or  ten  days.  The  skull 
soon  diminishes  in  size  to  a  very  marked  degree. 


Fig.  35. — Ballance's  method  of  ventricular  drainage. 

The  results  have  been  better  in  congenital  than  in  acquired  hydrocephalus; 
in  the  latter  it  has  been  extremely  difficult  to  keep  up  a  channel  of  communi- 
cation between  the  ventricles  and  the  subdural  space,  and  it  has  been  sug- 
gested to  use  a  more  resistant  form  of  drain.  In  spite  of  the  success  at- 
tained, the  patients  have  generally  succumbed,  after  a  few  months,  to  pro- 
gressive meningitis. 

Ballance  ("Am.  Surg.  Assoc,"  1906)  finds  the  thread  drainage  insufl&cient, 
therefore  he  uses  a  fine  F-shaped  tube  of  pure  platinum  or  of  gold  and  iridium 
(pure  gold  is  too  soft).  One  limb  of  the  tube  is  provided  with  a  small  ring  or 
loop  near  the  angle.  One  leg  of  the  tube  is  made  to  penetrate  the  ventricle, 
the  other  leg  lies  between  the  brain  and  the  dura,  being  fi.xed  to  the  latter  by 
sutures  (Fig.  35). 

Ballance  has  had  a  number  of  complete  recoveries  from  hydrocephalus 
following  ligation  of  both  common  carotid  arteries  at  an  interval  of  about  ten 
days.  In  these  cases  there  is  no  special  danger  from  shutting  off  both  common 
carotids. 

V,  Bramann  endeavors  to  attain  the  same  end  by  means  of  puncture  of 
the  corpus  callosum  (see  p.  t^;^. 

The  blood  pressure  in  the  cerebral  tissues  being  very  low  Payr  conceived 
the  idea  that  it  would  be  possible  to  drain  cerebrospinal  fluid  directly  into  the 
longitudinal  sinus.  As  an  aqueduct  from  the  lateral  ventricle  to  the  sinus  a 
tube  lined  with  endotheUum  and  provided  with  valves  to  prevent  reflux  of  blood 


PAYR  S    OPERATION  45 

is  desirable.  Such  a  vein  as  the  great  saphenous,  if  transplanted,  is  calculated 
to  fulfill  the  requirements. 

Payr's  Operation  ("Archiv  fiir  klin.  Chir.,"  Ixxxvii,  Hft.  4). 

1.  Make  a  transverse  U-shaped  flap  consisting  of  skin  periosteum  and  bone 
as  shown  in  Fig.  36.  The  convexity  of  the  flap  is  on  the  side  to  be  drained 
and  its  pedicle,  2  to  3  cm.  wide,  is  at  least  one  finger's  breadth  to  the  opposite 
side  of  the  mid-line.     Reflect  the  flap. 

2.  On  each  side  of  the  longitudinal  sinus  elevate  a  U-shaped  flap  of  dura 
having  its  base  towards  the  sinus. 

3.  With  an  exploring  needle  of  small  size  and  having  a  scale  marked  in 
3'^  cms.  on  it,  puncture  the  lateral  ventricle  at  a  spot  not  far  from  the  longi- 
tudinal fissure  and  drain  off  slowly  a  small  quan- 
tity of  fluid  and  at  the  same  time  note  the  depth 
of  the  ventricle  from  the  surface.  Remove  the  ex- 
ploring needle — it  has  served  its  purpose  of  reliev- 
ing tension  and  showing  the  distance  of  the  ven- 
tricle from  the  surface. 

4.  Have  an  assistant  make  an  incision  over 
the  long  saphenous  vein  and  by  sharp  dissection 
remove  a  segment  of  it.  There  must  be  no  bruis- 
ing of  the  vein.  The  length  of  the  vein  requisite 
must  be  from  50  per  cent,  to  60  per  cent,  longer 
than  the  distance  from  the  longitudinal  sinus  to 

the   ventricle   as    the   excised   vein   shrinks   very    pj^  ^5 Payr's  operation. 

markedly.     When  excised  place  the  vein  on  gauze  {Payr.) 

soaked  in  warm  salt  solution  and  keep  it  warm. 

Note  and  remember  which  is  the  proximal  end  of  the  vein  as  that  is  the  end 
which  must  be  sutured  to  the  sinus  in  order  to  take  advantage  of  the  valves 
in  the  vein. 

5.  Penetrate  the  ventricle  with  an  aluminum  trocar  (2  to  3  to  4  mm.  in 
diameter)  which  has  a  3=-^  cm.  scale  marked  on  it.  Permit  the  fluid  to  escape 
very  slowly;  a  plug  of  cotton  in  the  trocar  permits  the  fluid  to  escape  in  drops. 

6.  At  least  2  to  3  cm.  of  the  longitudinal  sinus  is  exposed.  Lift  up  the  two 
dural  flaps  made  in  Step  2.  This  permits  one  to  see  the  falx  under  the  sinus. 
With  semiblunt  needles  threaded  with  thin  elastic  or  with  a  thin  rubber  tube 
perforate  the  falx  anteriorly  and  posteriorly  to  the  exposed  segment  of  sinus.. 
In  this  manner  an  elastic  band  goes  from  side  to  side  under  the  sinus — one  in 
front  and  one  behind  the  site  of  proposed  anastomosis — and  when  fixed  by  a 
stitch  to  the  scalp  on  each  side  of  the  sinus  these  exercise  pressure  on  the  sinus 
and  so  stop  the  circulation  temporarily. 

7.  To  the  right  and  to  the  left  of  the  site  chosen  for  anastomosis  intro- 
duce and  tie  a  suture  of  fine  silk  which  penetrates  only  the  external  tunics  of  the 
sinus.  Leave  the  ends  of  these  sutures  long.  If  bleeding  takes  place  when 
the  sinus  is  incised  it  can  be  promptly  stopped  by  crossing  the  sutures. 

8.  Incise  the  sinus  and  introduce  into  it  obliquely  and  backwards  the 
proximal  end  of  the  excised  long  saphenous  vein.  It  is  wise  to  have  the  end  of 
the  vein  folded  back  like  a  cuff  so  that  any  part  of  it  which  may  protrude  into- 


46  THE  SKULL  AND  THE  BRAIN 

the  sinus  is  covered  with  endothelium.  With  fine  silk  sutures  fix  the  vein  to 
the  opening  in  the  sinus  and,  as  supporting  sutures,  tie  together  gently  the  two 
threads  introduced  in  Step  7. 

9.  Remove  the  aluminum  trocar  from  the  ventricle  and  push  the  free  end  of 
the  segment  of  vein  along  its  course  into  the  ventricle.  This  may  be  done  with 
a  stilet  of  stiff  silver  wire.  It  is  well  to  have  the  end  of  the  vein  turned 
back  on  itself  in  cufiF  fashion. 

10.  Remove  the  elastic  constrictors  from  the  sinus.  Close  the  dural  wound. 
Close  the  cranial-scalp  wound. 

Several  observers  have  noted  that  when  drainage  has  been  established 
between  the  ventricles  or  the  meninges  and  the  cellular  tissues,  absorption  of 
the  fluid  was  at  first  satisfactory  but  that  later  the  cellular  tissues  refused  to  con- 
tinue absorbing  the  fluid  and  encysted  it  instead.  A.  H.  Ferguson  drilled  a 
hole  through  the  body  of  the  fifth  lumbar  vertebra  and  passed  a  silver  wire 
through  it  from  the  spinal  to  the  peritoneal  cavity.  Nicoll  proposed  the 
following  steps:  laminectomy;  resection  of  a  transverse  process;  insertion 
of  a  tube  (decalcified  bone,  glass)  from  the  spinal  meninges  to  the  perito- 
neum; instead  of  inserting  a  tube  Nicoll  has  sutured  a  tag  of  omentum  to  the 
meninges. 

Heile  has  sutured  the  meninges  to  the  peritoneum  of  the  large  intestine. 
Harvey  Cushing  has  endeavored  to  establish  drainage  between  the  meninges 
and  the  neighborhood  of  the  peritoneum.  The  following  is  quoted  from 
Cushing's  article  in  Keen's  Surgery:  "It  is  essential  in  the  first  place  to  deter- 
mine if  possible  where  the  obstruction  lies,  for  if  it  is  evident  that  the  foramina  of 
Magendie  and  Luschka  are  occluded,  some  method  of  direct  ventricular  drainage 
must  be  resorted  to.  As  the  first  step  a  lumbar  puncture  is  performed,  the 
tension  of  the  fluid  is  registered,  and  if  an  amount  sufficient  to  demonstrate  that 
it  must  come  from  the  ventricle  can  be  withdrawn,  the  needle  is  removed  and 
the  fluid  analyzed. 

"The  second  step,  carried  out  some  days  later,  is  to  determine  whether  the 
child  will  withstand  the  withdrawal  of  a  large  amount  of  fluid,  for  though  I  have 
never  seen  convulsions,  collapse,  etc.,  from  this  source,  such  accidents  have  been 
recorded  by  Keen  and  others.  To  do  this,  a  combined  puncture  of  the  lumbar 
region  and  ventricle  is  performed.  A  long  glass  tube  of  small  calibre  connects, 
by  a  short  rubber  tube,  with  each  needle,  and  the  fluid,  when  lumbar  or  ven- 
tricular space  has  been  entered,  spurts  up  into  the  tube  to  its  tension  level,  about 
which  it  fluctuates  with  the  cardiac  and  respiratory  rhythm.  If  the  foramen  of 
Magendie  is  open  the  fluid  seeks  the  same  level  in  both  tubes,  and  when  either 
of  them  is  dropped  and  the  fluid  allowed  to  escape  the  level  in  the  other  falls. 
Thus,  the  ventricle  may  be  emptied  by  either  tube — rapidly  by  the  ventricular, 
slowly  by  the  lumbar — and  I  have  withdrawn  in  this  way  from  the  lumbar 
subarachnoid  space  alone  as  much  as  a  litre  of  fluid.  The  tubes  are  then  with- 
drawn, the  small  scalp  wound  closed,  dressed,  and  the  fluid  allowed  to  reaccu- 
mulate.  A  comparative  chemical  analysis  of  the  fluid  taken  from  the  two 
sources  should  show  them  to  be  the  same.  When  thus  demonstrated  that  the 
ventricular  fluid  already  communicates  by  natural  channels  with  the  subarach- 
noid space,  it  becomes  evident  that  an  additional  operative  communication 


HYDROCEPHALUS 


47 


between  ventricle  and  the  subarachnoid  spaces  over  the  hemisphere  is  super- 
fluous and  unavaiHng.  The  indication  is  clear  that  one  must  find  some  other 
means  of  escape  for  the  fluid,  and  I  have  attempted  to  drain  into  the  retro- 
peritoneal space  as  follows: 

''Third  Step. — It  having  become  established  (i)  that  the  ventricle  can  be 
emptied  by  the  lumbar  route  and  (2)  that  the  withdrawal  of  fluid  is  not  pre- 
judicial to  the  child's  well-being,  the  following  procedure,  after  an  interval  of 
some  days,  is  carried  out.  A  laparotomy  is  performed;  the  posterior  layer  of 
peritoneum  to  the  left  of  the  rectum  is  split;  the  body  of  the  fifth  lumbar  vertebra 
just  under  the  bifurcation  of  the  vessels  is  exposed;  the  bone  is  trephined  by  a 
specially  constructed  small-calibre  trephine,  and  one-half  (the  female  portion) 
of  a  silver  cannula,  exactly  the  size  of  the  trephine,  is  inserted  and  held  in  posi- 
tion. The  child  is  then  turned  on  its  face  and  a  laminectomy  is  performed; 
the  subarachnoid  space  is  opened,  the  strands  of  the  cauda  separated,  and  the 


Fig.  37. — Puncture  of  the  lateral  ventricle  by  the  lateral  route  at  A.     {Keen, 
Am.  Text-Book  of  Surg.) 

posterior  half  (male  portion)  of  the  cannula  is  invaginated,  so  that  it  locks  into 
the  portion  inserted  anteriorly.  Both  wounds  are  then  closed.  The  fluid 
for  a  time  finds  its  way  into  the  peritoneal  cavity,  but  ultimately  only  into  the 
retroperitoneal  space,  whence  it  is  taken  up  by  the  receptaculum  chyli,  as 
experimental  observations  have  shown.  It  can  be  seen  that  this  combined 
lumbar  method  is  especially  desirable  in  cases  of  hydrocephalus  complicated 
by  spina  bifida,  a  radical  cure  of  which  may  be  made  in  association  with  the 
posterior  part  of  the  operation.  I  have  carried  out  this  procedure,  which  is 
briefly  recorded  here  for  the  first  time,  in  twelve  cases,  with  a  considerable 
measure  of  success." 

ACUTE  HYDROCEPHALUS,  DRAINAGE  OF  LATERAL   VENTRICLE 

Keen's  Method. — (A)  Choose  a  point  i^  inches  above  the  upper  margin 

of  the  external  auditory  meatus  and  the  same  distance  behind  the  meatus. 


48  THE    SKULL   AND    THE   BRAIN 

Open  the  skull  at  this  point  with  a  3-^  inch  trephine.  On  the  opposite  side  of 
the  head  choose  the  point  H  (Fig.  37)  2}^^  to  3  inches  above  the  meatus  audi- 
torius.  Through  the  trephine  opening  pass  a  grooved  director  or  fine  cannula 
towards  the  point  H.  The  cannula  should  reach  the  ventricle  at  a  depth  of  2  to 
2^^  inches.  If  drainage  is  required  introduce  some  threads  of  horse-hair  or  a 
fine  tube  of  rubber. 

OPERATIONS   IN   CASE   OF  EPILEPSY 

I.  Idiopathic  Epilepsy. — (A)  Prophylactic  Treatment. — The  report  of  results 
obtained  in  Korte's  clinic  (see  p.  17)  in  cases  of  complicated  fractures  of  the 
skull  very  strongly  indicates  the  propriety  of  restoring  the  integrity  of  the 
skull  after  operations  or  fractures.  The  methods  of  doing  this  are  discussed 
elsewhere  (see  p.  11). 

Prophylactic  treatment  resolves  itself  essentially  into  the  avoidance  of  local 
irritation  and  obtaining  the  most  complete  repair  feasible. 

(B)  Operative  Treatment. — The  name  idiopathic  epilepsy  is  used  as  a  cloak 
for  ignorance  and  to  denominate  the  non-focal  forms  of  the  disease.  Many 
operations  have  been  performed  for  the  cure  of  the  disease;  the  results  have 
been  good,  bad  and  nil;  negative  results  being  the  rule.  The  fact  that  many 
operations  on  regions  apparently  unconnected  directly  with  the  head  have  been 
followed  by  symptomatic  cure  of  the  disease  led  J.  W.  White  to  speak  of  "opera- 
tions per  se"  being  occasionally  curative.  Undoubtedly  it  is  good  practice  to 
correct  possible  sources  of  irritation  in  epileptics,  such  as  eye-strain,  tight  fore- 
skin,  decayed   teeth,   etc. 

After  shaving  the  head,  scars  will  commonly  be  found  on  the  scalp,  even 
when  no  history  of  trauma  has  been  elicited.  Many  of  these  scars  are 
undoubtedly  the  result  of  accidents  directly  due  to  the  epilepsy,  but  as 
undoubtedly,  in  occasional  cases,  one  of  the  scars  is  the  visible  evidence  of  a 
trauma  which  occasioned  the  epilepsy.  All  such  scars  should  be  carefully  ex- 
amined as  regards  (o)  tenderness  to  touch  or  to  percussion,  {b)  mobility  or 
adhesion,  (c)  condition  of  periosteum  or  bone,  {d)  the  production  of  vasomotor 
or  psychic  symptoms  on  manipulation. 

Keen  is  so  strongly  convinced  that  a  scar  of  the  scalp  may  be  the  cause  of 
epilepsy  that  after  having  excised  the  scar  and  having  found  the  bone  without 
evidence  of  injury,  he  closes  the  wound  and  waits;  if  excising  the  scar  fails  to 
cure,  he  then — and  not  until  then — considers  the  advisability  of  performing 
some  other  operation. 

Friedrich,  in  traumatic  epilepsy,  chooses  the  site  of  trauma  as  the  site  for 
operation  even  when  the  "aura"  would  indicate  some  other  location  as  the 
starting-point  of  the  epileptic  explosion. 

Kocher,  believing  increased  intracranial  pressure  to  be  the  important 
etiologic  factor  in  idiopathic  epilepsy,  trephines  and  excises  the  dura  over  the 
right  fronto-parietal  region,  as  a  rule;  to  this  he  sometimes  adds  drainage  of  the 
lateral  ventricle. 

Friedrich's  results  ("Archiv  fiir  klin.  Chir.,"  Ixxvii,  Hft.  3)  in  eight  cases 
kept  under  observation  for  years  after  operation  show  one  case  cured  of  epi- 


EPILEPSY 


49 


lepsy  and  coincident  mental  disturbances;  two  cases  of  very  great  improvement; 
one  of  improvement;  one  of  temporary  improvement;  three  unimproved. 

If  not  guided  by  the  evidences  of  old  trauma  Friedrich  follows  Kocher  and 
operates  over  the  posterior  portion  of  the  frontal  lobes  (right). 

The  operation  is  as  follows: 

Step  I. — Reflect  a  large  flap  of  scalp,  having  its  pedicle  below.  Open  the 
skull  and  excise  with  forceps  or  other  instruments  a  segment  of  bone.  The  size 
of  the  segment  of  bone  removed  varies  from  20  to  48  sq.  cm.  (8  to  19  sq.  in.). 

Step  2. — Very  carefully  remove  an  area  of  dura  varying  in  size  from  9  to  33 
sq.  cm.  (3^-^  to  13  sq.  in.).  Do  not  injure  the  subjacent  pia.  Avoid  as  far 
as  possible  all  hemorrhage. 

Step  3  — Replace  the  flap  of  scalp  and  suture.     Apply  dressings. 

C.  H.  Mayo  has  had  some  success  after  operating  as  follows:  Reflect  a  large 
osteoplastic  flap;  cut  the  fractured  edges  of  the  bone  smooth.  Reflect  a  flap  of 
dura  corresponding  to  the  osseous  defect.     Push  the  dural  flap  into  a  pocket 


Fig.  38. — C.  H.  Mayo's  dural  drainage. 

between  the  scalp  and  the  bone  (Fig.  38).  Replace  the  osteoplastic  flap,  the 
bone  of  which  lies  next  to  the  pia  arachnoid.  The  dural  flap  acts  as  a  drain 
between  the  meninges  and  subcutaneous  lymphatics.  Gushing' s  decompressive 
operation  may  be  employed. 

Although  all  such  operations  are  perfectly  justifiable  under  proper  condi- 
tions, yet  the  surgeon  must  not  be  too  sanguine  as  to  results.  Almost  any 
operation  is  frequently  followed  by  a  temporary  cessation  of  epileptic  seizures, 
but  recurrence  is  the  almost  invariable  rule.  Jonnesco's  method  of  sympa- 
thectomy cannot  be  considered  of  proved  value. 

n.  Focal  or  Jacksonian  Epilepsy. — In  focal  epilepsy  the  irritation  seems 
to  originate  in  some  particular  point  on  the  surface  of  the  brain  and  to  radiate 
to  other  parts.  The  parts  affected  are  those  which  have  been  mapped  out  in 
the  study  of  cerebral  localization.  The  causes  of  this  condition  are  numerous. 
Depressed  fracture,  osteophytic  growths,  neoplasms,  localized  meningitis  caus- 
ing adhesions,  hemorrhage,  abscess,  etc.,  are  all  efl&cient  causes  and  ought  to  be 
removed  or  corrected.  If  no  macroscopic  lesion  can  be  found  when  the  skull  is 
opened  and  the  brain  exposed,  the  precise  area  from  which  the  attacks  radiate 


50 


THE  SKULL  AND  THE  BRAIN 


may  be  defined  by  means  of  stimulation  by  weak  electrical  currents.  The  gray 
matter  of  this  area,  plus  the  pia  mater  covering  it,  may  be  excised.  Of  course, 
excision  of  an  area  of  cortex  means  paralysis  of  the  regions  controlled  by  this 
area,  but  the  paralysis  seldom  remains  permanent.  Immediately  after  the 
operation  there  is  often  a  very  temporary  paralysis  of  parts  supplied  by  neigh- 
boring centres.  A  few  good  results  have  followed  cortical  excision,  but  the  rule 
is  that  epilepsy  recurs  when  healing  takes  place.  If  a  scar  is  removed  from  the 
brain,  another  scar  is  necessarily  formed  in  the  process  of  repair.  There  is  a 
great  difference,  however,  between  the  scar  resulting  from  a  clean  incision  or 
excision  and  one  resulting  from  a  coarse  trauma  or  from  inflammation.  Cover- 
ing a  cerebral  wound  with  celluloid,  goldfoil,  or  rubber  tissue  prevents  adhesion 
between  the  brain,  meninges,  and  scalp  or  skull,  and  is  a  useful  precaution.  An 
implant  of  fat  may  also  be  of  service. 

Carl  Beck's  Operation. — In  some  cases  of  epilepsy  ("Annals  of  Surg.," 
Aug.,  1906)  due  to  adhesions  at  the  site  of  a  hiatus  in  the  skull,  the  result  of 
fracture  or  operation,  Beck  has  obtained  some  good  results^by  plugging  the  skull 
defect  with  temporal  muscle  and  fascia,  the  fascia  being  placed  next  the  brain 
or  dura. 


Fig.  38A. — Beck's  operation  for  traumatic  epilepsy. 


The  Operation:  Step  i.— Make  the  fl  incision  ABC  (Fig.  38 A)  and  reflect  the 
flap  or  scalp  thus  formed.  This  exposes  the  defect  in  skull.  Carefully  remove 
all  scar  tissue  and  exostoses  from  the  defect  and  its  surroundings.  This  means 
usually  removal  of  dura.  With  chisel  or  rongeur  remove  enough  bone  from 
around  the  defect  so  that  an  edge  of  intact  healthy  dura  is  exposed.  Attend  to 
hemostasis. 

Step  2. — Continue  the  incision  BA  to  D  and  BC  to  E,  and  reflect  the  flap 
DFE.  This  flap  must  consist  of  scalp  alone;  the  temporal  fascia  must  be  left 
intact. 

Step  3. — Form  the  flap  HKI  consisting  of  temporal  fascia,  temporal  muscle 
and  pericranium,  and  having  its  pedicle  towards  the  skull  defect.  This  flap 
must  be  large  enough  to  completely  fill  the  defect.     Turn  the  flap  HKI  upwards 


EPILEPSY 


SI 


and  place  it  in  the  skull  defect,  the  temporal  fascia  lying  on  the  brain.     Suture 
the  temporal  fascia  to  the  dura. 

Step  4. — Attend  to  hemostasis.  Replace  the  flap  DEF  and  fix  it  with 
sutures,   providing   for   drainage,   if   necessary.     Apply   dressings. 

In  cases  similar  to  those  for  which  Beck  devised  his  operation  other  surgeons 
reflect  the  scalp,  remove  scar  tissue,  etc.,  at  the  same  time  excising  scars  in  the 
dura  and  freshening  the  edges  of  the  bony  hiatus.  The  usual  methods  of 
endeavoring  to  prevent  fresh  dural  adhesions  have  been  described  elsewhere. 
Finsterer  replaced  destroyed  dura  with  a  portion  of  a  hernial  sac  placed  with  its 
serous  surface  towards  the  brain.  The  sac,  obtained  during  an  operation  for 
hernia,  had  been  preserved  in  a  2  per  cent,  formol  solution  but  was  thoroughly 
washed  in  normal  salt  solution  before  use  ("Beitrage  z.  klin  Chir.,"  Ixvii, 
193).  In  experiments  made  on  dogs  Finsterer  found  that  such  peritoneal 
grafts  preserved  their  vitality  (?)  and  did  not  contract  adhesion  to  the 
subjacent  brain. 

Perthes  (German  Surg.  Congress,  191 2)  has  used  fresh  hernial  sac  after 
Finsterer's  method  in  seven  cases,  with  success  in  six,  and  death  in  one  due 
to  infection  secondary   to   a  meningeal  fistula. 

Hanel  ("Archiv  fiir  klin.  Chir.,"  xc,  823),  stimulated  by  Morris'  recommen- 
dation of  Cargile's  membrane,  prepared  material  from  the  intestines  of  sheep  as 
follows:  Bend  a  glass  rod  so  as  to  make  a  four-sided  frame;  split  open  and 
stretch  on  the  frame  a  segment  of  sheep's  intestine.  Soak  in  a  4  per  cent,  solu- 
tion of  formalin  for  twelve  hours;  wash  in  running  water  twelve  hours;  boil  in 
water  for  ten  minutes;  preserve  in  the  following  solution:  sublimate  0.8, 
glycerine  40.0,  alcohol  800.0.  Hanel  used  this  material  in  the  same  manner 
as  Finsterer  uses  hernial  sac  and  Morris  uses  Cargile  membrane.  Hand's 
membrane  is  absorbed  after  the  lapse  of  about  two  or  three  weeks. 

Kirschner  ('"Archiv  fiir  klin.  Chir.,"  xcii,  894)  recommends  the  use  of 
fascia  in  covering  dur^l  defects.  He  obtains  the  material  by  excising  a  suffi- 
ciency of  the  fascia  lata  from  the  patient  himself  and  after  cutting  away  all 
fat  from  it  places  it  over  the  dural  defect  and  pushes  its  edges  under  the  skull 
between  the  dura  and  the  bone.  At  the  German  Surg.  Congress,  191 2,  he 
reported  seventeen  cases  from  Korte's  clinic.  He  writes:  "(i)  In  all  the  cases 
the   transplanted  fascia  healed  without  reaction. 

"  (2)  In  the  cases  where  the  implantation  was  made  to  replace  dura  patho- 
logically affected  in  cortical  epilepsy,  there  were  no  more  convulsions."  (Too 
short  a  time  has  elapsed  to  permit  of  final  conclusions.) 

"  (3)  When  diseased  dura  was  widely  excised,  water-tight  closure  of  the  sub- 
dural space  was  at  once  obtained  by  implantation  of  fascia.  No  meningeal 
fistulas  developed. 

"  (4)  When  operation  is  imperative  in  circumstances  where  the  external 
wound  cannot,  with  certainty,  be  rendered  clean,  the  implantation  of  fascia 
hinders  infection  of  the  cerebrospinal  fluid."  (To  the  author  this  appears 
very  dubious  in  view  of  the  necessity  of  absolute  asepsis  when  implanting  any 
foreign  material,  even  autoplastic.) 

"  (5)  When  much  dura  and  bone  are  both  removed  the  implanted  dura 
prevents  cerebral  prolapse." 


52  THE  SKULL  AND  THE  BRAIN 

Lexer  in  a  case  of  traumatic  epilepsy,  after  excising  an  old  scar  uniting  the 
meninges  to  the  soft  parts,  implanted  a  free  (non-pedunculated)  flap  of  fat 
between  the  brain  and  the  scalp.  The  result  was  very  happy.  In  a  case  in 
which  pain  and  giddiness  resulted  from  adhesions  between  the  meninges  and 
scalp,  the  author  followed  Lexer's  method  and  implanted  a  free  flap  of  fat 
obtained  from  the  patient's  abdominal  wall.     The  result  was  very  satisfactory. 

HEMORRHAGIC   PACHYMENINGITIS 

BuUard  and  John  C.  ^Munro  have  made  strong  pleas  for  the  consideration 
of  hemorrhagic  pachymeningitis  as  a  surgical  condition  demanding  operation. 
The  disease,  when  not  found  in  infants  or  the  insane,  is  one  belonging  to  the 
later  years  of  life.  Alcoholism,  syphilis,  acute  and  wasting  diseases,  as  well  as 
trauma,  seem  to  have  some  causal  relation  to  the  disease.  The  symptoms  are 
those  of  diffuse  subdural  hemorrhage,  coming  on  slowly,  producing  mental 
irritation,  spasm,  paralysis,  the  sequences  being  more  or  less  irregular.  The 
cranial  nerves  are  not  liable  to  be  affected.  Without  relief  by  operation  the 
prognosis  is  practically  hopeless;  with  operation,  it  is  still  very  poor  but  better 
than  without.  One  of  JVIunro's  cases  recovered;  it  was  that  of  an  alcoholic 
sixty-two  years  of  age,  picked  up  on  the  streets  unconscious.  On  admission  to 
hospital  he  could  not  be  roused.  There  was  no  bleeding  from  the  mouth,  nose, 
or  ears.  Temperature  was  normal,  pulse  80;  right  knee-jerk  absent;  no  rigidity; 
hematoma  in  right  parietal  region.  Trephined  on  right  side;  no  pulsation  of 
dura,  which  was  bulging  and  dark  blue.  Subdural  clot  covering  the  whole 
hemisphere  removed.  Trephined  on  left  side;  a  diffuse,  thin  clot  was  found 
and  removed.  Towards  the  close  of  the  operation  consciousness  returned. 
The  result  was  complete  recovery.  In  another  case  failure  to  trephine  on  both 
sides  led  to  death,  though  immediate  improvement  followed  the  operation. 

HYPOPHYSECTOMY 

Attempts  have  been  made  to  cure  or  relieve  patients  suffering  from  hyper- 
pituitarism (acromegaly)  and  hypopituitarism  by  excising  the  hypophysis 
(pituitary  body)  either  completely  or  incompletely.  The  pituitary  body  lying 
as  it  does  in  the  sella  turcica  may  be  approached  from  above  and  the  side  through 
the  cranial  cavity  or  from  in  front  and  below. 

A.    Operation   from   Above. — 

Bogojawlensky's  Operation. — ("Zent.  fiir  Chir.,"  No.  7,  191 2). 

Stage  I. — From  a  point  23^^  cm.  (i  in.)  external  to  the  middle  line  of  the 
forehead  and  the  same  distance  above  the  upper  margin  of  the  orbit  make  a 
cut  upwards  for  about  9  cm.  (3^-^  in.),  then  continue  the  cut  backwards  for 
9  cm.  and  downwards  for  the  same  distance.  Along  the  line  of  the  scalp  inci- 
sion divide  the  bone  with  forceps,  saw  or  surgical  engine.  A  large  osteo- 
plastic flap  with  pedicle  below  is  thus  outlined.  Attend  to  hemostasis  and 
apply  dressings. 

Stage  2. — After  several  days  or  weeks  elevate  and  reflect  downwards  the 
outlined  flap  of  bone  and  scalp.  Raise  the  head  end  of  the  table  to  30°.  Let 
the  patient's  head  hang  backwards  over  the  end  of  the  table.     The  raising  of 


llVPOl'UVSECTOMY  53 

the  head  end  of  the  table  prevents  loss  of  cerebrospinal  fluid.  Make  an  H- 
shaped  incision  through  the  dura  and  reflect  the  dural  flaps  thus  formed.  With 
finger  and  brain  spatula  slowly  and  carefully  lift  the  frontal  lobe  from  the  roof 
of  the  orbit.  The  dependent  position  of  the  head  permits  the  weight  of  the  brain 
to  aid  in  this  maneuvre  so  that  it  is  not  necessary  to  apply  retractors  to  the  brain. 
The  optic  commissure  and  any  tumor  of  the  hypophysis  become  visible  and 
accessible. 

McArthur's  Method   (Trans.   Surg.   Section  A.   M.  A.,   191 2). 

1.  Place  the  patient  in  Bogojawlensky's  position.  Make  the  incision 
ABCD,  Fig.  39,  penetrating  to  the  bone.  The  incision  AB  is  3  to  4  cm.  (i^^ 
to  i}<2  in.)  long.  Reflect  the  flap  (including  the  periosteum)  upwards. 
With  the  elevator  introduced  through  the  wound  CD 
separate  the  periosteum  from  the  orbital  roof  and 
displace  the  orbital  contents  downwards  using  a  tea- 
spoon as  a  depressor.  The  periosteum  being  kept  intact 
the  orbital  contents  are  not  seen. 

2.  With  a  yi  inch  trephine  penetrate  the  frontal 
prominence  4  cm.  (i)^  in.)  above  the  middle  of  the  Fig.  39. — McArthur's 
supra-orbital  arch.  Preserve  the  button  of  bone  in  ^ectomy.  ^°'  ^>'P°P^>- 
warm  salt  solution.     Beginning  at  the  trephine  opening, 

with  DeVilbiss  forceps  make  a  curviHnear  cut  through  the  bone,  concavity  down- 
wards, the  inner  end  terminating  at  the  frontal  sinus,  the  outer  at  the  outer  aspect 
■of  the  external  angular  process,  thus  invading  somewhat  the  temporal  fossa.  With 
■an  osteotome  divide  the  outer  wall  of  the  frontal  sinus.  Divide  the  external 
angular  process.  Elevate  and  remove  the  loosened  frontal  fragment;  preserve  it 
in  warm  salt  solution.  With  rongeurs  cut  away  the  orbital  roof  back  close  to 
the  optic  foramen,  being  careful  not  to  injure  the  dura. 

"With  this  completed  one  can  slowly  and  carefully  detach  from  the  bone 
the  dura  covering  the  inferior  surface  of  the  frontal  lobe,  at  the  same  time  having 
the  latter  raised  by  a  long  thin  angular  retractor  in  the  hand  of  a  skilled  assistant, 
in  whose  other  hand  a  spoon  retractor  displaces  the  orbital  contents  downwards. 
When  one  has  reached  the  anterior  clinoid  process  and  the  free  edge  of  the  wing 
of  the  sphenoid,  which  can  be  recognized  with  probe,  blunt  hook  or  finger, 
orientation  becomes  easy." 

3.  Note  the  dura  between  the  chnoid  processes  and  make  a  2  to  3  cm. 
04:  to  i}i  in.)  transverse  incision  through  it  with  a  fine  hook-shaped  knife 
about  0.5  cm.  04  in.)  above  the  level  of  the  floor  of  the  anterior  fossa,  thus 
avoiding  ''  the  small,  transverse  venous  sinus  that  occupies  the  groove  between 
the  optic  foramina  (this  groove  it  was  long  taught,  harbored  the  optic  chiasm)." 
Through  the  dural  opening  the  optic  nerve,  chiasm  and  the  pituitary  tumor 
come  into  view. 

4.  Treat  the  disease  by  evacuating  fluid  or  removing  tumor  tissue  with  a 
fine  curette. 

5.  Permit  the  frontal  lobe  to  fall  back  into  place.  Replace  the  bone  re- 
moved. Replace  the  flap  of  soft  parts,  suturing  the  periosteum  separately. 
Close  the  skin  wound.     Introduce  a  rubber  tissue  drain  to  the  dura. 

McArthur  has  found  that  but  little  scar  or  deformity  results.     His  method 


54 


THE    SKULL   AND    THE   BRAIN 


is  perhaps  the  safest  and  easiest  means  of  performing  an  extremely  difficult 
operation. 

Frazier's  method  ("Annals  Surg.,"  Feb.,  1913)  is  almost  the  same  as 
McArthur's.  Reflect  an  osteoplastic  flap  from  the  right  frontal  region,  the 
pedicle  being  lateral;  remove  the  supra-orbital  ridge  en  bloc  with  a  portion  of  the 
orbital  roof;  remove  with  rongeurs  the  remainder  of  the  roof  of  the  orbit  down 
to  the  optic  foramen;  elevate  the  frontal  lobe;  depress  the  orbital  contents; 
incise  the  dura  sufficiently  to  lay  bare  the  cavity  of  the  sella  turcica  (Fig.  40). 


Fig.  40. — Hypophysectomy.     {Frazier,  Annals  of  Surgery.) 


B.  Operation  from  in  Front  and  Below. — 

Kanavel  ("  Journ.  A.  M.  A.,"  November  20,  1909)  devised  an  intranasal 
route  by  which  to  expose  the  hypophysis  and  yet  avoid  all  disfiguring  scars. 
This  operation  he  worked  out  on  the  cadaver,  but  it  was  first  used  on  the  living 
by  A.  E.  Halstead  ("Surg.,  Gyn.,  Obstetrics,"  May,  1910)  who  associated 
Kanavel  with  himself  in  the  operation.  Montgomery  West  ("Journ.  A.  M.  A.," 
April  2,  1910)  has  devised  a  method  similar  to  Kanavel's  but  does  the  work 
entirely  through  the  nostril  without  dislocating  the  nose.  Both  Kanavel  and 
West  suggest  that  it  may  be  well  to  operate  in  two  stages;  in  the  first  stage  clear- 
ing the  way  to  the  sella  turcica  (this  may  be  done  under  local  anesthesia),  in  the 
second  stage  removing  the  tumor. 


HYPOPHYSECTOMY 


55 


The  following  description  is  made  up  from  the  writings  of  Kanavel,  Halstead 
and  West  and  refers  to  operation  completed  in  one  stage. 

Anesthesia. — After  anesthesia  is  induced  in  the  usual  manner  Kanavel  con- 
tinues the  administration  of  ether  by  the  rectal  method,  while  Halstead  per- 
formiS  tracheotomy  and  gives  chloroform  through  a  Trendelenburg  cannula. 
To  the  author  it  seems  that  laryngotomy  and  the  use  of  chloroform  through 
Butlin's  cannula  is  simpler  and  safer  than  tracheotomy.  The  advantage  of 
anesthetizing  through  a  tracheotomy  or  laryngotomy  cannula  over  the  rectal 
method  consists  in  the  ability  to  plug  the  pharynx  thoroughly  and  the  avoid- 
ance of  all  respiratory  troubles.  Before  giving  the  anesthetic,  plug  the  nasal 
passages  carefully  from  the  anterior  nares  to  the  sphenoidal  cells  with  strips  of 
gauze  soaked  in  adrenalin  solution. 

The  Operation.  Step  i. — Tampon  the  pharynx.  Remove  the  adrenalin 
pack.  Raise  the  upper  lip.  Make  a  horizontal  incision  through  the  mucosa  of 
the  lip  about  %  inch  from  the  muco-cutaneous  junction  and  parallel  to  the 
alveolus.  Through  this  wound  dissect  upwards  freeing  the  nose  from  its  lateral 
attachments. 


Fig.  41. — Hypophysectomy.     {Kanavel,  Jour.  A.  M.  A.) 


Step  2. — With  strong  scissors  or  bone  forceps  divide  the  septum  along  its 
inferior  attachments  (line  b,  Fig.  41).  Divide  the  attachment  of  the  septum  to 
the  vertical  plate  of  the  ethmoid  (line  a,  Fig.  41).  Turn  the  nose  and  with  it 
the  separated  part  of  the  septum  upwards  on  to  the  forehead. 

Step  3. — Remove  the  lower  and  middle  turbinates,  the  vomer  and  the  per- 
pendicular plate  of  the  ethmoid.  The  anterior  wall  of  the  sphenoidal  sinus  is 
now  exposed. 

Step  4. — Penetrate  the  anterior  wall  of  the  sphenoidal  sinus.  Sometimes 
the  tumor  will  now  appear  having  eroded  the  sella  turcica.  If  this  has  not 
occurred,  open  the  sella  turcica  by  means  of  a  long  narrow  chisel.  While 
opening  the  sella  turcica  it  is  of  prime  importance  to  adhere  strictly  to  the 
middle  line  for  fear  of  damaging  the  carotid  arteries  and  the  optic  nerves. 

Step  5. — Treat  the  disease  by  evacuating  any  cyst  which  may  be  present  or 
gently  curetting  away  tumor  tissues. 


56 


THE  SKULL  AND  THE  BRAIN 


Step  6. — Pack,  the  cavity  with  iodoform  gauze.  Replace  the  nose.  Suture 
the  septum.     Suture  the  wound  in  the  mouth. 

Results. — The  results  of  Kanavel's  operations  have  been  most  excellent  as 
regards  absence  of  deformity.  There  has  been  no  recognizable  deformity  in 
any  of  the  patients  submitted  to  operation. 

The  following  surgeons  have  operated  by  the  Kanavel  method  or  some 
modification  of  it: 

Halstead,  A.  E.  ("Surg.,  Gyn.,  Obst.,"  May  lo),  two,  one  death.  Kanavel, 
two,  one  death.     Mixter,  S.  J.,  one,  no  death. 

In  Mixter's  case  and  in  Halstead's  successful  case  the  results  were  most 
gratifying.  Kanavel  (personal  communication)  writes:  "My  first  case  lived 
about  five  weeks  and  then  died  from  a  recurrence.     After  the  operation  he 


Fig.  42. — {Cushing,  Jour.  A.M.  A.) 


had  been  up  and  left  the  hospital.  My  second  case  was  one  of  the  adipose 
genital  type,  and  has  remained  perfectly  well  ever  since  the  operation,  which 
relieved  him  of  all  the  symptoms  of  which  he  complained,  and  with  the  use  of 
the  anterior  lobe  of  the  pituitary  gland  he  is  now  beginning  to  grow." 

Fig.  42  (Journ.  A.  M.  A.,  Oct.  31,  1914)  gives  some  idea  of  how  Cushing 
attacks  the  pituitary  body.  That  surgeon  in  1914  had  performed  16  trans- 
phenoidal  decompressions  with  3  deaths  and  58  transphenoidal  extirpations 
(on  52  patients)  with  4  deaths.     He  writes: 

"The  results  of  the  transphenoidal  operation,  which,  as  has  been  made 
clear,  is  carried  out  chiefly  for  the  relief  of  chiasmal  involvement,  have  been 
most  gratifying  in  the  61  survivors  in  the  68  cases.     Progressively  failing  vision 


EMPYEMA    OF    FRONTAL   SINUS  57 

has  become  stationary  or  has  been  slightly  regained  over  periods  varying  from 
a  few  months  to  several  years  in  22  cases.  There  has  been  a  prompt  widening 
of  the  field  with  marked  improvement  of  vision,  often  with  return  to  the  normal, 
in  another  22  cases.  In  two  patients  vision  was  temporarily  made  worse  as  a 
result  of  the  operation,  but  there  was  subsequent  great  improvement.  Though 
vision  had  been  completely  lost  in  5  cases  before  the  operation,  in  2  of  the 
cases  it  was  partially  regained.  In  8  cases  it  was  unaffected  before  the  opera- 
tion, and  still  remains  so.  In  only  3  cases  was  there  a  progressive  failure  of 
vision  despite  a  successful  operation  and  in  all  of  them  the  tissues  removed 
showed  a  malignant  transformation  of  the  lesion  to  which  the  patients  have 
since  succumbed." 


CHAPTER  III 
FRONTAL  SmUS 


Operation  on  the  frontal  sinus  is  indicated  in  empyema  of  that  cavity. 
Frontal  empyema  is  usually  a  concomitant  of  some  form  of  chronic  rhinitis. 
Either  as  a  preliminary  or  complementary  step  in  the  operation  it  is  wise  to 
remove  the  anterior  portion  of  the  middle  turbinated  bone  in  order  to  simplify 
drainage. 

The  Operation. — Shave  the  eyebrow.  Clean  the  field  of  operation.  Pro- 
tect the  eyes  with  aseptic  pads. 

Step  I. — From  the  root  of  the  nose  make  a  curved  incision  outwards,  parallel 
to  and  3'^  inch  above  the  upper  margin  of  the  orbit.  The  incision  extends  to  a 
point  just  external  to  the  supraorbital  notch  and  penetrates  to  the  bone.  With 
the  periosteal  elevator  separate  the  soft  parts  from  the  bone  until  the  outer 
wall  of  the  sinus  is  exposed 

Step  2. — With  a  bur,  small  trephine,  or  gouge  carefully  remove  the  exposed 
wall  of  the  sinus,  immediately  to  the  outer  side  of  the  middle  line,  above  the 
root  of  the  nose.  Only  a  very  small  area  of  bone  should  be  removed  at  this 
time,  and  care  is  necessary  lest  such  an  instrument  as  the  chisel  should  suddenly 
penetrate  the  thin  bone  and  injure  the  posterior  or  inferior  walls  of  the  cavity. 
As  soon  as  the  bone  is  penetrated,  the  mucosa  lining  the  sinus  pouts  into  the 
wound.  Incise  the  mucosa.  Gently  explore  the  cavity  with  a  probe  and  with 
gouge  or  forceps  (guided  by  the  probe)  remove  the  anterior  wall  of  the  sinus. 
Some  surgeons  are  careful  not  to  remove  any  of  the  orbital  margin  lest  an  ugly 
deformity  result;  others  carefully  remove  every  particle  of  bone  which  might 
interfere  with  the  soft  parts  being  brought  in  absolute  contact  with  the  deep 
wall  of  the  sinus,  the  aim  being  to  obliterate  the  cavity.  Obliteration  of  the 
cavity  is  often  necessary,  but  as  it  causes  marked  deformity  one  is  wise  to  try 
less  mutilating  procedures  first. 

Step  3. — With  a  sharp  spoon  remove  all  granulation  tissue  from  the  sinus 
and  from  its  opening  into  the  nose.  With  a  small  sharp  spoon  cleanse  every 
nook  and  cranny.  Be  careful  not  to  injure  the  orbital  plate.  Pass  the  sharp 
spoon  from  the  postero-internal  angle  of  the  sinus  downwards  into  the  nose. 


58  FRONTAL    SINUS 

The  instrument  goes  through  some  of  the  ethmoidal  cells  and  creates  a  good 
passage  for  drainage. 

Step  4. — Pass  a  rubber  tube  from  the  sinus  into  the  nose.  Some  surgeons 
do  not  permit  the  upper  end  of  the  tube  to  emerge  through  the  skin,  but  close  the 
cutaneous  wound  entirely,  trusting  to  nasal  drainage  alone,  as  in  Earth's  opera- 
tion; most  operators  place  the  tube  so  that  it  emerges  both  through  the  skin  and 
the  nose.  Through-and-through  drainage  is  probably  best  to  begin  with. 
During  the  after-treatment,  if  it  becomes  necessary  to  withdraw  the  tube  tern 
porarily,  it  is  well  to  fasten  a  thread  to  the  tube,  so  that  as  the  tube  is  withdrawn 
the  thread  may  take  its  place  and  serve  as  a  guide  for  the  introduction  of  a  clean 
drain.     Close  all  excess  of  wound  with  sutures.     Dress. 

After-treatment. — Warn  the  patient  not  to  blow  his  nose  violently,  other- 
wise emphysema  will  result.  When  nasal  drainage  alone  is  provided,  leave  the 
tube  in  situ  as  long  as  possible,  because  once  removed  it  is  very  difficult  to 
replace.  When  through-and-through  drainage  is  provided,  withdraw  the  drain 
gradually,  through  the  nose,  as  suppuration  lessens.  When  drainage  fails  to 
cure  the  disease,  the  sinus  must  be  obhterated  by  the  method  indicated  in  Step  2. 
Killian^s  operation  is  very  radical  and  successful.  (Freudenthal,  "Jour. 
Am.  Med.  Assoc,"  Feb.  11,  1905.) 

Step  I. — Make  an  incision  down  to  the  bone  the  whole  length  of  the  eyebrow, 
just  above  the  orbital  margin.  Continue  the  in- 
cision at  its  inner  end  down  the  middle  of  the 
nasal  process  of  the  superior  maxilla. 

Step.  2. — Open  and  explore  the  sinus  either 
above  or  below  the  orbital  margin. 

Step  3. — With  chisel  and  mallet  make  a  fur- 
row through  the  bone  immediately  above  and 
parallel  to  the  margin  of  the  orbit.  Remove  with 
forceps  the  whole  anterior  wall  of  the  frontal  sinus 
above  the  furrow. 

Step  4. — Clean  out  the  sinus  and  remove  its 
Fig.  43.— Earth's  operation,    mucous  membrane. 

Step  5. — Remove  with  forceps  the  whole  (or- 
bital) floor  of  the  sinus,  leaving  the  orbital  margin  intact  for  cosmetic  reasons. 
Step  6. — Resect  the  frontal  process  of  the  superior  maxilla  and  the  rest  of 
the  floor  of  the  sinus. 

Step  7. — Resect  the  anterior  and  middle  ethmoidal  cells  and  the  respective 
parts  of  the  middle  turbinal.     These  structures  are  always  affected. 

Step  8. — Close  the  wound  after  providing  for  drainage  by  a  rubber  tube. 
The  extensive  removal  of  the  floor  of  the  sinus  and  consequent  opening  of  the 
orbit  cannot  be  without  danger.     The  inevitable  entrance  of  pyogenic  organisms 
into  the  non-resistant  fatty  tissues  must  often  give  rise  to  orbital  abscess. 

Earth's  Operation. — A  little  to  the  side  of  the  middle  at  the  root  of  the 
nose  make  a  longitudinal  incision  i  inch  in  length,  down  to  the  bone.  With 
a  chisel  carry  the  above  incision  through  the  nasal  process  of  the  frontal  bone 
and  the  nasal  bone.  At  the  upper  and  lower  angles  of  the  wound,  by  means  of  a 
narrow  chisel,  make  horizontal  cuts  outwards  through  the  bone.     The  flap  of 


INJECTIONS    IN    TIC  59 

bone  thus  formed  is  pried  outwards  (Fig.  43)  like  a  trap-door  with  hinge  placed 
externally.  The  upper  part  of  the  opening  is  filled  with  the  mucous  membrane 
of  the  frontal  sinus.  Cut  through  this  bulging  mucous  membrane.  Through 
the  above  opening  diseased  tissue  may  be  inspected  and  removed,  free  drainage 
through  the  nose  may  be  provided,  and  if  necessary  the  opposite  sinus  may  be 
opened  and  treated.  When  the  operation  is  completed,  the  bone  flap  is  restored 
to  place  and  the  vertical  skin-incision  is  sutured. 


CHAPTER   IV 
TIC  DOULOUREUX 

In  severe  cases  of  trigeminal  neuralgia,  after  treatment  by  medicine  and 
by  removal  of  sources  of  peripheral  irritation  and  particularly  of  infection 
has  failed,  operation  offers  the  only  hope  of  amelioration  or  cure.  Very  many 
operations  have  been  devised,  but  not  all  of  them  are  useful.  The  earliest 
operations  consisted  in  the  subcutaneous  or  open  division  of  the  nerve 
trunks  as  they  left  or  entered  their  bony  canals.  The  supraorbital  nerve 
was  divided  as  it  emerged  from  the  notch  of  the  same  name,  the  infraorbital 
at  the  infraorbital  foramen,  and  the  inferior  maxillary  as  it  entered  the  pos- 
terior dental  canal.  In  certain  cases  such  operations  gave  marked  and  occa- 
sionally permanent  relief,  but  after  simple  division  of  a  sensory  nerve  repair 
can  take  place  with  great  rapidity,  so  that  the  neuralgia  usually  recurs  at  an 
early  date. 

Thiersch,  after  exposing  the  nerves  at  their  exit  from  their  bony  canals, 
seized  them  in  strong  forceps  and  by  slow  twisting  and  pulling,  forcibly  extracted 
a  varying  amount  of  them  from  their  canal.  Recurrence  after  this  procedure 
was  neither  so  prompt  nor  so  constant  as  after  simple  division.  Undoubtedly 
the  best  method  of  operating  upon  the  nerve-trunks  is  by  the  removal  of  as  much 
of  them  as  is  possible,  or  by  injecting  into  them  materials  which  will  either  de- 
stroy or  diminish  their  power  of  conduction. 

INJECTIONS   INTO  THE   NERVES 

Schlosser  was  the  first  to  make  injections  into  the  trunks  of  the  nerves  at  the 
base  of  the  skull  in  treating  trifacial  neuralgia.  Ostwalt  followed  him  and 
injected  the  three  branches  of  the  nerve  through  the  mouth.  Levy  and  Bau- 
douin  devised  and  systematized  a  simple  and  safe  method  for  making  the  injec- 
tions without  incurring  the  dangers  incident  to  invading  the  mouth.  Patrick 
has  followed  their  method  with  much  success.  The  author  has  followed  Mur- 
phy's modification  of  the  Levy-Baudouin  procedure  and  finds  it  easy  and 
fairly  satisfactory. 

Ostwalt's  Injections  ("La  Presse  Med.,"  Dec.  i6,  1905). — Ostwalt  in- 
jects I  to  1 3'^  c.c.  of  80  per  cent,  alcohol  (to  which  is  added  .01  cocaine  or 
stovaine)  into  the  trunk  of  each  of  the  branches  involved  where  it  emerges 
from  the  skull.  "As  usually  several  branches  (most  commonly  the  second  and 
third)  are  affected  at  the  same  time,  I  make  an  injection  in  two  or  three  stages; 


6o 


TIC    DOULOUREUX 


first  at  the  foramen  ovale  then  at  the  foramen  rotundum  and  last,  if  necessary, 
in  the  sphenoidal  fissure.  To  reach  the  foramen  ovale,  I  introduce  my  bayon- 
ette-shaped  needle  (Fig.  44),  mounted  on  the  syringe,  behind  the  wisdom  tooth 
and  make  it  penetrate  the  mucosa,  submucosa  and  external  pterygoid  muscle, 
then  I  pass  up  into  the  pterygoid  fossa  along  the  external  wing  of  the  pterygoid 
process  until  it  strikes  the  great  wing  of  the  sphenoid.  I  then  direct  the  point  of 
the  needle  backwards  into  the  angle  formed  by  the  pterygoid  process  and  the 
great  wing  of  the  sphenoid  until  bony  resistance  disappears,  and  the  foramen 
ovale  is  reached.  As  soon  as  the  fluid  is  injected  here  I  conduct  the  needle, 
always  in  the  above-mentioned  angle  of  the  pterygoid  fossa,  forwards  until  once 
more  the  sense  of  bony  resistance  is  lost.  The  needle  is  now  at  the  border  of  the 
sphenomaxillary  fossa.  Keeping  the  needle  continuously  on  the  anterior  surface 
of  the  pterygoid  fossa  I  push  the  needle  upwards  6  to  9  mm.,  reaching  the  fora- 
men rotundum,  and  can  feel  the  upper  border  of  the  foramen  formed  by  the 


Fig.  44. — (Ostwall.) 


little  osseous  bridge  with  separates  it  from  the  sphenoidal  fissure.  In  the  rare 
cases  where  the  first  branch  is  involved  along  with  the  second  or  with  the  second 
and  third  branches,  it  is  only  necessary  (once  the  injection  of  the  superior 
maxillary  is  completed)  to  pass  the  needle  about  2  mm.  higher,  passing  above 
the  little  osseous  bridge  already  mentioned,  where  it  encounters  the  ophthalmic 
branch  in  its  passing  through  the  sphenoidal  fissure."  Ostwalt  has  made  250 
deep  injections  in  tic  without  any  ill  effect.  In  at  least  one-third  of  the  cases 
there  was  recurrence  at  the  end  of  four  or  five  months,  but  these  recurrences 
were  less  serious  than  the  original  tic  and  were  relieved  by  one  or  two  more 
injections.  Although  as  a  rule  one  injection  gives  improvement  in  tic,  yet  two, 
three  or  four  seances  are  generally  required. 

Levy  and  Baudouin  write  ("La  Presse  Med.,"  Feb.  17,  1906):  "We  have 
used,  experimentally  and  clinically,  alcohol  and  chloroform  in  which  we  have 
dissolved  sublimate  or  carbolic  in  the  proportion  of  i  per  cent."  [One  per 
cent,  of  sublimate  is  evidently  a  mistake — Author.]  "We  do  not  employ  os- 
mic  acid  for  fear  of  necrosis.  The  following  is  our  practice.  We  inject  i  or  2 
c.c.  of  alcohol  (with  or  without  cocaine)  of  increasing  strength — 70,  80,  90 
per  cent.;  then  we  repeat  the  injections  of  these  strengths  of  alcohol  after 
adding  4  drops  of  chloroform  to  each  c.c.  of  alcohol.  Experiments  on  animals 
show  that  these  substances  in  the  doses  employed  by  us  are  harmless  even 
when  injected  intravenously.  The  puncture  itself  is  but  slightly  painful. 
Generally  when  the  nerve  trunk  is  reached  the  patient  complains  of  a  pain 


INJECTIONS    IN    TIC  6 1 

through  the  corresponding  territory.  .  .  .  The  injection  should  be  made 
very  slowly  and  the  needle  ought  not  to  be  withdrawn  for  fifteen  or  twenty 
seconds.  .  .  .  After  from  two  to  five  minutes  the  patient  complains  of  a 
feeling  of  stiffness,  of  swelling,  then  of  numbness  in  the  territory  of  the  in- 
jected nerve.  Sometimes  one  can  demonstrate  a  complete  anesthesia  which 
may  persist  for  a  long  time.  Usually  the  injection  is  followed  by  an  exacerba- 
tion of  the  pain  for  some  hours  and  the  patient  ought  to  be  warned  of  this.  In 
the  region  of  the  injection  there  is  a  slight  temporary  edema  and  after  injection 
of  the  inferior  maxillary  nerve  there  is  a  certain  difficulty  in  opening  the  mouth. 
As  a  rule  six  or  eight  injections  are  required  at  intervals  of  three  or  four  days. 
The  tolerance  of  the  patient  must  regulate  the  time  and  strength  of  the  injection. 
Experience  has  taught  us  that  it  is  necessary  to  inject  at  least  two  of  the  branches 
of  the  trifacial  nerve.  In  case  of  neuralgia  of  the  inferior  maxillary  or  of  the 
ophthalmic  nerves,  the  superior  maxillary  ought  also  to  be  injected.  In  case  of 
neuralgia  of  the  superior  maxillary  we  inject  the  inferior  maxillary  also."  J. 
B.  Murphy  uses  from  seven  to  fifteen  minims  of  a  2  per  cent,  solution  of  osmic 
acid  as  an  injection  material.  The  author  has  had  the  pleasure  of  seeing  some 
of  the  excellent  results  secured  by  Murphy. 

The  Operation. — The  only  special  instrument  required  is  the  Levy-Baudouin 
cannula.  The  cannula  is  of  steel  10  cm.  long,  i}'^  mm.  in  diameter  (Fig.  45), 
and.  is  graduated  in  centimeters.     The  mandrin  with  which  the  cannula  is 


Fig.  45. — -Levy-Baudouin  cannula. 


3<^3— ef 


provided,  when  pushed  home  protects  the  short  point  of  the  cannula  so  that 
no  injury  can  be  inflicted  on  such  structures  as  arteries. 
A.  Injection  of  the  Inferior  Maxillary  Nerve. 

1.  Levy-Baudouin  Method. — Note  the  bony  prominence  at  the  junction 
of  the  zygoma  with  the  anterior  bony  wall  of  the  external  auditory  meatus. 
Choose  a  point  on  the  lower  edge  of  the  zygoma  2.5  cm.  anterior  to  the  above 
bony  prominence.  At  this  point  introduce  the  cannula  directly  inwards  and 
immediately  under  (in  contact  with)  the  zygoma  for  a  depth  of  4  cm.  when  its 
point  must  be  at  the  foramen  ovale.  To  avoid  injuring  the  middle  meningeal 
artery,  push  the  mandrin  home  in  the  cannula  (thus  rendering  the  instrument 
blunt)  as  soon  as  a  depth  of  1.5  cm.  is  reached,  retire  the  mandrin  when  the 
depth  of  4  cm.  is  attained,  and  inject  the  chosen  solution. 

2.  Murphy's  Method. — Choose  a  point  at  the  middle  of  the  upper  edge 
(Figs.  46  and  47)  of  the  zygoma  and  here  introduce  the  needle  passing  it  directly 
inwards  until  it  strikes  either  the  squamous  portion  of  the  temporal  bone  or 
the  great  wing  of  the  sphenoid  and  guided  by  these  passes  inevitably  over  the 
foramen  ovale  at  a  depth  of  i3^  inches  (4  cm.)  from  the  outer  surface  of  the 
zygoma. 

3.  Gascard's  Method. — (La  Pr.  Med.,  August  25,  1919.)  Palpate  the  angle 
formed  by  the  zygoma  and  the  ascending  portion  of  the  malar  bone.     Introduce 


62 


TIC   DOULOURETJX 


the  needle  vertically  in  this  angle  immediately  above  the  zygoma.  At  a  depth 
of  about  23'-^  cm.  the  needle  will  hit  the  vertical  portion  of  the  great  wing  of 
the  sphenoid.     Lower  the  point  of  the  needle  a  few  millimeters  to  pass  round 


Fig.  46. — Injections  for  tic. 

the  angle  formed  by  the  vertical  and  horizontal  parts  of  the  great  wing  of  the 
sphenoid  and  push  the  needle  onwards  with  its  point  scraping  against  the  infe- 
rior surface  of  the  bone  until  it  reaches  the  foramen  ovale  exactly  5  cm.  from 


Fig.  47. — Injections  for  tic. 


the  superior  zygomato-malar  angle.  The  needle  cannot  penetrate  to  the  depth 
of  5  cm.  unless  it  is  in  the  right  direction. 

B.  Injection  of  the  Superior  Maxillary  Nerve. 

I.  Levy-Baudouin  Method. — Prolong  the  line  of  the  posterior  border  of  the 
ascending  (orbital)  process  of  the  malar  bone  to  the  lower  edge  of  the  zygoma 
and  insert  the  needle  3^  cm.  posterior  to  this  point.     Direct  the  needle  inwards 


INJECTIONS    IN   TIC  63 

and  slightly  upwards  in  a  direction  which  would  attain  at  the  depth  of  the  fora- 
men rotundum  (5  cm.),  the  level  of  the  inferior  extremity  of  the  nasal  bone. 
When  the  needle  has  penetrated  5  cm.  its  point  has  reached  the  nerve  where 
it  emerges  from  the  foramen  rotundum  into  the  pterygo-maxillary  fossa. 

2.  Murphy's  Method. — Draw  an  imaginary  line  vertically  downwards  from 
the  external  angular  process  of  the  frontal  bone;  where  this  line  crosses  the 
inferior  margin  of  the  zygoma  introduce  the  needle  directly  under  the  zygoma. 
Pass  the  needle  inwards  and  a  trifle  upwards  until  it  impinges  against  the  back 
of  the  superior  maxilla.  Guided  by  the  maxillary  bone  push  the  needle  on 
until  its  point  has  penetrated  i^  inches  (43^  cm.)  or  slightly  more  from  the 
surface  of  the  malar  and  has  reached  the  foramen  rotundum. 

C.  Injection  of  the  Ophthalmic  Nerve. 

Levy-Baudouin  Method. — These  authors  write:  "The  first  branch  of  the 
fifth  pair  dividing  inside  the  cranium  one  cannot  attack  its  trunk.  Of  the  three 
branches  the  nasal  is  hardly  accessible  in  the  midst  of  the  important  motor 
nerves  which  surround  it.  To  reach  the  frontal  and  lachrymal  nerves  the  orbital 
route  is  indicated.  As  a  path  to  the  nerve  we  have  chosen  the  external  wall  of 
the  orbit  at  the  level  of  the  inferior  extremity  of  the  external  angular  process  of 
the  frontal  bone.  Inserted  here  the  needle  passes  below  the  lachrymal  gland 
and  follows  the  periosteum  without  injury  to  the  eye  or  to  any  important 
organ.  At  a  depth  of  35  or  40  mm.  one  makes  the  injection  after  withdrawing 
the  mandrin.  The  patient  ought  to  have  his  eyes  closed.  The  needle  has 
some  difficulty  in  penetrating  the  outer  portion  of  Tenon's  capsule  which  is 
very  thick,'' 

Hugh  Patrick  has  had  much  experience  in  the  use  of  deep  injections  of 
alcohol  for  the  relief  of  tic  and  makes  some  characteristically  cautious  and 
sensible  remarks  thereon  ("Journ.  A.  M.  A.,"  Sept.  19,  1907),  a  synopsis  of 
which  is  given  here: 

The  number  of  injections  necessary  for  relief  depends  on  the  accuracy  with 
which  the  alcohol  is  placed.  A  single  injection  within  the  nerve  sheath  will 
stop  the  pain  at  once.  A  number  of  trials  may  be  necessary  before  this  can  be 
accomplished.  An  injection  near  though  not  in  the  nerve  is  not  without  value 
because  the  alcohol  "undoubtedly  diffuses  sufficiently  to  reach  it.  In  such 
cases  the  relief  comes  after  some  minutes  or  hours  and  does  not  last  long. 
Consequently  I  believe  it  is  wise  to  continue  the  injections  even  though  the 
patient  is  having  no  pain,  until  the  characteristic  sensory  phenoma"  (pain  and 
feeling  of  swelling  and  stiffness  in  the  area  supplied  by  the  nerve;  analgesia  in 
area)  "announce  marked  action  on  the  nerve."  If  pain  returns  there  seems  to 
be  no  objection  to  secondary  injections.  In  conversation  with  the  author 
Patrick  gave  the  impression,  no  doubt  correct,  that  a  permanent  cure  could 
hardly  be  expected  from  injections;  but  the  operation  is  trivial,  usually  gives  at 
least  temporary  relief  and  may  be  apparently  repeated  indefinitely. 

Fischer  ("Miinchener  med.  Woch.,"  1907,  No.  32)  reporting  the  result  of 
injections  of  alcohol  in  Erb's  clinic  for  various  neuralgias  warns  against  their 
use  in  mixed  or  in  motor  nerves  as  dangerous  consequences  have  arisen;  yet 
Patrick  and  others  have  injected  alcohol  into  the  facial  nerve  with  good  results 
in  facial  spasm  (not  tic)  without  causing  troublesome  facial  paralysis. 


64  TIC   DOULOUREUX 

D.  Injections  into  the  Gasserian  ganglion  itself  have  been  made  not  only^ 
to  relieve  the  pain  of  tic  but  to  produce  anesthesia  under  which  extensive 
operations  have  been  performed. 

Harris'  Method. — Step  i. — Draw  an  imaginary  line  from  the  "incisura  notch" 
(the  deep  notch  in  the  external  ear  above  the  lobule  and  between  the  tragus  and 
antitragus)  to  the  lower  border  of  the  ala  nasi.  This  line  in  the  average  skull 
corresponds  to  the  lower  border  of  the  sigmoid  notch.  Mark  out  the  lower 
border  of  the  zygoma,  especially  the  tubercle  in  front  of  the  glenoid  fossa; 
the  anterior  margin  of  this  tubercle  is  precisely  i  inch  in  front  of  the  external 
auditory  meatus.  Draw  a  vertical  line  through  the  anterior  margin  of  the  tuber- 
cle. This  line  meets  the  incisura-ala  nasi  line  practically  at  right  angles. 
"A  plane  through  this  vertical  perpendicular  to  the  zygoma  and  side  of  the 
cheek  passes  through  the  foramen  ovale." 

Step  2. — Choose  a  point  on  the  incisura-ala  nasi  line  /^  to  3^  inch  in  front 
of  the  crossing-point  of  the  two  lines  and  there  introduce  the  needle  upwards, 
backwards  and  inwards.  Harris  writes:  "My  needle  must  be  directed  very 
slightly  backwards  in  order  to  hit  the  plane  through  the  tubercle  line  at  the 
depth  of  the  foramen  ovale,  which  I  have  found  to  vary  from  42  to  54  mm., 
according  to  the  thinness  or  fatness  of  the  cheek,  and  according  to  the  narrow- 
ness or  great  width  of  the  head  of  the  individual.  The  angle  of  backward  direc- 
tion varies  from  15°  in  thin-faced  narrow-headed  subjects  to  even  vertically 
inwards  in  stout  wide-headed  people.  Similarly  the  angle  of  upward  direction 
varies  rarely  as  much  as  15°  and  it  may  be  almost  horizontal." 

When  the  inferior  maxillary  nerve  is  reached  the  patient  may  complain  of 
pain  in  the  lower  teeth  and  lip.  Attach  a  syringe  to  the  needle  and  inject  about 
i)-^  c.c.  of  I  per  cent,  eucaine  solution.  If  the  nerve  itself  has  been  injected 
there  will  be  immediate  anesthesia  of  the  lower  lip  and  chin  and  the  rest  of  the 
operation  will  be  practically  painless. 

Step  3. — Keeping  the  needle  in  the  original  direction,  feel  with  its  point  for 
the  foramen  ovale.  When  the  foramen  is  found  push  the  needle  onwards  into 
the  substance  of  the  ganglion  for  about  }/i  inch.  Attach  a  syringe  to  the 
needle  and  slowly  inject  a  drop  or  two  of  alcohol.  If  the  needle  is  in  the  gang- 
lion considerable  resistance  to  the  push  of  the  piston  will  be  noticed,  when 
another  i  to  1^2  c-C-  may  be  injected  a  few  drops  at  a  time.  During  the  in- 
jection test  sensation  on  the  forehead  by  pricking  with  a  blunt  pin;  when  a 
pin  prick  or  pin  pressure  is  no  longer  noticeable,  stop  the  injection  and  slowly 
withdraw  the  needle.  If  when  the  injection  is  begun  no  resistance  is  felt  to  the 
push  of  the  piston  and  if  the  patient  instantly  complains  of  severe  pain  at  the 
base  of  the  skull  and  back  of  the  head,  the  needle  is  not  in  the  nerve  but  in 
Meckel's  cave  and  cerebrospinal  fluid  may  escape  through  the  needle.  Under 
these  circumstances  withdraw  the  needle  slightly  and  reintroduce  it  through  the 
posterior  portion  of  the  foramen  so  as  to  keep  its  point  within  the  substance  of 
the  ganglion.  If  the  patient  complains  of  sudden  pain  in  the  cheek  and  nose 
after  the  needle  enters  the  foramen,  it  means  that  it  has  passed  in  front  of  the 
ganglion  and  has  struck  the  root  of  the  superior  maxillary  nerve  before  the  nerve 
has  reached  the  foramen  rotundum.  Harris  uses  nickelled-steel  needles  3 
inches  and  3^^  inches  in  length  and  1.25  mm.  and  1.4  mm.  diameter,  provided 


NEURECTOMY  65 

with  a  stylet,  and  with  a  short  sharp  point  bevelled  at  an  angle  of  20  per  cent. 
The  Levy-Baudouin  cannula — 10  cm.  long,  i^^  mm.  diameter,  graduated  in 
centimeters  and  provided  with  a  mandrin — ought  to  do  well. 

HdrteVs  Method.  ("Zent.  fur  Chir.,"  May  25, 191 2.) — A  stylet  passed  from 
the  "impressio  trigemini"  through  the  foramen  ovale  will  reach  the  masseteric 
region  midway  between  the  anterior  margin  of  the  ascending  ramus  of  the  lower 
jaw  and  the  posterior  margin  of  the  maxillary  tubercle;  in  90  per  cent,  of  skulls 
the  stylet  hits  the  upper  alveolus  in  the  molar  region.  The  distance  from  the 
foramen  ovale  (extra-cranial)  to  the  cheek  is  5  to  6  cm.;  from  the  outer  surface 
of  the  skull  at  the  foramen  ovale  to  the  impressio  trigemini  it  is  not  less  than 
1.5  cm.,  averaging  1.9  cm.  A  needle  passed  up  this  line  is  so  limited  in  its 
lateral  movements  that  it  cannot  injure  the  cavernous  sinus  internally,  the  brain 
above  or  the  carotid  below  the  Gasserian  ganglion. 

Technic. — Use  a  very  fine  graduated  canula  9  cm.  long.  Choose  a  point 
on  the  cheek  2  to  3  cm.  behind  the  angle  of  the  mouth.  Anesthetize  the  skin 
here  and  introduce  the  needle  upwards  to  pass  between  the  ascending  ramus  and 
the  maxillary  tubercle  until  the  infratemporal  plane  is  reached.  When  the 
needle  hits  the  hard,  smooth  temporal  bone,  feel  or  explore  backward  with  the 
point  of  the  needle  for  the  foramen  ovale.  Hartel  uses  the  following  important 
landmarks  to  direct  the  needle:  Viewed  directly  from  in  front  aim  the  needle 
at  the  pupil  of  the  eye  on  the  same  side;  viewed  from  the  side  aim  it  at  the 
articular  tubercle  of  the  zygoma. 

As  soon  as  the  third  branch  of  the  nerve  is  touched  there  is  paresthesia  or 
shooting  pains  in  the  lower  teeth  and  the  needle  may  be  slowly  pushed  through 
the  foramen  ovale  until  the  pain  in  the  upper  jaw  is  evident.  Now  inject  as 
slowly  as  possible  3^  to  i)^  c.c.  of  2  per  cent,  novocain-adrenalin  solution. 
Anesthesia  is  immediate  and  lasts  i  to  2  hours. 

NEURECTOMY  OF  THE   FIRST  DIVISION  OF  THE 
FIFTH  NERVE 

The  first  or  ophthalmic  division  of  the  fifth  nerve  enters  the  orbit  through 
the  sphenoidal  fissure  and  divides  into  three  branches — the  frontal,  lachrymal, 
and  nasal.  The  frontal  nerve,  the  only  branch  of  surgical  importance,  divides 
into  the  supraorbital  and  supratrochlear.  The  supraorbital  leaves  the  orbit 
through  a  notch  or  foramen  situated  at  the  junction  of  the  inner  and  middle 
thirds  of  the  supraorbital  margin.  With  it  run  the  supraorbital  artery  and 
vein. 

NEURECTOMY   OF  THE   SUPRAORBITAL  NERVE 

Locate  the  supraorbital  notch  or  foramen.  Make  a  horizontal  incision 
through  the  skin,  parallel  to  and  a  little  below  the  eyebrow.  Separate  the 
fibres  of  the  orbicularis  muscle.  Expose  the  nerve  as  it  passes  through  the  supra- 
orbital notch.  Divide  the  orbitotarsal  ligament.  With  a  flat  retractor  depress 
the  orbital  fat.  Follow  the  nerve  backwards  from  the  supraorbital  notch, 
separate  it  from  its  surroundings,  divide  it  as  far  back  as  possible,  and  remove 
all  of  it  in  front  of  the  point  of  section.     Close  the  wound  with  sutures.     Dress, 


66  TIC   DOULOUREUX 

A  good  modification  of  the  operation  is  the  following:  Expose  the  nerve 
at  its  exit;  isolate  it  for  a  short  distance;  seize  its  undivided  trunk  with  a  narrow- 
bladed  hemostat;  rotate  the  hemostat  so  that  the  nerve  becomes  wound  around 
the  jaws  of  the  forceps;  reverse  the  direction  of  rotation.  By  repeating  the 
manoeuvres  of  rotation  and  working  slowly  and  patiently  almost  the  whole 
peripheral  portion  of  the  nerve  and  much  of  its  central  trunk  can  be  extracted. 
(Thiersch.) 

NEURECTOMY  OF  THE  SUPRATROCHLEAR 

The  supratrochlear  nerve  is  generally  divided  in  the  preceding  operation, 
but  occasionally  it  is  missed  and  demands  special  attention.  Draw  an  imagi- 
nary line  from  the  angle  of  the  mouth  through  the  inner  canthus  of  the  eye. 
At  a  point  a  little  below  where  a  continuation  of  the  above  line  crosses  the 
eyebrow  make  an  incision  through  the  skin  parallel  to  the  fibres  of  the  orbicularis 
muscle.  Find  the  trochlea,  which  acts  as  a  pulley  for  the  superior  oblique 
muscle.  Locate  the  posterior  portion  of  the  superior  oblique  muscle.  The 
supratrochlear  nerve  and  its  branch,  the  infratrochlear,  lie  upon  the  superior 
oblique  muscle  and  may  be  separated  from  it  by  a  strabimus  hook  and  excised. 

NEURECTOMY  OF  THE   SECOND  DIVISION  OF  THE 
FIFTH  NERVE 

Anatomy. — The  superior  maxillary  nerve  "commences  at  the  middle  of 
the  Gasserian  ganglion,  and,  passing  horizontally  forwards,  soon  leaves  the 
skull  by  the  foramen  rotundum  of  the  sphenoid  bone.  The  nerve  then  crosses 
the  sphenomaxillary  fossa,  and,  taking  the  name  of  infraorbital,  enters  the 
infraorbital  canal  of  the  upper  maxilla,  by  which  it  is  conducted  to  the  face" 
(Fig.  48). 

"In  the  sphenomaxillary  fossa  an  orbital  or  temporo-malar  branch  ascends 
from  the  superior  maxillary  nerve  to  the  orbit,  and  two  sphenopalatine  branches 
descend  to  join  Meckel's  ganglion;  while  the  nerve  is  in  contact  with  the  upper 
maxilla  it  furnishes  the  superior  dental  or  alveolar  branches;  and  on  the  face 
are  the  terminal  branches"  (Quain). 

When  the  neuralgia  is  limited  to  the  facial  distribution  of  the  nerve,  the 
following  operations  may  be  performed: 

(A)  Locate  the  infraorbital  foramen  at  the  junction  of  the  inner  and  middle 
thirds  of  the  inferior  rim  of  the  orbit  and  about  half  an  inch  below  it.  It  is 
on  a  line  drawn  from  the  supraorbital  notch  to  a  point  between  the  two  bicuspids. 
Make  a  curved  transverse  incision  parallel  and  close  to  the  lower  margin  of  the 
orbit.  Divide  the  orbicularis  muscle  in  a  direction  parallel  to  its  fibres.  Expose 
the  nerve  as  it  leaves  the  infraorbital  foramen  (Fig.  49).  Seize  the  nerve  in 
forceps,  and  by  traction  and  torsion  extract  as  much  of  its  trunk  from  its  bony 
canal  as  is  possible.  In  the  same  fashion  extract  as  much  of  its  terminal  twigs 
as  possible  from  the  soft  structures  in  which  they  run.  It  is  extraordinary  how 
much  of  the  nerve  can  be  removed  in  this  manner  if  patience  is  exerted.  This 
operation  does  not  destroy  the  alveolar  branches  of  the  nerve.     In  an  endeavor 


NEURECTOMY   TIC 


67 


to  prevent  recurrence  one  may  plug  the  bony  canal  with  a  bone  peg,  silver  screw, 
rubber  tissue,  or  amalgam. 

(B)  Expose  the  nerve  as  in  Method  A,     Opposite  the  infraorbital  foramen 
make  a  vertical  incision  (a)  through  the  soft  parts  joining  the  horizontal  incision 


ophthalmicus 
supramaxiUaria 
sphenopatai 
For.  oval. 


iframaxillarit 


Fig.  48. — {Esmarch  and  Kowalzig.) 

at  right][angles  (Fig.  50).     Divide  the  periosteum  along  the  lower  margin  of  the 
orbit.     Separate  the  periosteum  covering  the  floor  of  the  orbit  from  the  bone. 


Fig.  49. — Evulsion  infraorbital  nerve. 

If  this  IS  done,  no  orbital  fat  should  be  seen.     With  a  flat  retractor  lift  the  orbital 
contents  upwards  (Fig.  51).     With  a  narrow  chisel  cut  through  the  bone  all 


68 


TIC   DOULOUREUX 


round  the  infraorbital  foramen  and  remove  it  until  that  part  of  the  osseous  canal 
which  is  covered  by  a  thin  shell  of  the  bone  forming  the  orbital  floor,  is  exposed. 
With  the  chisel  cut  away  the  bony  roof  of  the  infraorbital  canal  to  its  posterior 
extremity.     This  can  generally  be  accomplished  without  opening  the  antrum  of 


Fig. 
Figs.  50  .and 


ii. — Excision  infraorbital  nerve. 


Fig.  51. 
(Esmarch  and  K owalzig.) 


Highmore.  Lift  the  nerve  from  its  bed  and  excise  it.  Close  the  wound  with 
sutures.  Dress.  The  scar  left  by  the  operation  is  trifling.  Several  operations 
have  been  devised  to  excise  the  superior  maxillary  nerve  and  Meckel's  ganglion 
by  the  antral  route.     Any  operation  in  which  the  antrum  of  Highmore  is  opened 

is  undesirable  on  the  score  of  uncleanliness, 
and  the  advantages  of  such  methods  are 
more  fully  obtained  by  the  operation 
about  to  be  described. 

Ptery  go -maxillary  Operation.  (Braun 
and  Lossen's  Modification  of  Lucke's 
Operation.) — Step  1. — Expose  the  infra- 
orbital nerve  at  its  exit  from  the  bone. 

Step  2. — Beginning  at  a  point  just  be- 
hind and  below  the  external  angular  proc- 
ess of  the  frontal  bone,  make  an  incision 
backwards  and  downwards  to  near  the 
tragus.  From  the  same  starting-point 
make  another  incision  downwards  and 
forwards  to  the  lower  margin  of  the 
zygoma.  Reflect  downwards  the  triangu- 
lar flap  of  skin  and  subcutaneous  tissue 
thus  outlined.  With  a  finger  saw,  chisel, 
or  Gigli  wire  saw  divide  the  zygoma  in 
front  and  behind.  Rose  recommends  that  before  the  zygoma  is  divided  holes 
be  bored  on  each  side  of  the  line  of  section  so  that  everything  may  be  ready 
for  wiring  the  fragments  in  position  on  the  completion  of  the  active  part  of 
the  operation.  Separate  the  temporal  fascia  from  the  upper  edge  of  the  zygoma 
and  turn  the  bone  downwards.  Retract  the  tendon  of  the  temporal  mus- 
cle backwards.     The  pterygo-maxillary  fossa  is  exposed,  with  its  fat  and  plexus 


Fig. 


;2. — Excision    superior     maxillary 
nerve.     {Farabeuf.) 


NEURECTOMY    TIC  69 

of  veins.  If  one  now  pushes  the  fat  back  with  a  blunt  retractor,  one  at  the 
same  time  keeps  the  venous  plexus  and  internal  maxillary  artery  out  of  the 
way.  Demonstrate  the  posterior  orbital  fissure  with  a  probe  or  strabismus 
hook  and  distinguish  the  superior  maxillary  nerve  and  its  accompanying 
vessel  (Fig.  52).  The  course  of  the  nerve  from  its  exit  from  the  skull  is  down- 
wards, forwards  and  outwards.  The  artery  runs  inwards,  forwards  and 
upwards. 

Step  3. — Tie  a  ligature  round  the  nerve  for  the  purpose  of  traction.  Divide 
the  central  end  of  the  nerve  as  close  to  the  foramen  rotundum  as  possible. 
By  traction  and  torsion  pull  the  peripheral  end  of  the  nerve  out  of  its  bony 
canal.  By  this  operation  the  whole  trunk  of  the  nerve  is  excised  from  the 
foramen,  rotundum  to  the  cheek. 

Step  4. — Attend  to  hemostasis.  Replace  the  zygoma  and  fix  it  in  position 
by  wire  or  chromicized  catgut  sutures.  Provide  drainage.  Close  the  skin 
wound.     Dress. 

NEURECTOMY   OF   THE   THIRD    DIVISION   OF   THE   FIFTH 

The  inferior  maxillary  or  third  division  of  the  fifth  nerve  leaves  the  skull 
through  the  foramen  ovale  and  divides  into  an  anterior,  motor  and  a  postel 
rior  division.  The  latter,  almost  entirely  sensory,  divides  into  the  auriculo- 
temporal, the  lingual,  and  the  inferior  dental.  The  lingual  and  the  inferior 
dental  are  of  surgical  importance,  and  as  they  are  generally  both  involved, 
if  either  of  them  is  affected  by  neuralgia,  their  excision  may  be  considered  as 
part  of  one  operation.     (See  Fig.  48.) 

The  Operation. — Shave  the  temple.  Clean  the  side  of  the  face  and  the 
external  auditory  meatus,  and  plug  the  latter  passage  with  a  little  gauze  or 
better  with  non-absorbent  cotton. 

Step  I. — Beginning  about  the  middle  of  the  zygoma  cut  backwards  and 
slightly  downwards  to  a  point  a  little  below  the  tragus,  then  continue  the  in- 
cision downwards  along  the  posterior  margin  of  the  ascending  ramus  to  the 
angle  of  the  lower  jaw.  From  this  point  cut  forwards  along  the  inferior  edge 
of  the  horizontal  ramus  for  about  ^  inch.  The  cut  only  involves  the  skin 
and  subcutaneous  tissue.  Reflect  the  skin-flap,  outlined  as  above,  forwards. 
The  flap,  consisting  of  skin  alone,  leaves  the  branches  of  the  facial  nerve  un- 
injured. Note  carefully  the  position  of  Stenson's  duct  and  of  the  anterior 
lobules  of  the  parotid  gland.  Make  a  transverse  incision  parallel  to  and  below 
Stenson's  duct,  directly  down  to  the  bone,  at  a  point  about  3^2  inch  below 
the  sigmoid  notch.  Any  portions  of  the  parotid  gland  which  may  be  in  the 
way  must  be  retracted  backwards  uninjured.  With  a  periosteal  elevator  de- 
nude the  outer  surface  of  the  ascending  ramus  of  the  jaw  for  a  distance  of  one 
inch  or  more  below  the  sigmoid  notch. 

Step  2. — Apply  a  ^-inch  trephine  to  the  outer  surface  of  the  bone,  the  upper 
edge  of  the  trephine  being  not  more  than  }/i  inch  below  the  edge  of  the  sigmoid 
notch  (D,  Fig.  53).  With  the  trephine  perforate  the  ascending  ramus  and 
remove  the  button  of  bone.     With  rongeur  forceps  remove  the  bridge  of  bone 


70  TIC   DOULOUREUX 

(C,  Fig.  53),  separating  the  trephine  hole  from  the  sigmoid  notch.  The  result 
of  the  above  manoeuvres  is  to  deepen  the  sigmoid  notch  while  the  coronoid 
and  articular  processes  are  left  in  uninterrupted  connection  with  the  rest  of 
the  jaw. 

Step  3. — Retract  the  tendon  of  the  temporal  muscle  forwards.  With  two 
pairs  of  dissecting  forceps  pick  away  any  fat  which  may  be  in  the  way  and 
demonstrate  the  external  pterygoid  muscle,  which  passes  transversely  across 
the  wound  from  the  outer  surface  of  the  external  pterygoid  plate  to  the  articular 
process  of  the  lower  jaw.  Note  also  the  fibres  of  the  internal  pterygoid  run- 
ning downwards  and  backwards  from  the  pterygoid  fossa  to  the  inner  surface 

of  the  lower  jaw  near  its  angle.  Retract  upwards 
the  lower  fibres  of  the  external  pterygoid  and  thus 
expose  both  the  lingual  and  inferior  dental  nerves, 
which,  resting  upon  the  internal  pterygoid  muscle, 
come  out  from  under  the  external  pterygoid  and  run 
downwards.  The  lingual  nerve  lies  a  little  internal 
and    anterior    to    the    dental.     Tie    a    ligature,    for 

purposes  of  traction,  round  each  nerve.  Trace  the 
Fig.    5?. — Excision  inferior  .       ^1       r  1  j    j-    -j      .1 

dental  nerve.  nerves  up   to  the  foramen  ovale  and  divide  them 

there.  Trace  the  nerves  downwards  and  either  di- 
vide them  or  by  torsion  and  traction  tear  away  as  much  of  their  peripheral 
portion  as  can  be  extracted.  It  is  easy  to  remove  more  than  an  inch  of  the 
nerves. 

Step  4. — Attend  to  hemostasis.  Close  the  skin-wound  Drainage  may  or 
may  not  be  used.     Dress. 

In  certain  cases  of  very  painful  cancers  of  the  tongue  relief  may  be  secured 
temporarily,  at  least,  by  section  of  the  lingual  nerves. 

Leriche  (Lyon.  Med.,  Jan.  18, 1914)  agrees  with  Hayem  that  besides  aeroph- 
agy  due  to  a  reflex  having  its  origin  at  the  level  of  the  stomach  certain  cases 
are  due  to  a  primary  hypersalivation.  In  one  case  of  the  latter  after  various 
regimes  had  failed  to  relieve,  he  divided  both  lingual  nerves  and  the  right 
auriculo-temporal  nerve.  The  desired  result  was  obtained;  there  was  no  longer 
hypersalivation,  the  aerophagy  and  its  consecutive  gastric  disturbances  disap- 
peared. The  patient  was  satisfied  but  complained  of  an  impediment  due  to 
the  lingual  anaesthesia. 

The  simplest  method  of  exposing  the  lingual  nerve  is  through  the  mouth. 
Open  the  mouth  widely.  Pull  the  tongue  forcibly  to  the  opposite  side  so  as  to 
make  the  nerve  stand  out  in  relief  below  the  mucous  membrane  of  the  tongue 
behind  the  last  lower  molar  tooth.  Make  a  3^-inch  incision  along  the  course  of 
the  nerve  and  after  picking  it  up  with  a  blunt  hook  excise  as  much  as  desired. 
The  wound  in  the  mucosa  requires  no  sutures. 

The  auriculo-temporal  nerve  may  be  exposed  by  a  ^^-inch  vertical  incision 
midway  between  the  tragus  and  the  condyle  of  the  jaw  at  the  level  of  the  posterior 
root  of  the  zygoma.  The  nerve  is  posterior  and  parallel  to  the  superficial  tem- 
poral artery. 

Inferior  Dental  Nerve.    Transmaxillary  Neurectomy. 

Step  I. — From  the  angle  of  the  lower  jaw  make  an  incision  for  about  1}^^ 


NEURECTOMY   TIC  7 1 

inches  forwards  along  the  lower  border  of  the  horizontal  ramus.  With  an 
elevator  separate  the  masseter  from  the  bone.  If  necessary  continue  the 
incision  upwards  along  the  posterior  border  of  the  ascending  ramus  for  about 
^'4  inch.  Expose  the  greater  part  of  the  external  surface  of  the  ascending 
ramus. 

Step  2. — Note  the  line  of  the  free  border  of  the  teeth  of  the  lower  jaw  and 
continue  this  as  an  imaginary  line  across  the  ascending  ramus;  on  this  line  choose 
a  spot  midway  between  the  anterior  and  pos- 
terior borders  of  the  ramus  and  at  this  spot 
apply  a  Doyen's  bur  (about  i6  mm.  in  di- 
ameter) and  bore  a  hole  sufficiently  deep  to 
expose  the  inferior  dental  canal  and  the 
nerve  in  it.  The  bur  is  a  better  instrument 
to  use  than  a  trephine  as  it  is  not  so  liable 
to  injure  the  nerve. 

Step  3. — The  nerve  is  seen  lying  in  the 
depth  of  the  wound  (Fig.  54).     Pick  up  the  "'^^^^7:: 

nerve  in  a  forceps  and  evulse  it  after  the  fig.  54.— Excision  inferior  dental 
manner  of  Thiersch.     Pack  the  bone  canal  n^^^^e.    {Lemrmant.) 

with  rubber  tissue,  hard  paraffin,  amalgam  or  some  such  material. 

Step  4. — Close  the  wound. 

The  author  has  found  this  operation  very  satisfactory. 

All  the  operations  of  neurectomy  which  have  been  described  give  at  least 
temporary  relief,  but  too  frequently  the  tic  returns  after  the  lapse  of  a  year  or 
two.  Occasionally  the  patient  does  not  seem  to  get  immediate  relief  from 
his  pains.  The  author  has  in  mind  one  case  in  which  he  removed  portions 
of  the  inferior  dental  and  lingual  nerves.  The  patient  suffered  from  neuralgia 
for  one  or  two  djiys  after  the  operation.  The  pain  was  at  once  relieved  on 
the  removal  of  bloody  fluid  which  had  collected  in  the  deep  wound.  Had 
the  wound  been  efficiently  drained,  the  temporary  trouble  might  have  been 
averted. 

None  of  the  operations  of  neurectomy  for  tic  douloureux  which  have  been 
described  here  are  dangerous  when  performed  by  an  experienced  surgeon, 
but  they  are  not  a  proper  field  for  invasion  by  a  tyro  in  surgery.  In  almost 
all  the  operations  the  wounds  while  large,  are  so  situated  as  to  cause  but  little 
deformity  from  scar,  especially  if  the  subdermal  suture  is  used  in  closing 
them. 


HARTLEY-KRAUSE   OPERATION 

It  has  been  shown  that  tic  douloureux  almost  always  recurs  after  even 
the  most  extensive  excision  of  the  nerve-trunks  involved.  It  has  also  been 
shown  (Keen  and  Spiller)  that  in  the  Gasserian  ganglion  very  marked  degen- 
eration is  present.  When  neurectomy  fails  to  give  permanently  good  results,  it 
is  most  logical  to  attack  the  Gasserian  ganglion.  This  has  been  done  in  many 
cases  with  excellent  effect.     The  Gasserian  ganglion  may  be  exposed  either 


72 


TIC   DOULOUREUX 


from  below  or  from  above.  The  former  method  has  been  thoroughly  studied 
by  Rose,  Andrews  and  others.  Their  route  entails  temporary  resection  of 
the  zygoma  and  the  coronoid  process,  the  use  of  the  inferior  maxillary  nerve 
as  a  guide  to  the  foramen  ovale,  exposure  of  the  base  of  the  skull  beside  that 
opening,  the  removal  of  a  button  of  bone  from  the  exposed  portion  of  skull 
with  a  trephine,  and  lastly  a  rather  haphazard  removal  of  the  ganglion  when 
it  is  reached.  Anyone  who  has  had  occasion  to  operate  in  the  neighborhood 
of  the  foramen  ovale  can  appreciate  the  difficulties  of  the  operation.  Hartley 
and  Krause  almost  simultaneously  devised  a  method  of  reaching  the  Gasserian 
ganglion  by  an  intracranial  route. 


Fig.  55. — {Frazicr,  Jour.  A.  M.  A.) 

Position  of  Patient. — Frazier  places  the  patient  in  the  sitting  posture  (special 
operating  chair)  claiming  that  less  ether  is  required,  that  there  is  less  venous 
bleeding  and  that  as  the  plane  of  the  floor  of  the  skull  is  level  with  the  surgeons 
eye  he  may  stand  erect  and  look  directly  at  the  structures  on  which  he  is 
working. 

Pussep  (Russki  Wratsck,  191 2,  No.  2.  Zentfur.  Chir.,  191 2,  No.  24)  advises 
that  the  patients  head  be  placed  hanging  down  and  somewhat  to  the  side  so 
that  the  weight  of  the  brain  acts  in  place  of  a  retractor.  (See  Bogojawlensky's 
position.) 

Anesthetic. — Ether.  Deep  anesthesia  is  not  required  and  after  the  root  is 
divided  the  anesthetic  may  be  discontinued. 

The  Operation. — The  shortest  route  to  the  ganglion  is  from  the  middle  of  the 
zygoma. 


GASSERIAN    GANGLION 


73 


Step  1.— Make  and  reflecl  forwards  the  skin  flap  shown  in  Fig.  55.  This 
avoids  injury  to  the  upper  division  of  the  facial  nerve.  Make  and  reflect  liack- 
wards  and  forwards  the  temporal  musculo-aponeurotic  flaps  as  shown  in  Fig.  55. 


Fig.  56.— (/'Vc/c/o-,  Jour.  A.  M.  A.) 


Fig.  S7 -—(Frazier,  Jour.  A.  M.  A.) 

Attach  all  these  flaps  by  sutures  to  the  drapings  around  the  operative  area  and 
thus  avoid  the  use  of  retractors.  Control  hemorrhage  as  described  in  Cushing's 
subtemporal  decompression. 


74 


TIC    DOULOUREUX 


Step  2. —  A  short  distance  above  the  zygoma  ojien  the  skull  with  a  suitable 
bur.  Enlarge  the  opening  with  rongeurs  until  it  is  about  4  cm.  (i3^  in.)  in 
diameter.     The  lower  margin  of  the  opening  extends  to  the  base  of  the  skull. 

Step  3. — Separate  the  dura  slowly  from  the  temporal  bone  and  the  base  of 
the  skull  following  the  middle  meningeal  artery  to  the  foramen  si)inosumr     Plug 


^FiG.  58. — {Frazier,  Jour.  A.  M.  A.) 

the  foramen  with  a  twisted  bit  of  moistened  cotton  or  with  bone  wax,  and 
divide  the  artery  (Fig.  56,  ).  Continue  the  separation  to  the  foramen  ovale. 
Step  4. — Note  the  dural  reflection  on  the  mandibular  division  of  the  nerve 
as  it  enters  the  foramen  ovale  (Fig.  57).  Open  this  reflection  and  enlarge  the 
opening  until  the  upper  surface  of  the  ganglion  is  stripped  of  its  dural  covering. 
Follow  the  ganglion  upwards  until  at  the  apex  of  the  petrous  bone  the  sensory 
root  is  seen  (Fig.  58). 


Ophthalmic  division . 

Superior  Maxillary 
division. 


Hutchinson's  line  of  section. 
Casseriati  Cati^lion. 

Middle  Meninjeal Arfety. 


MecKal's  Canglii 

Ifif trior  Maxillar/ division. 
Fig.  59. — Left  Gasserian  ganglion  exposed  from  the  side. 

Step  5. — Isolate  the  sensory  root;  pick  it  up  on  a  small  blunt  hook  and  by 
gentle  traction  sever  it  from  its  central  attachment. 

Step  6. — Close  the  wound. 

During  the  operation  a  proper  retractor  provided  with  an  electric  light 
(Fig.  57)  is  valuable.  To  avoid  keratitis  Frazier  advises  the  use  of  goggles  for 
a  year  after  operation  when  the  patient  is  out  of  doors. 


GASSERIAN    GANGLION  75 

Jonathan  Hutchinson,  Jr.,  advocates  division  of  the  sujicrior  and  inferior 
maxillary  nerves  and  removal  of  the  corresponding  j)ortion  of  the  ganglion 
leaving  intact  the  ophthalmic  division  and  its  i)ortion  of  ganglion    (Fig.  59). 

THE   ABBfi   OPERATION 

Abbe,  to  avoid  the  dangers  of  hemorrhage,  shock,  and  prolonged  operation, 
has  given  up  attempts  to  formally  resect  the  Gasserian  ganglion.  He  performs 
an  intracranical  neurotomy  or,  preferably,  neurectomy,  and  then  prevents 
reunion  of  the  divided  nerves  by  interposing  a  layer  of  thin  rubber  tissue, 
sterilized  by  immersion  in  corrosive  sublimate  solution,  which  is  washed  ofif 
with  salt  solution.  To  lesson  hemorrhage  from  the  middle  meningeal  artery 
Abbe  ligates  the  external  carotid  just  above  the  thyroid. 

'*Ligate  the  external  carotid;  make  a  straight  incision  in  the  temporal 
fossa  above  the  zygoma;  split  the  temporal  muscle,  scraping  it  widely  from  the 
bone,  and  enter  the  skull  by  a  small  trephine  opening,  rapidly  enlarged  by 
rongeurs  to  one  and  one-half  inches  in  diameter.  Expose  the  second  and 
third  branches  from  the  Gasserian  ganglion  to  the  foramina.  Seize  each  at 
the  foramen  by  a  narrow  clamp,  cut  it,  and  resect  a  half-inch  or  tear  it  from 
the  ganglion;  push  back  the  dura  well  beyond  the  foramina;  arrest  bleeding 
by  a  moment's  pressure,  and  spread  over  the  bone  a  piece  of  sterile  rubber 
tissue,  enough  to  more  than  cover  both  foramina,  one  inch  wide  by  an  inch 
and  a  half  in  length,  which  must  be  pressed  upon  the  bone  by  a  strip  of  gauze 
packed  over  it  for  a  couple  of  minutes.  When  this  is  removed,  the  rubber 
tissue  lies  in  close  contact  with  the  skull  and  the  dura  is  allowed  to  settle  down 
to  its  place  upon  it.  The  wound  is  then  closed  by  a  few  fine  catgut  sutures 
and  drained  for  a  day  at  its  lower  angle."     ("Trans.   Am.   Surg.  Assoc," 

1903-) 

G.  R.  Fowler  has  used  Crile's  plan  of  temporary  occlusion  of  both  common 

carotids  and  found  it  useful.     In  one  case  a  tape  passed  round  the  carotid 

and  secured  by  a  clamp,  pressed  against  the  internal  jugular  vein  and  caused 

much  venous  oozing  during  the  operation. 

When  should  one  practise  excision  of  the  Gasserian  ganglion?  In  cases 
of  intolerable  tic  douloureux  one  should  try  the  milder  operations  of  neu- 
rectomy, as  they  give  at  least  temporary  relief,  and  so  permit  the  strength  of 
the  patients  to  be  built  up.  This  is  important,  as  the  sufferers  from  tic  doulour- 
eux are  often  much  reduced  from  their  long-continued  agony.  Surgeons  are 
coming  more  and  more  to  favor  excision  of  the  ganglion  as  the  primary  operation 
and  with  this  change  of  opinion  the  author  is  in  sympathy. 

V.  Pleth  (Am.  Jour,  of  Surg.,  May,  19 19)  reports  uniformly  good  results  in 
fifty  cases  of  Tic  in  which  he  performed  cervical  sympathectomy  with  or  with- 
out deep  and  superficial  injections  of  alcohol.  Apparently  it  is  the  superior 
ganglion  which  he  attacks.  In  some  cases  alcohol  injections  are  used  to  obtain 
immediate  results  as  the  full  benefit  from  the  sympathectomy  is  not  obtained 
until  three  months  or  more  have  elapsed. 


76 


EXTERNAL   EAR 


CHAPTER  V 
PLASTIC   OPERATIONS   ON  THE  EXTERNAL  EAR 

The  external  ear  when  very  large  or  very  projecting  may  be  operated  on 
for  cosmetic  reasons. 

Macrotia. — The  pinna  is  uniformly  enlarged  but  does  not  project  out- 
wards unnaturally.     Make  the  incision  AB  (Fig.  60)  through  the  whole  thick- 


ness of  the  pinna.  Pull  the  upper  segment  of  pinna  over  the  lower  segment 
to  see  how  much  tissue  must  be  removed  in  order  to  correct  the  deformity 
(Fig.   61).     Make  a  cut  from  D  to  B  and  remove  the  overlapping  triangle 


N'-' 


Fig.  63. 


of  tissue  DEC.  The  edge  of  the  pinna  at  D  does  not  correspond  with  the 
edge  of  the  pinna  at  A,  therefore  cut  away  a  wedge-shaped  segment  of  pinna 
DEB  (Fig.  62)  and  so  permit  the  point  D  to  be  brought  out  to  the  point  A. 
With  sutures  introduced  alternately  from  the  outer  and  inner  side  of  the  ear, 
unite  the  edge  DEB  to  the  edge  AB.  Instead  of  lengthening  the  wound  edge 
DB,  it  might  be  possible  to  shorten  the  edge  AB  by  cutting  out  the  wedge 
of  tissue  XYZ  (Fig.  62). 


SYNECHIA    EAR 


77 


(A)  Plastic  Restoration  of  Lobule.— The  lobule  of  the  ear  may  be  absent 
congeni tally  or  may  have  been  removed  by  accident  or  for  disease.  If  removed 
for  disease  it  may  be  replaced  at  the  primary  operation  or  later. 

GaveWs  Operation. — Step  i. — Freshen  the  stump  of  the  lobule.  Apply 
pressure  with  a  hot  pad  to  stop  bleeding.     Retract  the  stump  upwards. 

Step  2. — Reflect,  and  fold  on  itself  the  flap  ABC  (Fig,  63).  With  sutures 
keep  the  two  raw  surfaces  of  the  flap  together. 

The  flap  or  new  lobule  must  be  one-third  larger  than  the  normal  lobule; 
this  to  allow  for  shrinkage. 


Fig.  64. — {Laurens.) 


Fig.  65. — {Laurens.)  Fig.  66. — {Lauretis.) 


Step  3. — Suture  the  upper  edge  of  the  new  lobule  to  the  vivified  stump  of 
the  old  lobule. 

Step  4. — Close  the  wound  in  the  neck  either  by  sliding  of  skin  or  by  grafts. 

(B)  Coloboma  of  Lobule. — A  part  of  the  lobule  may  be  absent  either 
congenitally  or  as  the  result  of  accident,  usually  the  result  of  necrosis  follow- 
ing piercing   of   the  lobule  with  dirty  instruments.     Nelaton's  method  of 
operating  will  be  easily  understood  by  glancing  at  Figs.  64,  65,  66. 


SYNECHIA  OF  LOBULE 


Occasionally,  instead  of  hanging  in  the  normal  fashion  the  lobule  is  adherent 
to  the  body  through  its  whole  length.  The  deformity  may  be  annoying. 
The  following  method  is  suggested  for  correction  of  the  synechia:  Mark  the 
line  along  which  the  lobule  ought  to  be  separated.  In  front  of  the  ear  raise 
the  flap  X  (Fig.  67),  having  its  base  corresponding  to  the  above-mentioned 
line  and  attached  to  the  ear.  Behind  the  ear  elevate  the  flap  Y,  having  its 
base  or  pedicle  attached  to  the  neck  (Fig.  68).  Divide  the  lobule  along  the 
line   AB.     Attend   to  hemostasis.     With   the  flap  X   cover   the  wound  now 


78 


EXTERNAL   EAR 


existing  on  the  new  inner  edge  of  the  lobule.     With  the  flap  Y  cover  the  cor- 
responding wound  in  the  neck.     Fix  the  flaps  in  position  with  sutures. 


Fig.  67. 


Fig.  68. 


Fig.  69. — {Laurens.) 


Fig.  70. — {Laurens.) 


PROMINENT  EARS 

Instead  of  lying  parallel  to  the  head  the  auricles  may  stand  out  more  or 
less  at  right  angles  to  the  head.  The  deformity,  especially  when  the  ears 
are  large,  is  considerable  and  may  have  an  injurious  influence  on  the  patient's 
career.     There  are  several  methods  of  correcting  the  deformity. 

Method  A. — The  deformity  is  not  of  high  degree.  There  is  little  or  no 
macrotia,  there  may  be,  as  in  Bacon's  case,  some  microtia.  Remove  the  whole 
thickness  of  the  skin  from  the  area  abed  (Fig.  69).  Take  away  more  skin 
from  the  auricle  than  from  the  mastoid  region.  Suture  the  edge  adb  to  the 
edge   acb    (Fig.    70). 


PROMINENT   EAR 


79 


Method  B. — A  portion  of  the  skin  and  an  ellipse  of  cartilage  may  be  removed 
(Fig.  71),  and  the  wound  closed  (Fig.  72).     The  result  is,  however,  not  satis- 


FiG.  71. — {Payr. 


Fig.  73. — {Payr.) 


Fig.  74. — {Payr.) 


factory.     Payr  recommends  the  excision  of  a  sickle-shaped  portion  of  cartilage 
(Fig.    73).     This   gives   better   results. 


8o 


EXTERNAL   EAR 


Fig.  Ts.—{Payr.) 


Fig.  -je—iPayr.) 


Fig.  77. — (Payr.) 


PROMINENT   EAR 


8l 


Fig.    78.- 
Antihelix. 


Helix. 
Fossa 


Method    C    {Payr's   Operation). — Payr    found    ("Archiv    fur    klin.    Chir.," 

Ixxviii,  918)  that  the  results  from  Method  A  were  good  at  first  but  that  the 

spring-like  action  of  the  cartilage  of  the  ear  caused  stretching  of  the  scar  and 

some  recurrence  of  the  deformity.     In  cases  of  great 

deformity  he  operates  as  follows: 

Step  I. — Remove  the  skin  from  the  areas  I  and  II 

(Fig.  74).     Make  the  incisions  a-a,  b-b,  c-c,  down  to, 

but  not  into,  the  cartilage.     Reflect  the  flaps  abab  and 

aacc. 

Step  2. — From  the  most  prominent  part  of  the  concha 

posteriorly  make  two  parallel  incisions  about   %   inch 

apart,  through  the  cartilage  out  to  the  free  margin  of 

the  auricle.     Do  not  injure  the  skin  covering  the  anterior 

surface  of   the  cartilage.     Elevate  and  turn  back  the 

flap  of  cartilage    (Fig.   75).     From  the  cartilage  above 

and  below  the  transverse  wound  remove  sickle-shaped 

portions  of  cartilage  (Fig  75). 

Step  3. — With  sutures  close  the  wounds  in  the  carti- 
lage (Fig.  76). 

Step.  4. — In  a  convenient  location  make  two  parallel    antihdix 

incisions  through  the  mastoid  periosteum  and  elevate  a 

bridge  of  periosteum.    Pull  the  flap  of  cartilage  under  the  periosteal  bridge  and 

suture  it  there  (Figs.  76  and  77). 

Step  5. — Close  the  wounds  aa,  bb,  cc   with  sutures    (Figs.    74   and   77). 

Unite  the  edges  of  the  denuded  area  I  to 
the  edges  of  the  denuded  area  II  (Figs. 
74  and  77).  This  operation  corrects  both 
the  inacrotia  and  the  malposition.  If 
the  ear  is  not  much  enlarged  and  there 
is  marked  malposition  the  anchoring  flap 
of  cartilage  may  be  made  narrow  and 
the  sickle-shaped  resection  of  cartilage 
may  be  omitted. 

Method  Z>.— Luckett  C'Surg.,  Gyn., 
Obst.,"  June,  1910)  considers  that  in 
prominent  ears  the  deformity  is  due  to 
absence  or  insufiicient  development  of 
the  antihelix  (Fig.  78),  the  cavity  of  the 
concha  being  continuous  with  that  of  the 
helix.  To  form  an  antihelix  Luckett 
operates  as  follows: 

Step  I. — On  the  inner  or  posterior 
surface  of  the  auricle  make  a  crescentic 
incision  through  the  integument  opposite 

the  line  of  the  intended  new  antihelix.     Remove  the  inscribed  integument. 

Dissect    the    edges    of    the    skin    free  from  the  cartilage  and  retract  them. 

Remove  a   similar   crescentic    segment  from  the  cartilage.     The  amount  of 


^■■^t*!crr.  j 


Fig.  79. — {Luckett,  Surg.,  Gyn.,  Obslet.) 


82  EMPYEMA   OF   THE    ANTRUM    OF   HIGHMORE 

cartilage  removed  depends  on  the  extent  of  the  deformity.  Do  not  buttonhole 
the  skin  on  the  anterior  or  external  side  of  the  ear  when  removing  the  cartilage. 

Step  2. — Close  the  wound  in  the  cartilage  by  Lembert  sutures  so  as  to 
invert  the  edges  (Fig.  79)  and  form  an  antihelix. 

Step  3. — Close  the  skin  wound  with  horse-hair  sutures. 

Hematoma  Auris.  Othematoma.  Cauliflower  Ear. — Don  H.  Palmer 
(Northwest  IMed.,  Dec,  1913)  operates  with  good  results  in  this  deformity 
as  follows:  Sterilize  the  external  ear  and  surroundings  by  any  good  method 
without  iodin.  Plug  the  external  auditory  meatus  with  cotton.  Make  an 
incision  over  the  most  prominent  part  of  the  swelling  into  the  hemorrhagic 
cavity.  With  curette  or  fine  gouge  remove  all  clots,  new-formed  cartilage 
or  bone.  Gently  scrape  the  anterior  surface  of  the  old  cartilage  until  it  is 
smooth.  Close  the  incision  except  for  a  small  opening  which  will  just  admit  a 
Eustachian  catheter  connected  with  a  small  Pynchon  pump.  With  the  pump 
remove  all  accumulated  blood;  the  suction  compels  approximation  of  the  skin, 
perichondrium  and  cartilage.  Dry  the  skin.  Put  a  fresh,  dry  plug  of  non- 
absorbent  cotton  in  the  external  auditory  canal.  Apply  sterile  vaseline  gen- 
erously to  both  surfaces  of  the  ear  and  to  the  surrounding  parts.  Place  a  card- 
board mould  around  the  ear  and  fill  it  with  plaster-of-Paris  cream  so  that  the 
ear  is  completely  encased  in  the  plaster  through  which  the  Eustachian  catheter 
projects  with  the  connected  pump  working  continuously. 

As  the  plaster  hardens  rotate  the  catheter  sufficiently  to  permit  its  easy 
removal.  As  soon  as  hardening  is  complete  remove  the  catheter;  the  track 
left  by  its  removal,  permits  drainage.  Hold  the  plaster  cast  in  place  by 
bandages.     After  about  ten  days  remove  the  cast  by  fragmentation. 


CHAPTER  VI 
EMPYEMA  OF  THE  ANTRUM  OF  HIGHMORE 

INTRANASAL  OPERATION 

Cocainize  the  lower  meatus  of  the  nose.  Seat  the  patient  with  his  head 
well  thrown  back.  Introduce  a  stout,  curved  trocar  and  cannula  through  the 
nostril  to  a  point  immediately  under  the  inferior  turbinated  bone,  i.e.,  to  a 
point  in  the  highest  portion  of  the  inferior  meatus  of  the  nose.  Before  this 
can  be  done  it  may  be  necessary  to  remove  part  of  the  inferior  turbinate  bone. 
Turn  the  trocar  so  that  its  point  touches  the  outer  wall  of  the  nose  (inner  wall 
of  the  antrum)  at  right  angles.  Push  with  steady  force,  outwards  so  as  to 
make  the  trocar  enter  the  antrum.  Wash  out  the  antrum  with  warm  water 
or  a  mild  antiseptic.  Do  not  use  peroxide  of  hydrogen;  it  may  spread  infection. 
Remove  the  trocar.  No  dressings  are  required.  The  trocar  used  ought 
to  be  large  enough  to  leave  a  more  or  less  permanent  opening. 

Alveolar  Route. — Provide  a  drill  about  the  size  of  a  No.  16  French  sound. 
Provide  one  or  more  metal  drainage  tubes  about  %  to  i  inch  long,  provided 
with  a  flange  to  prevent  their  slipping  into  the  antrum.  Provide  a  nozzle 
which  can  slip  into  the  drain  and  permit  of  irrigation. 


friedrich's  operation  83 

Examine  the  teeth.  If  a  carious  tooth  is  found  it  is  probably  the  cause 
of  the  empyema,  and  must  be  extracted.  (The  teeth  at  fault  may  be  the  first 
premolar  or  the  first  or  second  molars.)  Through  the  tooth  socket  drill  a 
hole  upwards  and  backwards  (never  inwards)  into  the  antrum.  Remove 
the  drill,  substituting  a  drainage  tube.     Irrigate  daily  through  the  tube. 

Never  sacrifice  a  healthy  tooth  to  gain  access  to  the  antrum  by  this  route. 
The  drainage  tube  used  ought  to  fit  the  drill  hole  snugly  and  so  have  no 
tendency  to  fall  out. 

Radical  Operation. — This  method  is  based  on  the  obsolete  method  of 
drainage  through  the  canine  fossa.     Administer  a  general  anesthetic. 

Step  I. — Retract  the  upper  lip  upwards  and  outwards.  Make  an  incision 
to  the  bone  from  the  maxillary  tuberosity  to  a  point  immediately  below  the 
nares,  high  up  above  the  line  of  the  reflection  of  the  mucosa  from  the  alveolus 
to  the  cheek.  Attend  to  hemostasis  by  temporary  pressure.  Pull  the  upper 
edge  of  the  wound  upwards  with  a  retractor. 

Step  2. — With  a  periosteal  elevator  expose  the  whole  outer  wall  of  the  an- 
trum. Do  not  injure  the  infraorbital  nerve.  Open  the  antrum  with  a  chisel,  en- 
large the  opening  with  rongeur  forceps.  Cleanse  out  any  pus  and  blood  which 
may  be  present.     Attend  to  hemostasis  by  temporary  packing  gauze. 

Step  3. — Explore  the  antrum.  If  the  disease  is  catarrhal  merely  wash 
the  cavity.  If  granulation  tissue  is  present  in  quantity  remove  it  by  scraping 
it  away  with  pledgets  of  gauze  or  with  a  curette  used  gently.  If  necrosed 
bone  is  present  remove  sequestra  and  diseased  bone.  Occasionally  sinuses 
leading  through  thg  alveolus  to  the  mouth  require  excision  (Laurens)  through 
a  vertical  cut  reaching  from  the  primary  incision  to  the  alveolar  margin.  Ex- 
amine the  inner  wall  of  the  sinus  carefully  behind  the  normal  opening  into 
the  nares,  because  ethmoidal  disease  may  cause  necrosis  here,  and  unless 
the  ethmoid  trouble  is  treated  a  cure  may  be  prevented. 

Step  4. — Provide  permanent  drainage  for  the  sinus  as  follows: 

With  chisel,  forceps,  etc.,  remove  the  lower  ^^  of  the  nasal  wall  of  the  sinus. 
This  means  removing  the  lower  turbinate  bone  as  well.  Bleeding  will  be 
free  but  is  easily  stopped  by  gauze  pressure.  Be  sure  that  no  crest  of  bone 
remains  between  the  nasal  and  antral  floors  (Laurens).  Pack  the  cavity  with 
gauze  brought  out  through  the  nostril. 

Step  5. — Close  the  wound  in  the  mouth  with  sutures. 

Remove  the  pack  in  twenty-four  or  forty-eight  hours.  After  this  keep  the 
parts  as  clean  as  possible  without  greatly  disturbing  the  patient. 

P.  L.  Friedrich's  Radical  Operation. — Make  an  incision  down  to  the  bone, 
skirting  the  ala  of  the  nose  in  the  natural  groove  of  this  region.  Expose  the 
outer  and  lower  angle  of  the  pyriform  opening.  With  the  elevator  separate 
the  soft  parts  and  periosteum  together  from  the  outer  surface  of  the  superior 
maxilla;  it  may  be  necessary  to  make  an  incision  to  the  bone  from  the  middle 
of  the  primary  incision  downwards  and  outwards  for  about  three-fourths 
of  an  inch.  With  the  elevator  separate  the  muco-periosteum  of  the  outer 
wall  of  the  nose  from  the  edge  of  the  pyriform  opening  backwards  for  about 
one  inch.  A  fair  area  of  both  the  facial  and  nasal  walls  of  the  lowest  portion 
of  the  antrum  are  exposed  by  the  above  means.     With  chisel  and  rongeurs, 


84 


OSTEOPLASTIC    EXPOSURE    OF    THE    ORBIT 


beginning  at  the  lower  and  outer  angle  of  the  pyriform  opening,  cut  away  the 
bony  walls  (both  facial  and  nasal)  of  the  antrum.  In  doing  this,  part  of  the 
inferior  turbinate  bone  is  removed. 

Friedrich's  operation  gives  very  free  access  to  the  antrum  and  permits 
proper  treatment  both  of  the  antrum  and  of  any  fistula  leading  from  it. 

The  intranasal  and  alveolar  methods  of  treating  empyema  of  the  antrum 
are  suitable  in  cases  of  catarrhal  inflammation,  or  where  dental  disease  is  the 
primary  cause  of  the  trouble.  When  the  disease  resists  drainage  for  two  or 
three  weeks  the  probabilities  are  that  osteitis,  necrosis  or  some  granulomatous 
condition  is  present  and  only  the  radical  operation  will  avail. 


CHAPTER  VII 
OSTEOPLASTIC  EXPOSURE  OF  THE  ORBIT 

Frankes'  Modification  of  Kronlein's  Operation. — This  operation  is  of  value 
in  the  exploration  of,  and  removal  of  tumors  from,  the  orbit  when  it  seems  possi- 
ble to  preserve  the  eye. 

Step  I. — Below  the  level  of  the  eyebrow  make  an  incision  corresponding  to 
the  external  half  of  the  upper  margin  of  the  orbit.  Continue  the  incision 
downwards  along  the  outer  margin  of  the  orbit  to  a  point  near  the  lower  orbital 
margin.  From  this  point  cut  backwards  on  the  malar  to  the  middle  third  of 
the  zygoma. 


Fig.  8o. — Osteoplastic   exposure  of   the  orbit. 

Step  2. — (a)  Subperiosteally  divide  the  zygoma  near  its  middle,  {b)  Be- 
ginning at  the  upper  and  outer  part  of  the  orbital  rim,  subperiosteally  divide 
the  outer  orbital  rim  backwards  and  downwards  to  the  inferior  orbital  fissure 
(Fig.  80).  This  is  best  done  with  a  chisel,  (c)  Beginning  at  the  lower  and 
outer  part  of  the  orbital  rim,  subperiosteally  divide  the  malar  backwards  to 
the  inferior  orbital  fissure  and  to  the  origin  of  the  masseter. 

Step  3. — Reflect  the  bone  flap  thus  formed.  Remove  any  portions  of  the 
external  orbital  plate  which  obstruct,  and  so  expose  the  orbital  fat. 

Step  4. — Do  whatever  may  be  necessary  to  the  orbital  contents. 

Step  5. — Replace  the  bone  flap.  Suture  the  skin.  Suture  of  the  bone  is 
unnecessary. 


EXCISION    OF    UPPER    JAW  85 

CHAPTER   VIII 
EXCISION  OF  UPPER  JAW 

Resection  of  the  Alveolus,  Schlange's  Method. — This  is  usually  called  for  be- 
cause of  tumors.  Small  tumors  may  be  removed  by  the  methods  recommended 
in  excision  of  the  alveolus  of  the  lower  jaw.  When  much  of  the  alveolus  is 
involved  and  perhaps  part  of  the  palate,  Schlange  operates  as  follows:  Provide 
three  or  four  gouges  with  blades  i  to  2  inches  wide.  Tampon  the  nostril  on 
the  affected  side.  If  necessary  in  order  to  obtain  free  access,  split  the  cheek 
by  a  curved  incision  running  upwards  and  outwards  from  the  angle  of  the 
mouth.  Open  the  jaws  widely  with  a  gag.  Retract  the  cheek  and  upper  lip 
thoroughly.  Beginning  posteriorly  and  as  remote  as  possible  from  the  disease 
drive  the  gouges  one  after  the  other  vertically  upwards  through  the  alveolar 
and  palatal  processes  into  the  antrum.  Leave  each  gouge  undisturbed  in  situ; 
this  is  of  great  importance  because  removal  of  the  instrument  would  at  once  be 
followed  by  serious  bleeding.  ''When  the  horizontal  portion  of  the  superior 
maxilla  has  been  thus  divided  by  three  gouges  the  part  to  be  removed  is  held  in 
place  merely  by  the  anterior  wall  of  the  antrum.  With  the  fourth  gouge  quickly 
divide  this  connection  and  exerting  slight  leverage  on  the  chisels  remove  them 
and  the  separated  bone  together.  Before  the  gaping  wound  has  time  to  bleed 
pack  it  with  a  tampon  or  large  sponge  which  has  been 
held  in  readiness.  The  operation  can  be  carried  out  in  a 
few  minutes  and  with  almost  no  loss  of  blood."  When 
much  of  the  alveolus  is  removed  from  a  young  and 
growing  patient  great  deformity  of  the  jaw  and  teeth 
may  be  expected  unless  the  defect  is  properly  filled  by 
a  suitable  prosthesis. 

Many  incisions  have  been  devised  to  expose  the 
superior  maxilla.  Probably  the  best  are  those  of  Weber 
(A,  B,  C,  D,  Fig.  81)  and  Velpeau  (V,  P,  Fig.  8i). 

Weber's    Incision. — Beginning    immediately    below         ''       X 

the  inner  angle  of  the  eye,  make  the  incision  B,  C,  D,    „,^,^^-,^^.-~.A'  ^'  ^'  P' 
^  •'    '  .  !      J      7     Weber  s  incision;   P,   V, 

which  skirts  the  ala  of  the  nose  and  divides  the  upper    Velpeau's  incision. 
lip  in  the  middle  line.     From   the  point  B    (Fig.   81) 

make  the  curved  incision  (B,  A,  Fig.  81)  which  follows  the  lower  margin  of 
the  orbit.     Reflect  outwards  the  flap  outlined  by  the  complete  incision. 

Velpeau's  Incision. — This  incision  is  very  similar  to  that  of  Syme.  Be- 
ginning at  the  angle  of  the  mouth,  make  the  incision,  P,  V  (Fig.  81),  through  the 
whole  thickness  of  the  cheek.  The  cut  runs  obliquely  upwards  and  outwards 
from  the  angle  of  the  mouth  for  such  a  distance  as  will  permit  of  exposure  of  the 
superior  maxilla  by  reflection  of  the  cheek  upwards  and  inwards.  This  incision 
is  not  as  good  as  Weber's. 

Separate  the  periosteum  covering  the  floor  of  the  orbit  from  the  bone. 
Gently  lift  the  orbital  contents  upwards  with  a  flat  retractor.     With  a  bone 


86 


EXCISION   OF    UPPER   JAW 


forceps  or  Gigli  saw  divide  the  malar  bone  and  with  it  part  of  the  orbital  floor 
at  the  point  Z  (Fig.  82).  In  the  same  manner  divide  the  nasal  and  prbital 
processes  of  the  superior  maxilla  at  the  point  X.  Open  the  patient's  mouth 
and  with  a  knife  make  an  incision  through  the  muco-periosteuni  of  the  hard 
palate,  parallel  and  close  to  the  middle  line.  Continue  this  incision  forwards 
and  then  upwards  through  the  muco-periosteum  covering  the  alveolus  to 
the  nasal  aperture.  With  bone  forceps,  Gigli  or  finger  saw  divide  the  hard 
palate  and  alveolus  along  the  line  of  the  mucoperiosteal  incision.  With  knife, 
or  better  with  scissors,  separate  the  soft  palate  from  the  hard  palate  on  the 
side  being  excised.     Seize   the  superior  maxilla  with  lion-jawed  forceps  and 

forcibly  remove  it  with  a  twisting  motion. 
Any  undivided  strands  of  tissue  may  be 
severed  with  scissors.  The  internal 
maxillary  artery  will  generally  be  found 
bleeding  vigorously  in  the  depth  of  the 
wound.  It  should  be  seized  with  forceps 
and  ligated.  Oozing  is  stopped  by  pressure 
with  gauze  pads  wrung  out  of  very  hot 
water.  Pack  the  wound  with  iodoform 
gauze.  Replace  the  flap  of  soft  structures 
over  the  packing  and  suture  it  in  position. 
The  after-treatment  consists  in  having 
the  patient  lie  on  the  side  operated 
upon  or  sit  up  in  bed  or  a  chair  as  early 
as  possible.  This  is  to  avoid  danger  of 
pneumonia.  The  mouth  must  be  kept 
clean.  Closure  of  the  wound  usually  takes 
place  rapidly.  When  recovery  has  taken 
place,  consult  a  good  dentist  with  regard 
to  the  use  of  an  artificial  palate. 
Keen  notes  that  sarcoma  of  the  upper  jaw  often  extends  through  the 
infundibulum  into  the  frontal  sinus.  This  extension  must  be  looked  for 
and  removed.  Extend  the  incision  C,  B  (Fig.  81)  upwards  to  the  nasal 
side  of  the  inner  canthus  over  the  frontal  sinus.  Remove  with  a  smaller 
rongeur  the  anterior  wall  of  the  infundibulum  and  of  the  frontal  sinus;  wipe 
away  the  tongue-shaped  process  of  the  sarcoma  with  a  gauze  pad. 

W.  J.  Hearn,  Matas,  and  others  always  ligate  the  external  carotid  before  excis- 
ing the  jaw.  The  former  surgeon  finds  in  doing  so  that  he  always  exposes 
some  enlarged  glands  which  require  removal.  Matas  emphasizes  the  impor- 
tance of  ligating  the  external  carotid  high  up,  well  above  the  bifurcation,  other- 
wise there  is  danger  from  cerebral  embolism. 

A.  H.  Ferguson's  operation,  suitable  in  cases  where  the  skin  is  not  involved. 

1.  Place  the  patient  with  head  hanging  over  a  sand-bag. 

2.  Make  an  incision  about  one-half  inch  long  over  the  nasal  process  of  the 
superior  maxilla;  through  this,  with  an  osteotome,  divide  the  bony  process. 

3.  Repeat  Step  2  over  the  junction  of  the  superior  maxilla  and  the  malar 
and  divide  the  bone. 


Fig.  82. — Excision  of  upper  jaw. 

X,  Y,  Z.  Usual  lines  for  division  of  bone. 
P,  Q.  Sectipn  may  be  made  here  instead  of 
at  Z,  when  disease  is  extensive. 


EXCISION    OF   UPPER   JAW  87 

4.  Cut  through  the  alveolar  process  and  the  hard  palate.     Save  as  much 
of  the  soft  palate  as  possible. 

5.  With   elevator   or  forceps   evulse   the  jaw  and  pull  it  out  through  the 
mouth.     Pack  the  cavity  with  iodoform  gauze. 

BARDENHEUER'S  OPERATION  FOR  PARTIAL  EXCISION  OF  THE 
UPPER   JAW  AND   IMMEDIATE  PLASTIC   REPAIR 

By  means  of  the  incision  A,  B,  C  (Fig.  83)  the  flap  C,  E,  D  is  reflected 
and  the  jaw  and  tumor  exposed.     By  means  of  saw,  bone  forceps,  and  scissors 


Fig.  83. — {After  Bardenheuer.)  Fig.  84. — {After  Bardenheuer.) 

the  jaw  is  partially  excised,  the  object  being  to  remove  the  tumor  and  with 
it  a  safe  margin  of  healthy  bone.  Bleeding  is  arrested  by  ligature,  hot  water 
and  sponge  pressure.  The  incision  F,  G,  H  (Fig.  84)  outlines  a  skin-flap 
(hairless)  in  the  pedicle  of  which  is  a  portion  of  the  skin  of  the  upper  eyelid 
as  well  as  the  whole  eyebrow.  The  flap  is  turned  (epidermis  inwards)  into 
the  position  F,  I,  H,  and  there  sutured.  The  flap  C,  E,  D  is  now  turned  back 
into  its  old  position  and  there  sutured.  Most  of  the  wound  F,  G,  H  is  covered 
by  Thiersch's  grafts.  After  the  lapse  of  two  weeks  the  pedicle  of  the  flap 
F,  H,  I  is  divided  and  the  eyelid  and  eyebrow  contained  in  it  returned  to  their 
normal  position.  The  wound  left  where  the  pedicle  was  divided  must  be 
trimmed  and  closed.     The  result  is  seen  in  Fig.  85. 

EXCISION  OF   SUPERIOR   MAXILLA  WHERE   THERE   IS   TUMOR 
INVOLVING  BOTH  THE  BONE  AND  THE  SKIN 

Make  the  incision  A,  B,  C  (Fig.  86).  Isolate  the  tumor  from  the  rest  of 
the  skin  by  the  incision  D,  F,  E,  which  joins  A,  B  and  C  at  the  points  D 
and  E.  Reflect  the  flap  A,  D,  E,  C  towards  the  opposite  side  of  the  body 
(Fig.  87).  Reflect  the  skin  at  B  towards  the  ear  so  as  to  expose  the  zygoma 
and  the  frontal  process  of  the  malar.  Divide  the  bones  as  shown  in  the  dotted 
lines  in  Fig.  87.     Remove  the  tumor  and  superior  maxilla  as  in  the  classical 


88 


EXCISION    OF    UPPER   JAW 


operation    for   excision   of    the    upper   jaw.     Pack    the   wound  with  iodoform 
gauze.     Replace  the  flaps  and  suture  them  in  position. 


Fig.  85. — {After  Bardenheuer.) 


Fig.   86. — Author's  method  of  excising  upper 
jaw  for  disease  involving  the  skin. 


EXTENSIVE  EXCISION  OF   UPPER  JAW 

The  younger  Konig  in  very  extensive  disease  of  the  upper  jaw  necessitating 
removal  of  the  floor  and  outer  wall  of  the  orbit  recommends  the  following 
operation: 

I.  Ligate  the  external  carotid  between  the  origin  of  the  superior  thyroid 
and  lingual  arteries.     This  step  is  simple,  harmless,  and  very  useful. 


Fig.  87. — Author's  method  of  excising  upper  jaw  for  disease  involving  the  skin. 


2.  Expose  the  bone  by  Velpeau's  incision.     Remove  the  disease. 

3.  Recognize  and  expcse  the  temporal  muscle  in  the  outer  part  of  the 
wound.  At  the  level  of  the  coronoid  process  and  about  i}4,  finger-breadths 
from  its  anterior  margin  split  the  muscle  upwards  and  downwards.  With 
a  chisel  divide  the  ascending  ramus  of  the  lower  jaw  along  the  line  in  which 


RODENT    ULCER 


89 


the  muscle  was  split.     The  result  of  the  above  is  to  provide  a  flap,  consisting  of 
temporal  muscle  and  bone,  attached  above  to  the  skull  and  free  below  {¥ig.  88). 


Fig.  88. — F.  Konig's  operation. 


Fig.  89. — Author's  method  of  excising 
rodent  ulcer. 


4.  Turn  this  flap  inwards  and  unite  its  free  extremity  to  the  remains  of  the 
frontal  process,  so  that  a  firm  floor  is  provided  for  the  orbit  and  the  eye  is  kept 
in  place. 

5.  Complete  the  operation  by  closure  of  the  skin-wound  and  packing  with 
iodoform  gauze. 

RODENT   ULCER 

As  a  t)^e  of  operation  for  rodent  ulcer  an  example  may  be  taken  where 
the  disease  involves  the  malar,  the  superior  maxilla,  and  to  a  moderate  extent 
the  orbit. 


Fig.  90. — Author's  method  of  excising  rodent  ulcer. 


1.  Make  an  incision  around  the  disease,  and  distant  from  it  3^  inch  (Fig.  90). 

2.  Leaving  the  diseased  tissue  undisturbed,  reflect  the  soft  parts  all  around 
it  from  the  bones  so  as  to  lay  bare  to  touch  the  upper  margin  of  the  orbit, 
the  external  angular  process  of  the  frontal  bone,  the  temporal  process  of  the 
malar  (Fig.  90),  the  external  anterior  surface  of  the  superior  maxilla  above  the 
alveolar  process,  and  the  nasal  bone  on  the  afifected  side.  As  hemorrhage  occurs, 
it  must  be  arrested  at  once. 


90 


EXCISION   OF   UPPER  JAW 


3.  With  bone  forceps  or  chisel  cut  through  the  bones  as  shown  in  Fig.  91, 
Bone  incision  A  (Fig,  91)  penetrates  the  antrum  of  Highmore. 

4.  Separate  the  orbital  contents  from  the  roof  of  the  orbit  and  divide  the 
optic  nerve. 

It  is  now  easy  to  remove  the  disease  surrounded  by  a  fairly  large  zone  of 
healthy  tissue.  The  cavity  is  packed  with  iodoform  gauze.  After  the  lapse 
of  about  ten  days  endeavors  may  be  made  to  lessen  the  deformity  which  has 
been  produced.  As  the  cavity  is  largely  lined  by  mucous  membrane,  it  is  proper 
that  an  endeavor  should  be  made  to  provide  its  new  covering  with  an  epidermal 
surface  internally. 


Fig.  91. — Excision  rodent  ulcer. 


Fig.  92. — Plastic  repair  after  excision  rodent 
ulcer. 


T)rpe  of  Operation  to  Repair  the  Deformity.— On  the  hairless  forehead  make 
the  incision  A,  B,  C,  Fig.  92,  so  as  to  obtain  a  flap,  A,  C,  D,  of  size  and  shape 
suitable  to  provide  an  epidermal  outer  and  anterior  wall  to  the  cavity  left  by 
operation.  The  base  (A,  C)  of  the  flap  is  a  little  above  the  orbit  and  ought  to 
extend  beyond  the  orbit  on  one  side  or  the  other  so  as  to  have  plenty  of  nourish- 
ment. The  flap  is  now  turned  down  so  that  its  epidermal  surface  faces  inwards, 
its  raw  surface  outwards.  The  edges  of  the  flap  are  stitched  with  catgut  in 
the  position  A,  C,  D  (Fig.  92).  From  the  neck  the  flap  E,  F,  G  is  dissected  up 
and  sutured  in  the  position  F,  E,  H,  I.  The  raw  surfaces  A,  B,  C  and  E,  F,  G 
are  lessened  in  size  by  sliding  their  edges  centripetally  and  there  suturing  them. 
Any  parts  not  covered  by  skin  are  now  grafted  by  Thiersch's  method. 

After  the  lapse  of  two  weeks,  if  everything  has  gone  well,  the  pedicles  of 
the  flaps  A,  D,  C  and  H,  I,  E  are  divided  and  their  remnants  turned  back  into 
their  old  positions.  A  certain  amount  of  trimming  and  suturing  must  be  done 
at  the  margins  of  the  now  repaired  deformity. 


OSTEOPLASTIC    RESECTION  9I 

Note. — In  the  original  operation  when  the  bone  incisions  are  being  made  it  is  wise  to 
divide  the  nasal  bones  last,  so  as  to  avoid  the  entrance  of  blood  into  the  nose.  The  com- 
plete dissection  of  the  soft  parts  before  attacking  the  bones  ensures  that  most  of  the  bleed- 
ing will  have  been  attended  to  before  any  of  the  facial  cavities  have  been  opened.  Should 
the  patient's  strength  warrant,  the  reparative  work  might  be  done  at  the  same  sitting,  but 
the  disease  generally  affects  the  old  and  debilitated. 

Osteoplastic  Resection  of  Upper  Jaw  (Kocherj. — Suitable  for  Ihe  removal  of 
nasopharyngeal  and  retropharyngeal  neoplasms— e.g.,  sarcomata,  etc. 

Preliminary  ligation  of  both  external  carotid  arteries  may  or  may  not  be 
practised.  Place  the  patient  in  Trendelenburg's  position.  This  renders  pre- 
liminary tracheotomy  unnecessary. 

Step  I. — Split  the  upper  lip  near  the  middle  from  the  nostril  to  mouth. 
On  each  side  divide  the  buccal  mucosa  at  its  line  of  reflection  from  cheek  to 
alveolus.  Only  divide  the  mucosa  sufficiently  to  permit  the  performance  of 
Step  2. 

Step  2. — With  a  chisel  divide  the  anterior-external  wall  of  the  antrum  from 
the  nose  outwards  and  backwards  above  the  alveolus.     This  opens  the  antrum. 

Step  3. — With  a  wide  chisel  (better  osteotome)  of  thin  steel  divide  the 
alveolus  and  hard  palate  close  to  the  middle  line.  With  strong  sharp  hooks 
pull  the  halves  of  the  upper  jaw  apart,  pushing  the  vomer  to  one  side  and 
dividing  any  nasal  mucosa  which  hinders.  If  necessary  divide  the  soft  palate. 
Remove  any  of  the  turbinated  bones  which  obstruct. 

Step  4. — Free  access  to  the  base  of  the  skull  is  now  possible.  Remove  the 
tumor  secundum  artent,  using  the  cautery  if  necessary. 

Step  5. — Replace  the  halves  of  the  jaw  and  fix  them  by  a  suture  (wire  or 
silk)  penetrating  the  alveolus.     Suture  the  soft  palate  if  it  has  been  divided. 

Step  6. — Apply  iodoform  gauze  packs  to  the  bed  from  which  the  tumor 
was  removed  bringing  the  ends  of  the  pack  out  through  the  nose. 

Partsch's  Method. — (Beitrage  z.  klin.  Chir.,  xci,  555). — Place  the  patient 
on  a  table  which  is  slightly  inclined  to  one  side  and  has  its  lower  end  moderately 
elevated.  The  patient's  neck  is  supported  on  the  edge  of  the  table  (not  hanging 
as  in  Rose's  position).  A  general  anesthetic  is  administered  through  a  tube. 
The  external  carotid  arteries  may  be  ligated  or  hemorrhage  may  be  lessened 
locally  by  the  use  of  adrenalin. 

Make  an  incision  above  the  alveolus  of  the  upper  jaw  from  the  second  molar 
on  one  side  to  the  second  molar  on  the  other  side.  Retract  the  soft  parts  up- 
wards and  open  the  nasal  fossae  by  freeing  the  mucosa  at  their  anterior  orifices. 
With  a  thin  chisel  divide  the  septum  nasi  along  the  floor  of  the  nose.  Divide 
the  anterior  and  external  walls  of  the  antrum  of  Highmore  at  the  level  of  the 
antral  floor.  Do  this  on  both  sides  as  far  back  as  the  maxillary  tubercles. 
The  alveolus  and  the  palatal  vault  can  now  be  pushed  dowTi  as  a  flap  the  hinge 
of  which  corresponds  to  a  transverse  line  passing  through  the  posterior  extremi- 
ties of  the  maxillary  body.  This  gives  very  free  access  to  the  nasopharynx  w^ith- 
out  interfering  with  the  palatine  arteries.  When  the  operation  is  finished  the 
flap  is  easily  replaced  and  secured  by  some  stitches  through  the  mucosa. 

Reinhardt  ("Zentralblatt  fiir  Chir.,"  May  9,  1908)  has  collected  fourteen 
cases  in  which  this  operation  has  been  performed  without  a  death. 


92 


LOWER   JAW— RESECTION 


Exposure  of  the  Base  of  Skull  by  Temporary  Resection  of  the  Palate. — C. 
Hofmann's  method  ("Zentralblatt  fiir  Chir.,"  1910,  No.  24). 

Step  I. — Make  an  incision  through  the  mucosa  of  the  palate  from  the  pre- 
molar tooth  on  the  right  side  to  a  corresponding  point  on  the  left  side.  Nearly 
at  right  angles  to  the  above  incision  make  a  cut  immediately  to  the  inner  side 
of  the  alveolus  (on  the  right  or  left  side  of  the  palate,  according  to  the  location 
of  the  tumor  in  the  nasopharynx).  This  incision  extends  backwards  to  the  edge 
of  the  soft  palate  dividing  the  muco-periosteum  covering  the  hard  palate  and 
the  whole  thickness  of  the  soft  palate. 

Step  2. — With  a  chisel  divide  the  bone  of  the  palate  corresponding  to  the 
incision  made  in  Step  i.  With  an  elevator  raise  the  palate  and  reflect  the  flap 
of  bone  and  soft  parts,  fracturing  the  bone  in  the  pedicle  of  the  flap.  While 
this  is  being  done  the  nasal  septum  must  necessarily  be  either  fractured  or 
divided. 

Step  3. — After  removal  of  the  tumor  from  the  nasopharynx  replace  the  flap 
and  fix  it  with  a  few  sutures.  Hofmann  states  that  the  flap  tends  to  stay  in 
position  and  that  the  whole  operation  is  easy. 


CHAPTER   IX 

LOWER  JAW-RESECTION 

I.   RESECTION  OF   THE  .ALVEOLAR  PROCESS 

Incise  the  muco-periosteum  around  the  portion  of  bone  to  be  excised.  If 
the  portion  to  be  excised  is  small,  its  removal  may  be  effected  with  rongeur 
forceps  or  with  the  chisel  and  mallet.  In  using  the  chisel  the  surgeon  should 
hold  the  instrument  in  one  hand,  support  the  jaw  with  the  other,  and  let  his 
assistant  manipulate  the  mallet.     When  the  excision  is  to  be  more  extensive, 

one  may  with  a  finger  saw  make  a  vertical 
incision  through  the  alveolar  process  in 
front  of,  and  another  behind,  the  portion 
to  be  removed,  and  join  the  lower  ends  of 
the  vertical  incisions  by  a  horizontal  one 
cut  with  a  chisel  or  a  saw  operated  by  a 
surgical  engine. 

II.   PARTIAL    RESECTION  OF    THE 
HORIZONT.AL  RAMUS 

Make  an  incision  through  the  skin 
down  to  the  bone  along  the  inferior  edge 
of  the  jaw.  Separate  the  soft  parts  from 
the  inner  and  outer  surfaces  of  the  jaw.  If  the  operation  is  done  for  necrosis, 
preserve  the  periosteum;  if  for  tumor,  sacrifice  it.  Divide  the  jaw  by 
vertical  incisions  made  with  the  Gigli  wire  or  the  finger  saw,  in  front  of 
and  behind  the  disease.  If  teeth  are  present  at  the  lines  of  vertical 
incision,  they  must  be  removed  before  the  saw  is  applied.  Remove  the 
segment  of  bone  between  the  vertical  cuts.     Whenever  the  nature  and  extent 


RESECTION    LOWER   JAW  93 

of  the  disease  permit,  it  is  important  to  leave  the  lower  edge  of  the  jaw  in 
situ  (X,  Y,  Fig.  93),  as  then  the  continuity  of  the  maxilla  is  maintained. 
To  accomplish  this,  the  vertical  bone  incisions  do  not  completely  divide 
the  jaw,  and  the  excision  is  completed  with  the  chisel.  It  is  difficult  to 
use  a  saw  on  the  lower  jaw.  To  cut  accurately  with  a  chisel  is  no  easy 
task  and  the  bone  is  very  liable  to  fracture.  A  good  method  to  secure  pre- 
cision and  safety  is  as  follows:  After  incising  the  muco-periosteum  at  a  safe 
distance  from  the  tumor,  bore  a  series  of  holes  about  3^  inch  apart  all  around 
the  portion  to  be  removed.  When  this  has  been  done  it  is  easy  to  complete 
the  excision  with  rongeur  forceps  or  chisel.  If  possible,  suture  the  mucous 
membrane  of  the  floor  of  the  mouth  to  that  of  the  cheek.  Close  the  cutaneous 
wound  after  providing  for  drainage. 

III.   RESECTION  OF  ONE-HALF   OF  THE   INFERIOR   MAXILLA 

Transfix  the  tongue  with  a  stout  thread  for  purposes  of  traction.  Make 
a  vertical  incision  in  the  middle  line  through  the  chin,  beginning  a  little  below 
the  edge  of  the  lower  lip  and  ending  on  the  lower  edge  of  the  jaw.  Do  not 
include  the  margin  of  the  lower  lip  in  the  cut  unless  compelled  to  do  so  by  the 
size  of  the  tumor. 

From  the  lower  end  of  the  vertical  incision  make  a  cut  along  the  inferior 
edge  of  the  jaw  to  its  angle.  If  necessary,  continue  the  cut  up  the  posterior 
edge  of  the  ascending  ramus  of  the  jaw  to  a  point  not  less  than  one  finger- 
breadth  below  the  lobe  of  the  ear.  Before  the  facial  artery  is  divided  it  should 
be  ligated. 

With  periosteal  elevators,  scissors,  and  knife  separate  the  soft  parts  from 
the  outer  side  of  the  bone  to  be  removed.  If  the  operation  is  for  the  removal 
of  a  tumor,  sacrifice  the  periosteum.  Choose  the  line  in  which  to  divide  the 
bone  anteriorly,  extract  any  teeth  which  may  be  in  the  way,  and  divide  the 
bone  with  the  Gigli  wire  or  finger  saw  after  the  soft  parts  have  been  separated 
from  both  sides  of  the  bone  along  the  line  of  section.  Pull  the  jaw  down- 
wards and  outwards  and  separate  the  soft  parts  from  its  inner  surface  (my- 
lohyoid, geniohyoid,  and  internal  pterygoid  muscles,  submaxillary  gland,  etc.). 
Pull  the  jaw  downwards,  expose  the  coronoid  process,  and  divide  its  attach- 
ments to  the  temporal  muscle.  It  may  save  time  and  be  easier  to  cut  through 
the  coronoid  process  with  bone  forceps  than  to  separate  the  temporal  muscle 
from  it. 

By  blunt  dissection  separate  the  masseter  muscle  and  the  parotid  gland 
from  the  ascending  ramus.  With  a  twisting  movement  directed  downwards 
and  outwards  tear  the  head  of  the  bone  out  of  its  bed  and  the  active  part  of 
the  operation  is  completed.  Attend  to  hemostasis.  If  possible,  suture  the 
mucous  membrane  of  the  floor  of  the  mouth  to  that  of  the  cheek.  Close  the 
external  wound  after  providing  for  drainage. 

The  after-treatment  consists  in  endeavoring  to  keep  the  mouth  clean  by 
means  of  frequent  washing  with  mild  antiseptic  solutions,  in  nourishing  the 
patient,  and  in  encouraging  him  to  sit  or  walk  about  at  as  early  a  date  as 
possible. 


94  LOWER    JAW  — RESECTION 

When,  after  any  operation  in  which  one-half  of  the  inferior  maxilla  or  a 
segment  of  it  is  removed,  deformity  results  and  the  teeth  of  the  lower  jaw  no 
longer  articulate  with  their  fellows  above,  some  surgeons  or  dental  surgeons 
have  managed  by  a  long  and  painful  process  to  push  the  fragments  of  the  lower 
jaw  back  into  their  normal  position  after  healing  has  taken  place  and  have 
maintained  the  position  by  means  of  a  plate  or  of  bridge-work. 

Sinclair  White  ("Brit.  Med.  Journ.,"  Nov.  27,  1909),  in  removing  two 
inches  of  the  lower  jaw  for  a  tumor  preserved  the  periosteum  of  the  lower 
edge  of  the  excised  segment.  "The  resected  surfaces  of  the  lower  jaw  were 
pierced  with  a  drill  to  the  depth  of  ^  inch.  The  drill  hole  in  the  body  was  hori- 
zontal and  placed  near  its  lower  margin,  so  as  to  miss  the  teeth  roots;  that  in  the 
ramus  was  vertical  and  somewhat  posterior  to  the  mandibular  foramen.  The 
ends  of  a  suitable  length  of  stout  silver  wire  were  jammed  tightly  into  the  drill 
holes,  and  the  wire  completely  covered  by  suturing  together  the  mucous 
membranes  of  the  cheek  and  the  floor  of  the  mouth  over  it.  The  diagram 
(Fig.  94)  indicates  the  position  and  curve  of  the  wire. 


Fig.  94. — Metal  splint  used  after  resection         Fig.  95. — Metal  splint  used  after  resection 
lower  jaw.     {Sinclair  White.)  lower  jaw. 

A  small  drain  tube  was  placed  in  the  neck  end  of  the  wound  and  retained  for 
forty-eight  hours,  and  the  mouth  was  rinsed  frequently  with  hydrogen  peroxide 
solution.  A  little  pus  formed  in  the  track  of  the  tube,  but  the  wound  in  the 
mouth  healed  quite  kindly. 

"At  the  present  time,  except  for  the  skin  scar,  there  is  absolutely  no  external 
deformity.  He  can  open  his  mouth  almost  to  the  full,  and  when  the  jaws  are 
closed  the  teeth  on  the  right  side  meet  accurately  those  in  the  corresponding  side 
of  the  upp  er  jaw.  He  is  able  to  bite  soft  things,  and  has  to  be  restrained  from 
attempting  greater  masticatory  feats." 

Partsch,*  after  removing  a  segment  of  the  lower  jaw,  keeps  the  ends  of  the 
bone  in  correct  position  by  means  of  a  perforated  metal  plate  united  to  the  bone 
by  a  couple  of  wire  stitches.  (See  Fig.  95.)  The  metal  plates  are  protected 
with  rubber  tubing,  and  the  mucous  membrane  of  the  floor  of  the  mouth  and 
of  the  cheek  are  sutured  together  below  the  metal  plate  so  that  the  latter  lies 
exposed  in  the  oral  cavity.  As  soon  as  a  proper  dental  apparatus  or  plate  can  be 
made  and  properly  fitted,  the  temporary  metal  plates  are  removed.  Berndt,  in 
cases  where  half  the  inferior  maxilla  has  been  removed,  replaces  it  with  an  ap- 
paratus of  celluloid.  After  the  bone  has  been  removed  he  sutures  the  mucous 
membrane  of  the  floor  of  the  mouth  to  that  of  the  cheek,  packs  the  wound,  and 
lays  silkworm-gut  cutaneous  sutures  in  position  but  does  not  tie  them.  After 
the  lapse  of  about  ten  days  he  takes  a  celluloid  ring  pessary,  softens  it  by  boiling, 
*"Archiv  f.  klin.  Chir.,"  Iv,  746. 


REPAIR    LOWER    JAW  95 

moulds  it  to  the  proper  shape,  and  puts  it  into  the  wound  so  that  one  end  is  in 
the  glenoid  cavity  while  the  other  rests  against  the  sawed  surface  of  the  remnant 
of  the  lower  jaw.  He  next  closes  the  skin-wound  and  ties  the  sutures  already  in 
place,  thus  completely  covering  the  celluloid  apparatus.  Berndt  reports  that 
slight  suppuration  often  takes  place  anteriorly  from  irritation  to  the  sawed  sur- 
face of  bone,  but  that  if  a  small  portion  of  the  celluloid  is  then  cut  away  by 
forceps,  a  little  fibrous  tissue  forms  between  the  bone  and  the  foreign  body,  and 
the  wound  heals.  One  patient*  seven  months  after  operation  claimed  to  have 
celebrated  Christmas  by  cracking  nuts  with  his  jaw,  one-half  of  which  was  cellu- 
loid, and  to  have  suffered  no  ill  consequences. 

By  an  incision  made  through  the  skin  below  the  jaw  Macewen  has  im- 
planted a  piece  of  rib  between  the  fragments  of  jaw.  Of  course  no  communica- 
tion existed  between  the  site  of  implantation  and  the  mouth.  The  implanted 
bone  was  obtained  from  a  rib  near  the  axilla.     The  result  was  perfect. 


(Stillman.) 


Macewen's  method  has  been  successfully  carried  out  by  a  number  of  surgeons. 
Clarence  McWilliams  found  that  if  the  transplant  was  entirely  deprived  of 
periosteum  it  became  absorbed.  This  does  not  agree  with  Macewen's  observa- 
tions. Stanley  Stillman  ("Annals  Surg.,"  July,  1912)  uses  Murphy's  silver-wire 
girder  (Fig.  96)  to  hold  the  remnants  of  the  inferior  maxilla  in  good  position 
until  healing  has  advanced  far  enough  to  permit  bone  implantation.  He  finds 
the  silver  cannot  be  left  in  situ  permanently  but  that  when  it  is  removed  the 
scar  tissue  keeps  the  bones  in  a  useful  position — so  useful  that  the  patient  may 
prefer  not  to  have  the  transplantation  made. 

H.  Nimierf  gives  an  admirable  description  of  Martin's  prosthetic  apparatus 

*"Archiv  f.  klin.  Chir.,"  Ivi,  210. 

f'Traite  de  Chir."  Delbet  and  Le-Dentu,  v,  793. 


96 


LOWER  JAW — RESECTION 


suitable  for  use  after  even  very  extensive  excision  of  the  inferior  maxilla.  He 
says:  Provided  with  a  segment  of  maxilla  formed  out  of  hard  rubber,  moulded 
in  advance  to  represent  the  bone  to  be  excised,  the  surgeon  cuts  and  fashions 
it  so  as  to  fit  between  the  remaining  portions  of  the  bone  and  to  reestablish 
the  exact  shape  of  the  inferior  maxilla.  Two  small  platinum  plates  at  each 
end  of  the  apparatus  are  attached  to  the  bones  by  screws,  and,  acting  as  fish- 
plates between  the  bone  and  the  substitute  for  bone,  keep  the  latter  in  position. 
If  much  of  the  ascending  ramus  has  been  removed,  the  anterior  portion  of 
the  apparatus  is  fixed  to  the  remnants  of  the  coronoid  process,  while  that 
portion  corresponding  to  the  articulation  is  left  unattached.  To  assure  solidity 
in  such  cases  it  is  necessary  to  attach  the  apparatus  to  the  palate  by  a  moulded 
J  plate.     On    the   upper  edge  of  the  appa- 

ratus a  band  of  hard  rubber  roughly 
simulates  the  teeth.  It  is  necessary  to 
disinfect  the  tissues  in  which  the  foreign 
body  is  implanted,  and  for  this  purpose 
the  apparatus  is  perforated  in  various 
directions,  so  that  irrigation  is  easy.  Fig. 
97  shows  apparatus  used  after  an  almost 
complete  excision  of  the  lower  jaw.  The 
above  description  applies  to  the  implanta- 
tion of  a  temporary  splint.  When  cica- 
trization is  complete,  a  permanent  one 
Art^ficiii  replaces  it.     The  permanent  apparatus  is 

lower  jaw."  4.  Fish-plate  uniting  remnants  of  ^yip^plv    a     mnrp    plahnrfltP    pHitinn     of    the 
bone  to  the  apparatus,     s-  Fish-plate  uniting  "lereiy    a    more    eiaoordie    euiuon    01     LUC 

tuberforlrrigation^^  apparatus,  c.  System  of  temporary.     In  cases  of  extensive  excision 

the  apparatus  may  be  introduced  in  two 
parts,  which  are  then  united  by  fish-plates  and  screws. 

Such  extremely  ingenious  and  complicated  prosthetic  devices  will  rarely 
be  available  when  required,  and  if  available,  must  rarely  be  serviceable.  The 
tissues  do  not  tolerate  foreign  bodies  well  for  any  length  of  time,  and  especially 
mobile  bodies,  such  as  described  above.  They  have  been  described  here  more 
as  examples  of  surgical  ingenuity  than  as  practical  aids. 

Fractures  of  the  Mandible  or  Lower  Jaw. — Few  recent  fractures  of  the 
mandible  require  operative  treatment.  Malunion  and  non-union  usually  de- 
mand operation.  When  there  is  little  or  no  loss  of  substance,  wiring  or  plating 
is  usually  suitable.  When  there  is  considerable  loss  of  substance,  some  form 
of  bone  grafting  is  essential.  In  cases  of  malunion  with  great  deformity,  cor- 
rection of  the  deformity  is  impossible  without  penetrating  the  mouth.  Under 
such  circumstances  the  mobilized  fragments  should  be  wired  together  in  spite 
of  the  inevitable  infection.  With  the  above  exception  all  operations  should  be 
performed  with  the  most  painstaking  aseptic  care  and  without  penetrating  the 
mouth.     The  ideal  is  '  knife  and  fork '  operating,  no  finger  touching  the  wound. 

I.  Wiring  and  Plating.— V .  P.  Cole  (Brit.  J.  Surg.,  July,  1918)  writes  "cases 
suitable  for  wiring  are  those  in  which  there  is  little  or  no  loss  of  substance.  As 
has  been  pointed  out,  these  fractures  occur  in  the  neighborhood  of  the  angle. 
The  posterior  fragment  is  left  free.     The  anterior  fragment,  if  not  edentulous, 


Fig.  97. 

I.  Articular   process    lower    jaw 
rubber   ridge   representing   teeth 


FRACTURES    LOWER    JAW 


97 


is  splinted  in  correct  alignment.  When  the  lower  jaw  is  edentulous,  no  splint 
is  used.     Cases  have  been  treated  in  this  way  with  consistent  success." 

As  a  preliminary  to  operation,  splinting  ought  to  be  fitted  and  put  in  place 
(p.  98). 

Expose  the  bone  by  a  suitable  incision.  Remove  tissues  interposed  between 
the  fragments.  Vivify  the  ends  of  the  bone.  Perforate  each  fragment  with  a 
drill.  Wire  the  fragments  together.  To  do  this  requires  free  exposure  of  the 
deep  surfaces  of  the  bone  and  thus  involves  danger  of  penetrating  the  mouth. 
If  a  metal  plate  is  used,  denudation  of  the  deep  surface  of  the  bone  is  unneces- 
sary, but  it  is  imperative  to  hold  the  fragments  in  accurate  apposition  while 
the  plate  is  being  applied.  To  avoid  these  troubles  Cole  combines  the  plate 
and  wire  method. 


Fig.  g8.— {Cole,  Brit.  J.  of  Surg.) 


Fig.  99. — (Cole,  Brit.  J.  of  Surg.) 


2.  Bone  Grafting. 

A.  Free  or  N onpedunoulated  Graft. — When  there  is  much  loss  of  bone  sub- 
stances, there  are  commonly  much  loss  of  soft  parts,  much  scar  tissue  and  often 
fistulae.  Before  any  grafting  may  be  attempted  various  plastic  operations  are 
essential.     Cole's  description  of  a  concrete  case  is  a  model  of  clearness. 

"Fig.  98  shows  the  condition  of  a  patient  immediately  before  the  plastic 
operation  was  undertaken.  A  suitable  splint  was  adapted  to  retain  the  frag- 
ments in  correct  position.  A  wide  exposure  of  the  area  was  then  obtained  by 
free  reflection  of  the  soft  parts.  The  ends  of  the  fragments  were  exposed,  and 
the  mucous  membrane  of  the  floor  of  the  mouth  was  dissected  up  and  united 
to  the  mucous  membrane  of  the  cheek.  Under  cover  of  this  the  bone  ends  were 
shut  off  from  the  buccal  cavity,  and  between  them  was  inserted  a  piece  of 
decalcified  bone.  The  soft  parts  on  the  outer  aspect  of  the  bone  were  brought 
together  in  such  a  way  as  to  raise  the  corner  of  the  mouth.  Counterdrainage 
through  a  stab  wound  was  established.  The  parts  healed  uneventfully.  Nu- 
trition was  promoted  by  radiations  and  massage,  and  the  patient  is  now  ready 


98 


LOWER    JAW RESECTION 


for  the  insertion  of  the  graft  (Fig.  99).  In  order  to  eliminate  the  possibility 
of  infection  from  latent  sources  of  sepsis,  an  interval  of  three  months  is  allowed 
to  elapse  in  such  a  case  before  the  grafting  operation  is  undertaken. 

"The  technique  of  this  operation  is  as  follows:  Two  or  three  days  previously, 
upper  and  lower  cast-metal  cap-splints  are  cemented  in  place.     These  splints 


Fig.  100. — {Cole,   Brit.\  J. 
of  Surg.) 


Fig.  ioi.— {Cole,  Brit.  J.  of  Surg.) 


are  provided  with  bilateral  overlapping  threaded  flanges,  which,  when  fixed 
together  by  screws,  determine  the  position  of  the  fragments  in  correct  alignment 
(Fig.  100) .  When  the  patient  is  on  the  operation  table  these  screws  are  removed , 
allowing  the  mouth  to  be  freely  opened  for  the  passage  of  the  intratracheal 


^^. 


Fig.  102. — {Cole,  Bril.  J.  of  Surg.) 

catheter.  As  soon  as  the  catheter  is  passed,  the  screws  are  replaced.  It  will 
be  noticed  that  the  jaws  so  disposed  are  in  the  open  bite  position.  This  position 
is  essential,  if  intratracheal  methods  are  employed.  The  anesthetist  is  then 
isolated  from  the  operation  area.  A  curved  skin  incision  extending  well  into 
the  neck  is  now  made,  and  a  flap  turned  up  to  expose  the  site  of  the  fracture 


COLE  S    OPERATION 


99 


(Fig.  loi).  Bleeding  vessels  are  ligatured  and  towels  clipped  to  the  skin  margins. 
The  ends  of  the  fragments  are  then  exposed,  cleared,  freshened,  and  shaped 
for  the  reception  of  the  graft.  The  graft,  taken  as  a  rule  from  the  tibia,  is 
now  cut,  the  length  and  shape  being  determined  by  the  use  of  calipers  and  a 


Fig.   103. — {Cole,  Brit.  J.  of  Surg.) 


pattern  cut  in  sheet  lead.  The  plates  are  screwed  to  the  graft  before  the 
detaching  cross-cuts  are  made  (Fig.  102).  The  graft  with  detached  plates  is 
then  transferred  to  its  destined  site  and  fixed  in  the  gap  by  two  screws  attach- 
ing each  plate  to  the  corresponding  fragment  of  the  fractured  mandible  (Fig. 


Fig.  104. — {Tainter,  Jour.  A.  M.  A,) 


103),  and  the  wound  sewn  up.  A  similar  technique  is  adopted  when  rib  is 
employed."  The  graft  may  be  obtained  from  any  convenient  bone  such  as 
the  tibia  or  a  rib.  No  particular  attempt  need  be  made  to  preserve  the  perios- 
teum.    Grafts  from  2}^  to  y}^  cm.  (i  to  3  in.)  in  length  have  been  used. 


lOO 


LOWER    JAW RESECTION 


B.  Pedunculated  Grafts. — Cole's    ()|)C'ration.     (P.   P.   Cole,   Brit,  J.   Surg., 
July,  1918,  B.  M.  J.,  Jan.  18,  igiq.     Tainter,  Journ.  A.  M.  A.,  Oct.  25,  1919.) 


Fiu. 


lainia-,  Jour.  .1.  .1/.  .1.) 


Before  operation  have  the  dentist  prepare  a  proper  splint  from  impressions 
taken  in  sections  and  assembled  on  a  proper  articulator.  V^ery  carefully  con- 
trol the  posterior  fragment  and  put  it  in  proper  relation  to  the  anterior  fragment 


I'lc.    io(>. —  (Tdinlcr,  .Jour.  .1.  .1/ 


and  the  upper  jaw.     Figs.  104,  105,   106,  and   107  sufficiently  describes  the 
operation. 

The  Birmingham  Operation  (Billington,  Parrott,  Round,  B.  M.  J.,  Dec.  21, 
1918). — Preparatory  treatment,  often  prolonged,  is  necessary  to  secure  com- 


THE   BIRMINGHAM    OPERATION 


lOI 


plete  healing  of  the  wounds.  It  consists  in  removal  of  dead  bone,  in  provision 
for  drainage,  in  correction  of  displacements  by  means  of  dental  splints,  etc., 
and  lastly  in  building  up  the  general  health.  Unlike  Cole  the  Birmingham 
surgeons  remove  all  splints  immediately  before  ojjcrating  and  do  not  replace 
them  until  the  operative  wound  has  healed  after  which  the  case  is  treated  as  a 
simple  fracture. 

Step  I. — Choose  a  point  on  each  side  of  the  bony  defect  i  inch  behind 
the  extremity  of  the  posterior  fragment,  i  inch  in  front  of  the  fractured  end  of 
the  anterior  fragment  and  about  i%  inch  above  the  lower  border  of  the  jaw. 
Join  these  two  points  by  a  curved  incision,  which  crosses  the  neck  about  an 
inch  below  the  jaw.  Turn  up  the  flap  thus  outlined  and  with  it  all  the  soft 
parts  covering  the  jaw  for  a  distance  of  i  inch  from  the  fracture.  If  the  mouth 
is  penetrated  completion  of  the  operation  must  be  put  off  until  the  wound  has 
healed. 


Fig.   107. —  {Tai liter,  Jour.  A.  M.  A.) 


Step  2. — Remove  all  scar  tissue  between  the  fragments.  With  bone  forceps 
remove  a  shell  of  bone  from  about  i  inch  of  the  outer  surface  of  each  fragment. 
Attend  to  hemostasis  and  temporarily  pack  the  wound. 

Step  3. — Make  an  incision  from  the  anterior  superior  iliac  spine  backwards 
along  the  iliac  crest.  With  a  saw,  excise  a  segment  of  the  crest  2  inches  longer 
than  the  gap  to  be  filled.  (If  a  greater  curve  in  the  graft  is  necessary  the  bone 
between  the  Ant.  Sup.  and  Ant.  Inf.  spines  may  be  used.)     Close  the  wound. 

Step  4. — With  forceps  bevel  the  ends  of  the  graft  so  that  they  can  lie  flatly 
on  the  prepared  outer  surfaces  of  the  jaw.  Place  the  graft  in  position  and  retain 
it  by  careful  suturing  of  the  soft  parts  over  it.  Close  the  skin  wound  with  a 
few  interrupted  sutures.  No  drainage  tube  is  used.  Serum  can  escape  between 
the  sutures.     Apply  dressings  but  no  splints. 

The  wound  is  usually  sufficiently  healed  in  two  weeks  to  permit  the  use  of 
dental  splints.     "Firm  osseous  union  occurs  in  from  two  to  four  months,  but 


I02 


LOWER    JAW RESECTION 


it  is  inad\'isable  to  fit  the  final  dentures  until  at  least  four  months  have  elapsed 
and  it  is  perhaps  wiser  to  allow  an  interval  of  six  months." 

Undeveloped  Lower  Jaw. — When  there  is  a  marked  want  of  development  of 
the  lower  jaw  there  is  not  only  present  a  disfiguring  recession  of  the  chin  but 
the  patient  may  be  unable  to  open  the  mouth  more  than  one-eighth  of  an  inch. 


,t'.i-»* 


Fig.  io8. — {Eisenstaedt,  Surg.,  Gyn.,  Obst.) 

V.  P.  Blair  ("Journ.  A.  M.  A.,"  July  17,  1909),  has  twice  successfully  operated 
as  follows: 

Step  I. — Make  an  incision  about  3^  inch  in  length  in  front  of  the  lobe  of 
each  ear  and  retract  the  parotid  backwards. 

Step  2. — Pass  a  curved  needle  with  thread  through  the  incision,  under  the 
ramus  and  out  through  the  cheek.  By  means  of  the  thread  pull  a  Gigli  saw 
round  the  ramus  and  divide  the  bone  horizontally. 


Fig.   109. — {Eisenslaedl,  Surg.,  Gyn.,  Obst.) 


Step  3. — Forcibly  stretch  the  muscles  of  mastication. 

Step  4. — Pull  the  body  of  the  jaw  forwards  if  possible  until  the  lower  in- 
cisors are  in  front  of  the  upper.  Wire  teeth  of  the  lower  jaw  to  teeth  of  the 
upper  until  sufficient  fixation  is  obtained. 

Prognathism. — The  lower  jaw  extends  forwards  beyond  the  upper  so  that 
proper  articulation  of  the  upper  and  lower  teeth  is  impossible.     In  adolescents 


ANCHYLOSIS  I03 

orthodontic  appliances  are  capable  of  greatly  improving  or  curing  the  deformity; 
in  adults  the  aid  of  operative  measures  becomes  necessary  for  a  cure.  The 
surgeon  must  always  have  the  aid  of  a  good  dentist  or  orthodontist. 

Harsha  and  Eisenstaedi's  Method  (Surg.,  Gyn.,  Obst.,  July,  1912). — Have 
plaster-of-Paris  models  of  both  upper  and  lower  jaws  prepared,  also  skiagraphs. 
Make  careful  measurements  to  ascertain  the  shape,  size  and  location  of  the 
wedge  of  bone  which  it  is  necessary  to  excise  on  each  side  of  the  lower  jaw  to 
permit  proper  articulation  with  the  upper  jaw.  If  it  is  necessary  to  extract 
any  teeth  do  so  long  enough  before  operation  to  permit  of  healing  and  to  ren- 
der submucous  resection  possible. 

Cardboard  models  of  the  lower  jaw  should  be  made  on  which  to  carry  out 
experimental  operations,  as  it  is  desirable  to  alter  the  angle  of  the  jaw  as  well  as 
to  shorten  the  horizontal  ramus.  Make  an  incision  about  2)^  inches  long 
beneath  the  border  of  the  jaw.  Through  this  separate  the  periosteum  and  muco- 
periosteum  from  the  bone  completely  around  the  segment  of  bone  it  is  desired 
to  remove.  Do  this,  if  possible,  without  entering  the  mouth.  With  forceps  and' 
saw  cut  out  the  desired  segment  of  bone.  Unite  the  bone  wound  with  wire 
sutures  or  Lane's  plates.  Close  the  skin  wound,  if  necessary  providing  drainage. 
Carry  out  a  similar  operation  on  the  opposite  side.  If  necessary  reinforce  the 
union  of  the  bone  by  interdental  splints  and  wiring  the  teeth  of  the  lower  to 
those  of  the  upper  jaw  (Figs.  108  and  109). 

ANCHYLOSIS   OF  TEMPORO-MAXILLARY  JOINT 

The  usual  procedure  for  the  operative  treatment  of  bony  anchylosis  of  the 
temporo-maxillary  joint  consists  in  mere  excision  of  the  condyle  of  the  lower 
jaw.  Helferich,  having  had  poor  results  from  the  above  operation,  modified 
it  slightly.  His  modification  is  founded  on  the  fact  that  interposition  of  the 
muscle  between  the  fragments  is  a  common  cause  of  non-union  in  fractures. 

Helferich's  Operation. — Make  a  vertical  incision  ij^  to  2  inches  in  length, 
one  finger-breadth  in  front  of  the  ear.  Ligate  the  temporal  artery.  Push  the 
parotid  gland  aside;  expose  the  condyle  and  neck  of  the  lower  jaw.  The 
temporo-maxillary  joint  may  be  indistinguishable  because  of  anchylosis.  With 
a  chisel  divide  the  neck  of  the  bone  at  a  point  about  J-^  inch  below  the  site  of 
the  joint.  Do  not  preserve  the  periosteum.  Excise  the  condyle  and  neck  of 
the  jaw  above  the  point  of  section,  taking  away  the  periosteum  with  them.  If 
only  one  joint  is  anchylosed,  the  mouth  can  now  be  easily  opened.  If  necessary, 
enlarge  the  skin-incision  upwards.  Reflect  a  long  flap  from  the  temporal  mus- 
cle, about  one  inch  wide  and  with  its  base  below.  Turn  the  flap  downwards 
so  that  its  free  end  can  be  tucked  into  the  defect  left  by  the  excision  of  the 
condyle.  To  turn  the  flap  down  and  put  it  in  position  requires  that  a  portion 
of  the  zygomatic  arch  be  removed.  This  is  easily  done  with  rongeur  or  bone 
forceps.  Fix  the  muscular  flap  in  position  by  a  few  sutures  of  catgut.  Close 
the  wound  without  drainage.  Apply  dressings.  The  result  obtained  from 
Helferich's  operation  was  most  happy.  Murphy's  experience  seems  to  show 
that  a  flap  of  fat  is  preferable  to  muscle  in  the  above  operation. 


104 


LOWER   JAW — RESECTION 


J.  B.  Murphy's  Operation  (Journ.  A.  M.  A.,  June  6,  1914.) — This  operation 
will  be  best  comprehended  by  a  study  of  the  accompanying  figures.  Figure  no 
shows  the  L-shaped  incision  which  gives  good  exposure  but  avoids  injury  to  the 
facial  nerve.     The  internal  maxillary  artery  is  shown  passing  inward  behind 


*     If         ' 


V, 


,  uUl  [^■■ll         i« 


Fig.  1 10. — L-shaped  skin  incision  above  the  zygoma  and  in  front  of  the  ear,  so  placed  to 
avoid  injury  to  the  facial  nerve.  Note  the  relation  of  the  external  carotid,  the  temporal, 
and  internal  maxillary  arteries  to  the  field  of  operation.  The  last-named  vessel  in  passing 
inward  behind  the  neck  of  the  mandible  lies  close  to  the  bone  and  must  be  carefully  protected 
from  injury  during  the  operation,  especially  at  the  time  when  the  neck  of  the  mandible  is 
divided.     {Murphy.) 


and  close  to  the  neck  of  the  mandible  where  it  is  liable  to  injury  unless  well 
protected  during  the  operation.  Figure  in  shows  the  neck-of  the  bone  exposed 
and  being  divided  with  a  Gigli  saw  while  the  internal  maxillary  artery  is  pro- 
tected by  means  of  two  curved  periosteal  elevators. 


ANCHYLOSIS 


lOS 


In  Fig.  112  the  neck  of  the  bone  has  been  divided,  the  cut  ends  of  the  bone 
have  been  separated  by  traction  during  which  time  the  protecting  curved  ele- 
vators were  kept  in  situ.  A  flap  of  fat  and  fascia  is  dissected  from  the  temporal 
region  and  is  turned  downwards  and  inwards  between  the  divided  end  of 
the  mandible  where  it  is  securely  anchored  by  tacking  stitches. 


Fig.  III. — Dividing  the  necli  of  the  mandible  with  the  Gigli  saw.  (In  actual  operation 
the  saw  is  not  allowed  to  make  so  acute  an  angle  as  shown  in  the  illustration,  because  of  its 
great  tendency  to  break  when  sharply  bent.)     (Murphy.) 

The  after-treatment  consists  in  keeping  the  mouth  open  by  means  of  a 
wooden  block  until  healing  is  complete. 

How  to  know  which  side  is  anchylosed  is  important.  Murphy's  rules  for 
this  are: 

I.  There  is  flattening  of  the  jaw  on  the  tmaffected  side,  most  pronounced 
near  the  tip  of  the  chin. 


io6 


LOWER  JAW — RESECTION 


2.  When  the  patient  attempts  to  open  his  mouth,  the  teeth  move  from  }^q 
to  Koo  iiich  downwards  and  deviate  a  little  in  the  direction  of  the  anchylosed 
side,  because  of  a  slight  sliding  forwards  of  the  mandibular  articulation  on  the 
unafifected  side  as  the  muscles  of  the  neck  are  put  on  tension  in  the  effort  made 
to  open  the  mouth. 


Fig.  112. — The  pediclcd  fascia  and  fat  flap  is  dissected  out  Irom  the  temporal  fascia,  and  the 
free  end  of  the  flap  is  turned  inward  between  the  divided  ends  of  the  mandible  and  sutured 
securely  in  place  with  tacking  stitches.     {Murphy.) 


3.  A  sliding  motion  on  the  unaffected  side  can  be  felt  by  the  palpating  fin- 
gers, and  the  muscular  activity  on  that  side  is  very  much  greater  on  attempted 
opening  of  the  mouth  than  on  the  anchylosed  side. 

4.  The  muscles  on  the  anchylosed  side  are  more  atrophied  than  those  on 
the  unaffected  side. 

L.  W.  Arlow*  finds  that  in  severe  cases  of  temporo-maxillary  anchylosis 
the  pathological  changes  are  by  no  means  limited  to  the  joint,  but  that  osteitis 

*  Ref.  Centralblatt  f.  Chir.,  1903,  No.  28. 


ANCHYLOSIS 


107 


alters  the  form,  size,  and  relations  of  the  articular  process,  the  coronoid  process, 
the  incisura  semilunaris,  the  zygoma,  etc.  As  a  consequence  simple  division 
of  the  articular  process  is  insufficient  to  give  motion,  and  even  when  combined 
with  osteotomy  of  the  coronoid  it  often  fails  and  resection  of  a  part  of  the  full 
width  of  the  upper  portion  of  the  ascending  ramus  becomes  necessary.  Facial 
paralysis  is  more  common  as  a  result  of  tearing  and  distraction  than  of  acci- 
dental division  with  knife  or  chisel.  Recurrence  is  avoided  by  extensive  removal 
of  bone,  by  the  implantation  between  the  fragments  of  muscle  or  even  of  metal 
plates,  and  by  early  passive  and  active  motion.  Monod  and  Van  verts  strongly 
recommend  osteotomy  of  the  ascending  ramus  as  being  easier  than  resection 
of  the  neck  of  the  bone,  as  efficient,  and  not  liable  to  cause  injury  to  the  facial 
nerve.     Rochet's  method  of  operating  is  as  follows: 

Step  I. — Make  an  incision  bordering  the  angle  of  the  jaw.     About  one  inch 
of  this  incision  runs  along  the  lower  edge  of  the  horizontal  ramus,  and  about 


Figs.   113  and  114. — Rochet's  operation.     {After  Monod  and   Vanverts.) 


one  inch  along  the  posterior  edge  of  the  ascending  ramus.  Through  this  expose 
the  inferior  insertion  of  the  masseter  and  detach  it  from  below  upwards  with 
an  elevator.  This  exposes  the  outer  surface  of  the  bone.  In  the  same  way  ex- 
pose the  inner  surface  of  the  bone  by  separating  the  insertion  of  the  internal 
pterygoid. 

Step  2. — With  chisel,  forceps,  or  Gigli  saw  divide  the  bone  along  the  lines 
marked  in  Fig.  113,  and  remove  the  bone  between  the  lines  of  section.  The 
amount  of  bone  should  be  as  great  as  possible,  to  permit  wide  range  of  motion 
subsequently. 

Step  3. — From  the  deep  surface  of  the  masseter  dissect  a  flap  about  i3^ 
inches  long,  with  its  pedicle  above,  consisting  of  about  half  the  thickness  of  the 
muscle.  Pass  the  free  end  of  this  flap  through  the  breach  in  the  bone  and  suture 
it  to  the  pterygoid  (Fig.  114).  Should  the  flap  from  the  masseter  be  insufficient 
for  the  purpose,  a  subsidiary  flap  may  be  taken  from  the  pterygoid. 

Step  4. — Close  the  wound. 


Io8  ODONTOMATA 

CHAPTER  X 
ODONTOMATA 

Odontomata  are  tumors  arising  from  teetli  germs  or  teeth  still  in  process  of 
growth.  Bland-Sutton  described  seven  varieties  of  this  tumor  besides  the  sim- 
ple dental  cyst  which  develops  at  the  root  of  a  dead  tooth.  The  odontomata 
are  often  called  dentigerous  cysts.  The  chief  importance  of  these  tumors  is  that 
they  are  rarely  recognized  prior  to  operation,  that  they  are  often  wrongly  diag- 
nosed as  malignant  neoplasms  and  the  whole  jaw  needlessly  extirpated.  The 
tumors  are  non-malignant  and  are  readily  removable. 

Bland-Sutton  writes:  "In  the  case  of  a  tumor  of  the  jaw,  the  nature  of  which 
is  doubtful,  particularly  in  a  young  adult,  it  is  incumbent  on  the  surgeon  to 
satisfy  himself  before  proceeding  to  excise  a  portion  of  the  mandible  or  maxilla 
that  the  tumor  is  not  an  odontome,  for  this  kind  of  tumor  only  requires  enuclea- 
tion." The  following  operation  performed  by  the  author  explains  the  principles 
of  procedure.  Incision  through  muco-periosteum  over  the  prominence  of  the 
tumor.  With  chisel,  trephine,  or  bur  cut  through  the  shell  of  bone  (about  two 
lines  in  thickness).  In  the  posterior  part  of  the  tumor  a  cavity  was  found  con- 
taining a  perfect  premolar  tooth  with  thick  mucous  membrane  attached  all 
round  its  neck.  Tooth  removed.  The  mucosa  was  attached  to  a  purplish, 
soft,  round,  grape-like  mass  which  filled  the  anterior  part  of  the  tumor  or  bone 
cavity.  This  was  easily  shelled  out.  The  cavity  left  was  the  size  of  a  hen  egg, 
was  smooth  and  lined  with  mucous  membrane.  The  root  of  the  first  molar 
projected  into  the  cavity.  Extracted  this  tooth.  Partly  closed  wound  and 
packed  with  gauze.  The  tumor  was  a  typical  odontoma.  After  many  weeks 
the  cavity  closed  completely. 

A  more  rapid  closure  would  have  been  obtained  had  the  operation  been  per- 
formed as  follows: 

1.  Free  incision  of  muco-periosteum  over  the  growth. 

2.  Reflection  of  muco-periosteum  from  over  the  whole  external  of  the  promi- 
nent surface  of  the  tumor. 

3.  Penetration  of  the  bone  and  removal  of  the  contents  of  the  bone  cavity. 

4.  Removal  of  all  the  external  wall  of  the  cavity  and  destruction  of  the 
mucous  membrane  lining  the  rest  of  the  cavity. 

5.  Application  of  the  reflected  muco-periosteal  flaps  to  the  bottom  of  the 
cavity.     Application  of  dressings  to  keep  the  flaps  in  position. 


EXCISION    OF    THE    CHEEK  I09 

CHAPTER  XI 
EXCISION  OF  THE  CHEEK 

If  a  tumor  is  located  on  the  buccal  surface  of  the  cheek,  is  not  extensive,  and 
does  not  involve  the  skin,  it  may  be  excised  through  the  mouth  by  an  elliptical 
incision  and  the  wound  closed  by  sutures.  Should  the  amount  of  mucous  mem- 
brane and  subjacent  tissue  removed  be  great,  then,  when  healing  has  taken 
place,  there  may  result  fibrous  anchylosis  of  the  jaw.  To  prevent  this  contrac- 
tion, one  must  fill  the  defect  by  means  of  a  graft  covered  with  epithelial  tissue. 
Of  course,  when  the  anchylosis  is  the  result  of  an  old  burn  or  similar  lesion  one 
must  excise  the  scar  tissue  before  implanting  the  graft. 

The  Operation. — The  tumor  or  old  scar  tissue  has  been  excised  through  the 
mouth,  leaving  the  defect  a,  b,  c  (Fig.  115).     On  the  neck  trace  the  flap  D,E,F, 


Figs.  115  and  116. — Repair  of  buccal  mucosa. 

the  distal  portion  of  which  consists  of  hairless  skin  large  enough  to  more  than 
fill  the  defect.  Dissect  free  the  fiap  outlined.  Be  sure  that  the  pedicle  is  wide, 
thick,  and  so  placed  that  when  turned  into  position  its  vessels  will  not  be  injuri- 
ously twisted.  Make  an  incision  (X,  Fig.  115)  through  the  cheek  into  the 
mouth.  Through  this  incision  pass  the  flap  D,  E,  F,  and  suture  its  edges  to  the 
margins  of  the  defect  a,  b,  c.  After  the  lapse  of  ten  days  divide  the  pedicle  of 
the  flap  at  X  and  replace  its  remnant  in  its  normal  position.  Close  the  wound  in 
the  cheek.  Close  the  wound  in  the  neck  partly  by  sliding  the  edges  towards 
each  other  and  partly  by  skingraf  ts.  [This  closure  of  the  wound  in  the  neck  may 
properly  be  attended  to  at  the  original  operation.] 

When  it  is  impossible  to  remove  the  tumor  through  the  mouth,  although  the 
skin  is  not  involved  one  may  make  the  incision  A,  B  (Fig.  116)  through  the  skin 
alone,  reflect  the  skin-flaps  X,  Y  (Fig.  117),  and  thus  expose  the  mucous  mem- 
brane and  tumor  (T,  Fig.  117).  Next  excise  the  tumor  and  fill  the  resulting  de- 
fect by  the  flap  (C,  E,  D,  Fig.  118)  taken  from  the  neck  (or  forehead).  Replace 
the  flaps  X  and  Y  and  secure  with  sutures. 


no 


EXCISION    OF    THE    CHEEK 


Shelton  Horsley  (Journ.  A.  M.  A.,  Jan.  30,  1915),  if  necessary,  provides  an 
epithelial  lining  for  the  mouth  by  means  of  a  flap  turned  up  from  the  neck  or 
from  the  tongue.     The  flap  to  replace  the  skin  defect  is  taken  from  the  forehead 


Figs.   117  and  118. — Repair  of  buccal  mucosa. 


i[,>rjlcy.  J,',: 


and  instead  of  being  provided  with  the  usual  pedicle,  transplantation  of  the 
anterior  temporal  artery  is  practised  according  to  the  method  published  by 
Monks  (Boston  Med.  and  Surg.  Journ.,  1898)  but  of  which  Horsley  was  ignorant 
at  the  time. 


PLASTIC   REPAIR 


III 


The  Operation.     Anesthetize  preferably  by  the  rectal  method. 

1.  Prepare  the  cheek  by  trimming  away  the  scar  tissue  around  the  defect  and 
by  undermining  the  skin  slightly.  If  it  is  necessary  to  replace  the  mucosa  do  so 
by  implanting  the  flap  A,  B,  C,  D  (Fig.  ii8). 

2.  Outline  the  flap  E,  F,  G.  Make  the  straight  incision  G,  H  along  the 
line  of  the  anterior  temporal  artery.  Expose  the  artery,  but  do  not  injure  it  or 
grasp  it  with  forceps.  Dissect  the  artery  free  along  with  a  considerable  amount 
of  surrounding  tissue  so  as  to  preserve  the  nerve  supply  of  the  vessel.  Make  the 
incision  H,  I  through  the  skin  alone  and  prepare  a  bed  for  the  artery.  Complete 
the  mobilization  of  flap  E,  F,  G  and  place  it  in  the  defect  in  the  cheek.     Place 


Figs.  120  and  121. — Plastic  operation  on  cheek.     {Monod  and  Vanverts 


the  artery,  which  of  course  runs  into  the  flap  E,  F,  G  into  the  gutter  prepared 
along  the  line  H,  I  and  suture  the  skin  over  it.  Unite  the  flap  E,  F,  G  by  dijew 
stitches  to  the  defect.  As  the  drainage  of  the  flap  and  not  its  blood  supply  is 
liable  to  be  faulty,  plenty  of  opportunity  for  escape  of  blood  and  fluids  must  be 
provided,  hence  few  stitches  are  used.  "By  the  second  day  the  flap  is  swollen 
and  becomes  a  dark  purple  color.  If  it  is  too  tense,  every  few  hours  a  sharp 
knife  can  be  inserted  along  the  edges  of  the  flap  to  scrape  it  a  little  so  as  to  pro- 
mote bleeding  and  relieve  the  tension.  After  a  week  the  swelling  begins  to  dis- 
appear and  new  capillaries  drain  away  the  blood." 

Bardenheuer  has  devised  some  excellent  and  ingenious  methods  of  repairing 
defects  in  the  cheek,  defects  left  after  the  removal  of  disease  or  of  scar  tissue 
which  gave  rise  to  fibrous  anchylosis.  Fig.  120  represents  a  case  in  which  the 
mucous  membrane  was  replaced  by  a  flap  of  skin  taken  from  the  forehead  and 
provided  with  an  enormously  wide  and  reliable  pedicle;  the  skin  was  replaced  by 
a  flap  of  skin  taken  from  the  neck.  After  healing  was  secured  the  pedicles  were 
divided,  the  wound  trimmed,  and  all  raw  surfaces  on  forehead  or  neck  covered 


112 


EXCISION    OF    THE    CHEEK 


by  skin-grafts.  Fig.  121  represents  a  case  in  which  Bardenheuer  brought  a 
skin-flap  down  from  the  forehead.  The  flap  was  nourished  through  a  narrow 
flap  which  contained  the  supraorbital  artery.  The  defect  in  the  skin  was  cov- 
ered by  a  flap  taken  from  below. 

The  above  operations  are  described  as  suggestive  types  for  the  repair  of  de- 
fects in  the  cheek.  The  operations  of  Kraske  and  Israel  are  also  good  types 
(Figs.  122,  123,  124,  125,  126). 


Figs.  122  and  123. — Kraske's  operation.     {Esmarch  and  Ko'iiolzig.) 


I 


Figs.  124,  125,  126. — Israel's  operation.     (Esmarch  and  Kowalzig.) 


W.  D.  Gillies  (Surg.  Gyn.,  &  Obst.,  Feb.,  1920)  uses  a  postauricular  flap  in 
closing  defects  of  the  cheek.  When  insufficient  skin  is  available  from  over  the 
mastoid,  he  includes  some  skin  from  the  posterior  surface  of  the  pinna  (Figs. 
127,  128,  129,  Gillies). 

In  cases  where  part  of  the  lower  jaw  has  been  removed  and  where  there  is  a 
corresponding  loss  of  substance  in  the  cheek  Sonnenburg  ("Archiv  fiir  klin. 
Chir.,"  Ixxviii,  820)  makes  an  incision  along  the  corresponding  side  of  the  tongue 
(Fig.  130)  and  so  obtains  a  flap  of  tissue  covered  with  mucosa.  This  flap  Sonnen- 
burg sutures  to  the  freshened  upper  edge  of  the  defect  in  the  cheek  (Fig.  131.) 
The  oral  side  of  the  defect  being  filled  as  above,  the  outer  or  skin  side  may  now  be 
covered  by  an  appropriate  flap  from  the  neck.* 


PLASTIC    REPAIR    CHEEK 


113 


Figs.  127,  128,  129. — Post  auricular  flap  for  cheek  replacement.     {Gillies,  Surg.,  Gyn.  b'Obst.) 

Drawn  by  S.  Hernswick. 


Figs.  130,  131. — (Sonnenburg.) 


114 


EXCISION   OF   THE    CHEEK 


Hotchkiss'  Operation, — Planned  for  cases  of  extensive  cancer  of  the  cheek 
with  involvement  of  the  jaw. 


Fig.  132. — {Hotchkiss,  Annals  of  Surg.) 


Fig.  133. — {Hotchkiss,  Annals  of  Surg.) 


Step  I. — Make  the  incision  i,  2,  3,  8,  4  (Fig.  132),  through  the  skin,  and 
reflect  the  flaps  outlined  so  as  to  expose  the  lower  border  of  the  inferior  maxilla, 


Fig.  134. — {Hotchkiss,  Annals  of  Surg.) 


Fig.  135. — {Hotchkiss,  Annals  of  Surg.) 


the  platysma  overlying  the  submaxillary  gland,  and  the  deep  structures  of  the 
neck. 


LOWER    LIP 


115 


Step  2. — Free  the  anterior  border  of  the  sternomastoid  exposing  the  chain 
of  glands  extending  from  the  submaxillary  space  to  below  the  level  of  the  cricoid 
cartilage.  From  below  up  remove  en  masse  the  entire  lymphatic  chain  along 
the  internal  jugular  vein  and  beneath  the  sternomastoid  muscle  until  the  bellies 
of  the  digastric  come  into  view  when  the  contents  of  the  submaxillary  space 
(both  salivary  and  lymphatic  glands)  must  be  dissected  free  and  retracted 
upwards  in  one  piece  (Fig.  133).  Doubly  ligate  and  divide  the  external  jugular 
and  facial  veins  and  the  external  carotid  artery. 

Step  3. — Expose  the  outer  surface  of  the  lower  jaw  and  prepare  it  for  section. 
Protect  the  neck  wound  with  gauze.  Make  an  incision  all  around  the  disease 
on  the  face  and  at  a  safe  distance  from  the  disease  (i,  2,  10,  9,  Fig.  132).  This 
incision  penetrates  the  mouth.  Divide  the  lower  jaw  with  a  Gigli  saw  well  in 
front  of  the  growth.  Retract  the  divided  jaw.  Divide  the  floor  of  the  mouth 
along  the  groove  of  the  tongue  severing  the  mylohyoid  and  hyoglossus  muscles. 
Pull  the  lower  jaw  and  attached  structures  outwards,  and  if  the  disease  involves 
the  upper  jaw  remove  the  affected  bone.  Disarticulate  and  remove  the  lower 
jaw  along  with  the  diseased  tissues.  (Fig.  134). 

Step.  4. — In  Hotchkiss'  cases  "  the  mucous  membrane  at  the  side  of  the  tongue 
was  united  to  the  cut  edge  of  the  hard  palate,  the  tongue  thus  being  elevated 
as  a  sort  of  wedge  against  leakage  from  the  mouth.  The  edges  of  the  cut 
mucous  membrane  in  front  and  behind  this  were  united  by  suture  and  the  cut 
edge  of  the  mylohyoid  muscle  was  brought  up  over  this  line  of  union  of  the 
mucous  membrane,  and  the  skin-flap  shown  in  Fig.  135  was  then  sutured  up  to 
fill  in  the  defect  in  the  cheek.  A  portion  of  the  incision  in  the  neck  was  left  un- 
sutured  and  filled  with  loose  gauze  packing  extending  up  to  the  glenoid  and  tem- 
poral fossae"  ("x'Vnnals  Surg.,"  Oct.,  1908). 


CHAPTER  XII 
LOWER  LIP 

Epithelioma  is  the  most  common  cause  for  removal  of  the  lower  lip.  The 
classical  method  of  removing  labial  cancers  is  by  a  V-shaped  incision.  This 
method  is  applicable  to  cases  in  which  not  more  than  two-thirds  of  the  width  of 
the  lip  is  involved.     The  resulting  deformity  is  slight. 

The  operation  is  performed  as  follows:  A  general  or  local  anesthetic  having 
been  administered,  an  assistant  controls  the  coronary  arteries  with  his  fingers 
and  thumbs;  the  surgeon  rapidly  cuts  through  the  whole  thickness  of  the  lip  on 
each  side  of  the  tumor.  The  two  cuts  thus  made  meet  at  an  angle  below  the 
tumor,  which  is  now  removed.  Before  the  assistant  relaxes  his  control  of  the 
coronary  vessels  the  surgeon  applies  silk  or  silkworm-gut  sutures,  either  through 
the  whole  thickness  of  the  lip  or  with  the  exception  of  the  mucous  membrane. 
The  sutures  are  tied  and  form,  a  sufficient  guard  against  hemorrhage. 

When  performed  as  above,  the  operation  is  very  speedy;  so  speedy,  in  fact, 
that  the  surgeon  may  inadvertently  make  his  incision  approach  a  little  too  close 
to  the  tumor.     In  such  operations  there  is  usually  nothing  to  be  gained  and 


ii6 


LOWER    LIP 


much  may  be  lost  through  great  speed.     A  sHght  modification  in  operating 
leads  to  greater  deliberation  and  hence  greater  thoroughness. 

The  surgeon  seizes  the  tumor  and  lower  lip  between  the  finger  and  thumb 
of  the  left  hand,  and  pulls  them  forwards  and  upwards  in  such  a  way  as  to  guard 
against  blood  entering  the  mouth.  Beginning  on  the  lip  margin,  at  least  one- 
fourth  of  an  inch  from  the  growth,  a  curved  incision  is  made  downwards  until  the 
lower  limits  of  the  tumor  are  passed.  This  incision  is  made  to  but  not  through 
the  mucous  membrane.  Bleeding  vessels  are  caught  up  with  hemostats.  A 
similar  incision  is  made  on  the  opposite  side,  and  only  after  bleeding  is  stopped  is 
the  mucous  membrane  divided  and  the  growth  removed.  The  wound  is  closed 
as  in  the  previous  operation.  Many  surgeons  prefer  to  stitch  the  mucous  mem- 
brane with  catgut  and  close  the  rest  of  the  wound  with  silk  or  silkworm-gut.  As 
a  matter  of  routine,  the  glands  through  which  the  lymphatics  of  the  lip  drain 
should  be  removed  even  if  not  enlarged.  He  would  be  a  bold  fool  who  would 
say  a  field  had  no  seed  in  it  because  no  sprouting  verdure  was  visible.  Experi- 
ence seems  to  show  that  it  is  unnecessary  to  remove  the  lymphatics  leading  from 
the  tumor  to  the  lymph  nodes,  although  theoretically  such  ought  to  be  removed. 


Collectors  0/  tipfier  Up  ending  in 
submaxillary  nodes 


Collectors  of  lower  Up  ending  in 
same  nodes 


Vessel  passing  to  node  of  internal 
jugular  chain 


Fig.  136. — The  lymphatics  of  the  lips.     {Morris  After  Dorcndorf.) 

For  the  sake  of  obtaining  aseptic  healing  of  the  wound  made  in  removing  the 
lymph  glands  this  part  of  the  operation  may  be  performed  through  a  separate 
incision  which  is  closed  before  the  primary  disease  is  attacked.  "The  capillary 
plexuses  of  the  skin  and  mucous  membrane  are  continuous  at  the  free  border 
of  the  lips.  The  ducts  of  the  upper  lip,  of  which  there  are  about  four  on  each 
side,  pass  to  the  submaxillary  nodes.  From  the  lower  lip  the  trunks  from  near 
the  angle  of  the  mouth  pass  to  the  submaxillary  nodes,  while  those  from  the  cen- 
tre of  the  lip  pass  to  the  submental  nodes.  There  are  from  two  to  four  subcu- 
taneous ducts  and  from  two  to  three  submucous  ducts  on  either  side.  The 
collecting  trunks  passing  to  the  submaxillary  nodes  do  not  anastomose,  and 
the  same  is  true  of  the  submucous  ducts  of  the  lower  lip.  The  subcutaneous 
ducts,  on  the  other  hand,  passing  to  the  submental  nodes,  anastomose  freely — 
an  important  fact  in  connection  with  the  extension  of  cancer  of  the  lower  lip." 
("Morris'  Human  Anatomy")  Fig.  136. 

The  submental  nodes  ought,  therefore,  to  be  removed  on  both  sides.  Re- 
member that  some  lymph  nodes  are  closely  attached  to  the  submaxillary  sali- 
vary glands  and  hence  these  glands  should  be  excised  on  the  afifected  side.     A 


REGNIER  S    OPERATION  II7 

continuation  downwards  of  the  incision  for  the  removal  of  the  tumor,  the  V 
incision  being  converted  into  a  Y,  and  elevation  of  the  skin  on  each  side  of  the 
cut  give  excellent  access  to  the  structures  requiring  removal. 

Bloodgood  found  that  excision  of  the  lip  and  glands,  when  there  was  no  ap- 
parent glandular  involvement,  resulted  in  twenty  cures  among  twenty-one  cases, 
while  the  same  operation  gave  six  cures  out  of  twelve  cases  when  metastasis  was 
demonstrably  present  in  the  glands.  In  the  six  cases  in  which  recurrence 
took  place  it  was  local  in  one  and  in  the  cervical  glands  in  five. 

When  there  is  palpable  glandular  involvement  in  the  neck  the  operation 
becomes  similar  or  practically  identical  with  that  required  in  cancer  of  the 
tongue.  (See  Butlin's,  Crile's,  Maitland's  methods  described  in  chapter  on  the 
Tongue.) 

Very  superficial  cancers  of  the  lip  may  be  removed  by  a  curved,  more  or  less 
horizontal  incision,  the  mucous  membrane  and  skin  being  subsequently  sewed 
together. 

A  large  number  of  methods  for  the  removal  of  cancers  of  the  lower  lip  and 
for  remedying  the  resulting  deformity  will  be  found  sketched  at  the  end  of  this 
article. 


Figs.  137  and  138. — Regnier's  operation. 

Regnier's  Operation. — Step  i. — The  tumor  and  the  whole  of  the  lower  lip, 
from  one  angle  of  the  mouth  to  the  other,  are  removed  by  a  curved  incision.  In 
making  this  incision  it  is  well  to  have  all  bleeding  arrested  before  the  mucous 
membrane  is  divided  and  the  mouth  is  penetrated. 

Step  2. — The  skin  and  mucous  membrane  at  the  edge  of  the  wound  are 
united  by  sutures  (A,  Fig.  137). 

Step  3. — From  the  lower  edge  of  the  middle  of  the  upper  lip  measure  down- 
wards to  the  lower  edge  of  the  middle  of  the  lower  jaw  {e.g.,  call  the  distance 
2^  inches).  From  the  middle  of  the  wound  (A,  Fig.  137)  measure  downwards 
and  mark  a  point  the  same  distance  below  A  as  the  mental  process  is  below  the 
edge  of  the  upper  lip  (in  our  example,  2}/^  inches).  Take  a  point,  B,  in  the 
middle  line,  ^'4  inch  lower  than  the  above  {i.e.,  in  our  example,  3  inches  below  A). 
In  the  submental  region  or  in  the  neck,  as  the  case  may  be,  make  a  curved  inci- 
sion parallel  to  the  wound  in  the  lower  lip,  and  having  the  point  B  as  its  centre. 
This  curved  incision  must  be  from  5  to  6  inches  in  length. 


ii8 


LOWER    HP 


Step  4. — Through  the  incision  at  B  dissect  the  skin-flap,  A,  B,  from  the  sub- 
jacent tissues  in  such  a  way  as  to  enter  the  mouth  at  the  line  of  reflection  of  the 
mucous  membrane  from  lip  or  cheek  to  gum.  In  this  way  a  vizor-shaped  or 
double-pedicled  flap  is  formed  and  can  be  slid  over  the  lower  jaw  to  re-form  the 
lower  lip.  The  lower  edge  of  this  flap  is  sutured  to  the  periosteum  at  the  lower 
edge  of  the  jaw  (Fig.  138). 

Step  5. — A  space,  C,  is  left  in  the  submental  region  through  which  any  en- 
larged glands  may  be  removed.  Ogston  maintains  that,  when  the  submaxillary 
gland  is  enlarged  and  even  slightly  adherent  to  the  bone,  the  bone  is  probably 
already  involved  in  the  disease  and  ought  to  be  removed.  If  this  is  the  case, 
then  it  is  quite  feasible  to  remove  the  whole  thickness  of  the  bone  involved, 
along  with  the  gland,  though  the  triangular  space  C.  The  skin  of  the  neck 
being  very  lax  and  mobile,  it  is  a  simple  matter  to  cover  at  least  a  large  part  of 
the  space  C  with  skin.  Any  uncovered  portions  may  be  grafted  according  to  the 
Thiersch  method. 

Dressings. — Iodoform  gauze  should  be  loosely  packed  between  the  newly 
formed  lower  lip  and  the  upper  part  of  the  external  surface  of  the  lower  jaw. 
Externally  the  usual  antiseptic  dressings  may  be  applied.  The  mouth  should 
be  frequently  washed  with  a  weak  solution  of  permanganate  of  potash  and  the 
dressings  changed  as  required. 

JRegnier's  operation  is  capable  of  being  modified  to  meet  man}'  conditions, 

and  very  great  deformities  may  often  be 
/^^%\  avoided  by  its  means.     To  the  writer  it 

has  given  great  satisfaction. 


DOWD'S  OPERATION 

Step  I. — iSIake  the  incisions  A,  B  and 
C,  D  below  and  parallel  to  the  lower  jaw. 
Be  careful  to  leave  the  point  X  (Fig.  139) 
attached  to  the  jaw.  Expose  and  remove 
the  fatty  and  lymphatic  tissue  of  the 
whole  submental  and  submaxillary  region. 
Remove  also  the  submaxillary  salivary 
glands.  If  the  lymphatics  above  men- 
tioned are  visibly  and  palpably  enlarged, 
continue  the  incisions  backwards  and  expose  the  carotid  packet  of  vessels. 
Remove  the  lymphatic  glands  in  this  region  whether  they  are  palpably 
enlarged  or  not. 

Step  2. — Remove  the  disease  by  means  of  the  incisions  A,  E,  F;  C,  G,  H;  A, 
C.     These  incisions  should  be  }4  to  ^  inch  distant  from  the  disease. 

Step  3.— Make  the  incisions  I,  E  and  G,  K  (each  two  inches  or  more  in 
length),  down  to  but  not  through  the  buccal  mucosa.  Divide  the  mucosa  along 
lines  at  least  ^i  inch  higher,  so  as  to  form  a  flap  which  may  be  stitched  to  the 
skin  and  serve  as  mucous  membrane  for  the  new  lower  lip. 

Step  4.— Unite  the  raw  surface  A,  E  to  C,  G  with  sutures.     The  wedge- 
shaped  incisions  L  and  M  may  aid  in  the  approximation  of  the  new  lower  lip. 
Step  5.— Close  the  wounds  A,  B  and  C,  D,  after  providing  for  drainage. 


Fig.  139. — Dovvd's  operation. 


SUTTON  S   OPERATION  II9 

Trendelenburg's  position  ought  to  be  used  throughout  the  operation.  In 
operating  on  cancer  of  the  lip  it  is  a  good  rule,  where  possible,  to  begin  by  dis- 
secting out  the  lymphatics  which  may  be  diseased.  It  is,  of  course,  imperative 
to  remove  all  evidently  involved  lymphatics,  but  it  is  prudent  to  go  further 
and  remove  the  apparently  unaffected  ones  next  in  order.  For  example :  the  sub- 
mental and  submaxillary  group  of  lymphatics  appear  healthy,  or  but  very 
slightly  diseased:  remove  them  and  then  excise  the  primary  disease  of  the  lip  as 
well  as  perhaps  the  fatty  connections  between  the  primary  and  the  secondary 
foci  of  disease;  again,  the  submental  and  submaxillary  group  are  evidently  dis- 
eased; expose  the  carotid  group  of  lymphatics,  excise  them,  as  well  as  the  sub- 
maxillary, etc.  One  great  reason  for  beginning  with  the  lymphatics  is  that  by 
so  doing  the  mouth  is  not  penetrated  until  the  difl&culties  of  the  operation  are 
practically  ended. 


Fig.  140. — Sutton's  operation.     (Sutton.) 

W.  S.  Sutton  devised  an  ingenious  and  successful  method  of  removing 
tumors  involving  both  upper  and  lower  lips  at  the  angle  of  the  mouth  ("Jour. 
A.  M.  A.,"  Aug.  20,  1910).  Fig.  140  is  self-explanatory.  Grant's  operation  is 
sufficiently  explained  by  Figs.  141  and  142. 

Nelaton  and  Ombredanne  recommended  the  two  following  operations  as  the 
methods  of  choice  in  cancers  of  different  extent. 

Method   A . 

Step  I. — Excise  the  cancer  by  a  V-shaped  incision.  From  the  apex  of  the  V 
make  one  or  if  necessary  two  incisions  parallel  to  and  a  finger's  breadth  below 
the  border  of  the  lower  jaw,  outwards  to  the  line  of  the  carotid  artery  (Fig.  143). 
Excise  the  lymphatics  extensively. 


120 


LOWER    LIP 


Step  2. — Close  the  wound  by  suture,  after  providing  for  drainage  (Fig. 
144).  Closure  of  the  wound  produces  a  very  ugly  deformity  of  the  upper  lip. 
To  correct  this  make  an  angled  incision  E,  B,  C  (Fig.  144)  on  each  side  of  the 
mouth.  Suture  the  cut  surface  E,  B  to  the  cut  surface  B,  C.  This  restores 
the  upper  lip.  Along  the  line  E,  D,  C  unite  the  buccal  mucosa  to  the  skin. 
This  gives  a  presentable  lower  lip  (Fig.  145). 


Fig.  141. — Grant.     {Bryant's  Op.  Surg.) 


Fig.  142. — Grant.     (Bryant's  Op  Surg.) 


Method  B. — For  very  extensive  lesions. 

Step  I. — Excise  the  tumor,  preferably  by  incisions  which  form  a  triangle 
with  its  apex  below,  so  that  a  cut  may  run  down  from  the  apex  to  expose  the 
lymphatics  beneath  the  jaw. 

Step  2. — On  each  side  proceed  as  follows:  From  the  angle  of  the  mouth  make 
an  incision  (A,  B,  Fig.  146)  directed  towards  the  inferior  border  of  the  tragus. 


s?^>  y_  ^  ^(^Sife^ 


Fig.  143. — {Nilalon  and  Ombridanne.) 

Divide  the  skin  only.  Open  the  mouth.  Mucous  membrane  exists  under  the 
anterior  portion  of  the  cut  A,  B.  Divide  the  mucous  membrane  parallel  to  but 
about  }/s  inch  above  the  skin  incision.  (By  suturing  the  mucosa  to  the  skin  a 
red  border  is  provided  for  the  new  lower  lip.)  Make  the  skin  incision  B,  C 
parallel  to  the  wound  made  in  the  excision  of  the  disease.  The  lower  end  of  the 
cut  B,  C,  is  about  a  finger's  breadth  below  the  lower  border  of  the  lower  jaw.  In 
making  the  cuts  A,  B  and  B,  C  do  not  injure  the  parotid.     Reflect  the  flap  out- 


NELATON-OMBREDANNE    OPERATION 


121 


lined  by  the  cuts  AB,  BC;  to  do  this  it  is  necessary  to  divide  the  mucosa  verti- 
cally along  the  the  anterior  edge  of  the  masseter.  Be  careful  not  to  divide  the 
facial  artery  where  it  crosses  the  border  of  the  lower  jaw,  but  separate  it,  with  the 
flap,  from  the  jaw. 

Step  3. — Clear  away  the  lymphatics  and  the  submaxillary  glands  but  care- 
fully preserve  the  facial  artery;  if  necessary,  the  facial  vein  may  be  sacrificed. 


^•^^^  y_  V  ^^^^ 


Fig.  144. — {Nelaton  and  Omhredanne.) 

Step  4. — Suture  the  mucosa  to  the  skin  on  the  upper  edge  of  the  flap  (see 
Step  2)  so  as  to  form  a  red  border  for  the  new  lower  lip  (X,  A,  Figs.  147  and  148). 

Step  5. — Suture  the  lower  edge  of  the  mucous  membrane  of  the  new  lip  to 
the  cut  edge  of  the  mucous  membrane  on  the  lower  jaw  (L,  L,  Figs.  147  and  148). 


^^^^   j_  V    ^^^^ 


Fig.  145. — (Xelaton  and  Omhredanne.) 

This  forms  the  line  of  reflection  of  the  mucous  membrane  between  the  lip  and  the 
jaw.     The  rest  of  the  operation  is  sufficiently  explained  by  Figs.  148  and  149. 

Clark  Stewart's  operation  ("Jour.  A.  M.  A.,"  Jan.  15,  1910)  gives  good 
exposure  of  the  submaxillary  lymph  nodes  and  permits  of  the  excision  of  the 
lymph  nodes,  submaxillary  glands  and  the  tumor  in  one  piece. 


122 


LOWER   LIP 


"The  first  incision  extends  just  below  the  jaw  from  one  angle  to  the  other 
and  cuts  the  skin  and  platysma  muscle,  which  are  then  carefully  dissected  down 


Fig.  146. — {Nilaion  and  Omhredanne.) 


Fig.  147. — {Nilaton  and  Ombridanne.) 


Fig.  148. — {Ndlaton  and  Ombridanne.) 


Fig.  149. — (Nilaton  and  Ombridanne.) 


to  the  level  of  the  thyroid  cartilage  (Fig.  150).  All  tissues  down  to  the  muscles 
are  then  sectioned  at  this  line  and  a  clean  dissection  is  made  elevating  all  loose 
connective  tissue,  lymph  nodes,  etc.,  in  a  flap  which  extends  laterally  to  the  great 


STEWARTS    OPERATION 


123 


vessels  on  each  side.  The  facial  artery  and  vein  are  ligated  and  the  submaxil- 
lary glands  are  loosened  and  raised  in  the  flap  on  each  side.  Incisions  are  now 
made  at  each  side  of  the  epithelioma  far  enough  away  to  include  all  infiltrated 
tissue,  and  these  are  carried  down  to  the  cross-section  already  made. 


Fig.   150. — {Stewart,  Jour.  A.  M.  A.) 

The  lateral  flaps  are  now  dissected  free  from  the  jaw,  keeping  close  to  the 
skin  at  the  lower  part  to  avoid  lymphatics,  and  finally  the  intervening  central 
mass  is  loosened  from  the  jaw  and  removed.  This  contains  the  tumor  and  a 
fan-shaped  mass  of  skin  and  the  deeper  tissues  attached  to  the  lympth  nodes  of 


the  neck,  and  the  submaxiUary  gland  by  a  loose  flap  of  tissue  which  contains  the 
connecting  lymphatics. 

The  submaxillary  glands  should  always  be  removed,  not  because  they  are 
infected  in  early  cases,  but  because  there  is  regularly  a  lymph  node  attached 
to  each  which  is  one  of  the  first  to  be  involved.  In  cases  in  which  not  over 
three-fourths  of  an  inch  of  the  vermilion  edge  of  the  lip  has  been  removed, 


124 


LOWER    LIP 


simple  suture  of  the  wound  with  drainage  of  the  submaxillary  fossae  completes 
the  operation.  In  cases  in  which  the  mouth  must  be  extended  on  account  of 
more  extensive  removal  of  the  lower  lij),  the  procedure  shown  in  the  drawings  is 
convenient. 

The  mouth  is  broadened  by  a  straight  incision  outwards  at  either  or  both 
angles,  and  this  incision  is  carried  down  to  but  not  through  the  mucous  mem- 
brane; the  latter  is  then  cut  one-half  inch  higher  and  stitched  to  the  raw  surface 
of  the  new  lip  (Fig.  151).  To  avoid  puckering  of  the  upper  lip  a  triangle  of  the 
skin  is  taken  out  of  the  cheek  to  allow  of  the  smooth  drawing  together  of  the 
lower  lip  (Fig.  152).  The  new  chin  should  be  sutured  to  the  soft  tissues  over 
the  lower  jaw  to  exclude  mouth  fluids  from  the  neck  wound." 


Fig.   152. — {Stewart,  Jour.  A.  M.  A.) 


Mayo's  Operation. — Step  i. — Make  a  collar  incision  through  the  skin  and 
platysma  ^  inch  below  the  mandible  from  one  sternomastoid  to  the  other. 
Reflect  the  skin  and  platysma  down  to  the  hyoid  bone  and  up  to  the  mandible. 
Remove  all  fascia  and  fat  as  well  as  the  submaxillary  salivary  glands  from  the 
submental  and  submaxillary  triangles  on  both  sides.  Ligate  the  facial  arteries 
and  veins  but  preserve  the  hypoglossal  and  lingual  nerves. 

As  soon  as  the  glands  have  been  removed  from  one  side  have  them  examined 
microscopically  while  those  on  the  other  side  are  being  removed.  If  they  are 
innocent  of  cancer  complete  the  operation  by  suturing  the  platysma  and  then 
the  skin  after  providing  for  drainage  and  proceed  to  the  excision  of  the  lip.  If 
the  glands  are  cancerous  further  dissection  is  essential  as  described  in  Step  2. 
If  they  are  not  cancerous  proceed  to  Step  3. 

Step  2. — Make  an  incision  along  the  sternomastoid  muscle,  reflect  the  skin 
and  platysma  sufficiently  to  expose  the  whole  region  of  the  sternomastoid  on 
that  side  of  the  neck  from  which  cancerous  glands  were  obtained.  Divide  the 
sternomastoid  at  its  lower  end  and  from  below  up  make  a  block  dissection  of  all 
the  glands  and  gland-bearing  fascia  of  the  entire  neck,  including  the  anterior  and 


RESULTS 


125 


posterior  deep  jugular  glands  up  to  the  mastoid  process.  Removal  of  the  sterno- 
mastoid  is  necessary  to  a  complete  dissection.  lie  very  careful  to  clean  out  the 
glands  in  the  posterior  part  of  the  submaxillary  triangle. 


Fig.   153. — {Beckinan.) 

Provide  for  drainage.     Close  the  wound.     Delay  operation  upon  the  lip 
until  danger  from  infection  of  the  great  cervical  wound  is  past. 


Results  after  Operation  for  Cancer  of  thf 

Lower 

Lip  (Beckman,  Mayo  Clinic 

,  1913) 

Group 

No.  of   No.  op- 
cases      erated 

Traced 

^'ot       r,,„H       Not       Inop- 
traced  1  ^'^'^^'^     cured     erable 

Per 
cent, 
cured 

I.  Clinical  diagnosis  only 

II.  Primary  radical  operation .  . . 
Glands  involved 

III.  Late  radical  operation 

Glands  involved 

IV.  Glands  removed  one  side  or 
incomplete 

V.  Local  excision  only 

25 

126 

18 

25 

12 

s 
18 

2 

126 

18 

25 
12 

5 

18 

6 

99 
18 
20 
12 

5 

15 

19              2 
27           83 

9 

S          14 
0            4 

1 
0     1       2 
3          II 

23 
16 

9 

6 
8 

3 

6 

17 






,83.8 

^0.0 

70.0 

33-3 

40.0 
73-3' 

126  LOWER    LIP 

Step  3. — Figure  153  sufficiently  elucidates  the  removal  of  the  disease  in  the 


lip. 


CHIN  AND  JAW 


Occasionally  an  operable  cancer  involves  the  soft  parts  of  the  chin,  the  floor 
of  the  mouth,  and  a  portion  of  the  lower  jaw.  The  following  method  has  proved 
useful  in  such  cases: 


Fig.  155. 


Step  I. — A  stout  thread  is  passed  through  the  tongue  so  as  to  have  command 
over  that  organ. 

Step  2. — An  incision  is  made  through  the  skin  around  the  tumor.  From  the 
lowest  part  of  this  a  cut  is  made  downwards  through  the  skin  of  the  submental 
region  and  neck  to  a  point  A  (Fig.  154).     The  cut  A,  B,  is  made  through  the 


^ — ^ 

Fig.  156. — Author's  operation  for  epithelioma  of  the  chin  and  jaw. 


skin.  The  incision  around  the  tumor  is  deepened  until  the  bone  is  reached,  but 
the  mouth  should  not  be  penetrated  until  all  bleeding  vessels  have  been  caught. 
By  proceeding  thus,  time  is  not  wasted  by  the  necessity  of  swabbing  blood  from 
the  pharynx. 

Step  3. — The  flaps  A,  C  and  B,  D  (Fig.  155)  are  reflected,  giving  easy 
access  to  the  bone.  The  horizontal  ramus  of  the  lower  jaw  is  divided  by  a 
chain  or  finger  saw  on  each  side  of  the  tumor. 


CANCER   LOWER   LIP 


127 


Figs.   157   and   158. — Bruns.     {Esmarch   and  Kowalzig.) 


Figs.  159  and   160. — Estlander.     {Esmarch  and  Kowalzig.) 


Figs.  161  and  162. — Dieffenbach.     {Estnarch  and  Kowalzig.) 


Figs.  163  and   164.— (a)   Jaesche;   (6)  Trendelenburg.     {Esmarch  and  Kowalzig.) 


128 


LOWER   LIP 


Step  4. — Posteriorly  to  the  tumor  and  from  below  upwards  the  floor  of  the 
mouth  is  divided  in  such  a  maimer  that  all  bleeding  is  invited  and  arrested  before 
the  scissors  or  knife  enters  the  mouth. 

Step  5. — It  is  now  easy  to  remove  all  the  diseased  structures — chin,  jaw, 
floor  of  mouth,  glands,  etc.,  en  masse. 

Step  6. — If  possible,  the  edges  of  the  oral  mucous  membrane  should  be 
united  by  silk  or  catgut  sutures.     The  skin-wound  is  closed  by  silkworm-gut. 


Figs.  165  and  166. — Burow.     {Esmarch  and  Ko-d'ahig.) 


Figs.  167  and  168.— Blasius.     (Esmarch  and  Kowalzig.) 

51  '      (    \ 


Figs.  169  and  170. — Langenbeck.     {Esmarch  and  Kowalzig.) 


Dressings. — The  floor  of  the  mouth  should  be  lightly  packed  with  iodoform 
gauze.  The  external  wound  should  be  covered  by  an  antiseptic  dressing.  Fre- 
quent washing  of  the  mouth  with  a  weak  permanganate  of  potash  solution  is 
necessary.  Food  ought  to  be  given  through  the  stomach-tube,  though  the 
patient  may  drink  water  if  he  so  desires.  It  is  important  in  all  such  cases  to 
encourage  the  patient  to  leave  his  bed  as  early  as  possible.  This  helps  to  avoid 
the  great  danger  in  such  cases,  viz.,  septic  pneumonia. 

Should  the  first  part  of  Step  6  of  the  previous  operation  be  impossible  owing 
to  lack  of  mucous  membrane,  then  an  attempt  may  be  made  to  supply  the  de- 
fect as  follows:  In  the  neck  (where  hairs  are  absent)  trace  out  a  flap  of  skin 
(F,  Fig.  156)  in  such  a  position  and  of  such  a  size  that,  allowing  for  shrinkage  it 


UPPER    LIP 


129 


can  be  made  to  fit  into  the  floor  of  the  mouth.  Turn  the  flap  F  up  and  stitch 
its  distal  or  free  end  to  the  anterior  portion  of  the  mucous  membrane  wound. 
The  most  posterior  stitches  unite  the  mucous  membrane  of  the  side  of  the  mouth 
near  the  root  of  the  tongue  to  the  raw  edges  of  the  flap  near  its  pedicle.  This 
gives  an  epithelial  lining  to  the  floor  of  the  mouth.  The  flaps  A,  C  and  B,  D 
(Fig.  156)  are  now  sutured  over  flap  F;  both  flaps,  A,  C  and  B,  D,  having  been 


Figs.  171  and  172.— Trelat.     {Monod  and  Vanverts.) 


Figs.  173  and  174. — Serre.     {Monod  and  Vanverts.) 

split  (G)  to  permit  the  passage  of  flap  F  into  the  mouth.  The  wound  left  by  the 
transplantation  of  flap  F  is  to  be  closed  by  sutures  or  by  Thiersch's  skin-grafts. 
Of  course,  a  secondary  operation  will  be  necessary  to  close  the  hole  G  and  to 
divide  the  pedicle  of  flap  F. 

Several  well-known  methods  of  excising  the  lower  lip  and  repairing  the  defect 
are  illustrated  by  Figs.  157  to  174. 


CHAPTER  XIII 


UPPER  LIP 

Excision  of  the  upper  lip  is  usually  demanded  because  of  malignant  disease, 
but  scars  resulting  from  infective  lesions,  burns,  etc.,  may  require  excision  and 
repair. 

As  in  other  regions,  when  operating  for  malignant  disease,  it  is  necessary  to 
know  the  anatomy  of  the  lymphatics  as  the  lymph  nodes  into  which  the  diseased 
area  drains  must  be  thoroughly  removed.  The  lymphatics  of  the  upper  lip 
pass  into  the  submaxillary  lymph  nodes  but  on  their  way  they  may  pass  through 
certain  facial  nodes,  viz.,  (a)  the  infra-maxillary  and  supra-maxillary  nodes 
resting  on  the  lower  jaw  near  where  it  is  crossed  by  the  facial  artery,  (b)  the 
anterior  and  posterior  buccinator  nodes,  superficial  to  the  buccinator  fascial 


I30 


UPPER    LIP 


lying  on  a  line  connecting  the  lower  margin  of  the  ear  and  the  angle  of  the 
mouth. 

The  posterior  nodes  lie  near  where  the  parotid  duct  perforates  the  buccinator 
muscle,  the  anterior  nodes  lie  between  the  facial  artery  and  vein  (Fig.  175). 
In  excising  malignant  neoplasms  from  the  upper  lip  remember  that  the  mid- 


■-  Suborbital  nodes 

-  Node  of  nasogenial  fold 


Buccinator  node 


-  Supra-maxillary  node 

-  Infra-maxillary  node 


Fig.  175. — The  facial  nodes.     {Morris  after  Buchbinder.) 

groove  of  the  lip  is  of  the  same  developmental  origin  as  the  columella  nasi  and 
that  disease  may  early  pass  from  the  former  to  the  latter  structure.  Removal 
of  the  diseased  upper  lip  scarcely  requires  description;  repair  of  the  resulting 
defect  may  be  difficult. 

Principles  of  Repair. — Union  of  the  edges  of  the  defect  must  be  accomplished 
without  tension  being  exerted  on  the  sutures;  without  too  great  puckering  of 


Fig.  176. 

the  lower  lip;  without  disfiguring  twisting  of  the  angles  of  the  mouth  which 
might  give  the  expression  of  a  fixed  sneer;  without  displacement  of  the  alee  nasi 
sufficient  to  interfere  with  the  patency  of  the  nostrils. 

Method  I, — The  neoplasm  is  at  or  near  the  middle  line  and  is  not  of  great 
size.  Step  i. — Make  the  vertical  incision  AB  and  A'B',  Fig.  176,  on  each  side 
of  and  three-fourths  of  an  inch  distant  from  the  disease.     Cut  through  the^whole 


REPAIR    UPPKR    LIP 


131 


thickness  of  the  lip.  Continue  the  incisions  upwards  curving  around  the  alae 
of  the  nose  to  the  points  D  and  D'.  By  a  transverse  cut  join  the  points  B  and 
B'  thus  separating  the  alse  of  the  nose  from  the  cheeks  and  upper  Hp  and  divid- 
ing the  columella  nasi.  Remove  the  diseased  segment  of  the  lip.  Attend  to 
hemostasis. 

Step  2. — Everting  the  remnant  of  the  lip  on  one  side  make  an  incision  through 
the  mucosa  to  the  bone  along  the  reflection  of  the  mucosa  from  the  cheek  to  the 
upper  jaw.  With  blunt  and  sharp  dissection  separate  the  soft  parts  from  the 
bone  to  such  an  extent  that  the  whole  cheek  is  fully  mobilized.  Do  the  same  on 
the  opposite  side. 

Step  3. — Try  to  approximate  the  cut  surfaces  AB  and  A'B'.  If  tension  is 
too  great,  mobilize  the  cheek  more  thoroughly.  This  mobilization  may  be  very 
extensive  and  without  danger  if  the  surgeon  "hugs  the  bone"  in  carrying  it  out. 
When  AB  is  approximated  to  A'B'  the  cuts  BD  and  B'D'  often  become  puckered 
and  press  objectionally  against  the  alee  nasi  causing  obstruction  of  the  nostrils. 
To  avoid  this  excise  the  segments  of  cheek  BED  and  B'E'D',  Suture  AB  to  A'B' 
as  in  hare-lip.  Suture  the  divided  columella  to  the  new  upper  lip.  The  upper 
lip  may  be  repaired  in  this  fashion  after  three-fourths  of  it  has  been  excised. 

If  there  is  much  puckering  of  the  lower  lip  resulting  from  the  operation  it 
may  be  corrected  by  an  operation  the  same  as  that  described  for  the  lower  lip 
(p.  120)  the  lines  of  incision  being  of  course  reversed. 


Fig.  177. 


Fig.  178. 


During  the  operation  the  facial  lymph  nodes  may  be  looked  for  and  removed. 
On  completion  of  the  operation  remove  the  submaxillary  nodes  through  a  special 
incision  and  if  necessary  remove  other  suspected  cervical  nodes. 

Method  2. — ^Lenthal  Cheatle's  operation.  At  a  distance  of  at  least  three 
quarters  of  an  inch  from  the  tumor  make  the  vertical  incision  AB,  Fig.  177, 
through  the  whole  thickness  of  the  lip.  Continue  the  incision  along  the  curved 
line  BCD  a  short  distance  lateral  to  the  groove  separating  the  ala  nasi  from  the 
cheek.  On  the  opposite  side  of  the  growth  make  the  corresponding  incision 
A'B'C'D'.  From  the  point  D  make  an  incision  along  the  ala  nasi  groove, 
skirting  the  ala  and  cutting  it  off  from  the  lip.  Do  the  same  on  the  opposite 
side.  Divide  the  columella  nasi,  sacrificing  a  part  of  its  base.  Remove  the  area 
of  lip  and  cheek  between  the  incisions  ABCD  and  A'B'C'D'. 

To  facilitate  approximation  of  the  edges  of  the  wound  make  the  two  curved 
incisions  BE  and  B'E'  about  i}4  inches  long,  through  the  whole  thickness  of  the 
cheek.     These  incisions  must  not  injure  Stenson's  duct  which  is  easily  seen  in 


1,32  UPPER    LIP 

the  mouth  and  avoided.  Through  the  incisions  BE  and  B'E'  look  for  the  buc- 
cinator lymph  nodes  and  remove  them  if  they  are  present.  Suture  the  wound 
AB  to  the  wound  A'B'.  Close  the  curved  incisions  beside  the  alee  nasi.  Suture 
the  columella  nasi  to  the  new  upper  lip. 

Method  3. — The  disease  is  not  extensive  and  is  situated  in  the  lateral  portion 
of  the  lip. 

Lenthal  CheatJe's  Operation. — Three-fourths  of  an  inch  internal  to  the  disease 
divide  the  lip  vertically  from  its  margin  up  into  the  nostril  or  to  the  columella. 
From  the  point  A,  Y\g.  178,  three-fourths  of  an  inch  external  to  the  disease,  at 
or  near  the  angle  of  the  mouth  make  an  incision  AB  upwards  and  outwards  to- 
wards the  external  canthus  of  the  eye.  The  upper  end  of  the  incision  is  on  the 
level  of  the  upper  end  of  the  ala  nasi.  Make  the  incision  BC  down  to  the  bone. 
From  the  point  C  make  an  incision  following  the  curve  of  the  ala  nasi  to  meet  the 
original  vertical  incision. 

Remove  the  disease  along  with  the  tissues  in  the  shaded  area  in  Fig.  178. 
Repair  must  be  eflfected  by  bringing  the  opposite  half  of  the  upper  lip  over  to 
meet  the  edge  of  the  wound  AF.  To  do  this  without  undue  tension  divide  the 
connections  between  the  remnants  of  the  lip  and  the  jaw;  cutting  against  the 
bone,  widely  separate  the  tissues  of  the  cheek  from  the  bone  on  the  healthy  side 
By  incision  separate  the  ala  tiasi  of  the  healthy  side  from  the  cheek  and  from  the 
lip.  To  avoid  puckering  of  tissues  excise  the  crescent  of  tissue  DE,  Fig.  178. 
Divide  the  columella  at  its  junction  with  the  upper  lip.  If  tension  has  been 
sufficiently  relieved  the  remnant  of  lip  can  now  be  brought  near  the  wound  AF. 
To  prevent  puckering  of  the  angle  of  the  mouth  and  to  relieve  tension  make  the 
incision  AY  outwards  and  downwards  from  the  angle  of  the  mouth,  through  the 
whole  thickness  of  the  cheek.  From  the  point  F  on  the  level  of  the  nostril,  make 
the  incision  FZ  through  the  whole  thickness  of  the  lip.  From  the  point  B  make 
the  incision  BX  down  to  the  bone.  Reflect  the  flap  ZFBX  and  excise  the  buc- 
cinator lymph  nodes.  Suture  the  wound  AF  to  the  remnant  of  the  upper  lip. 
Suture  the  wound  BF  to  the  ala  nasi.  Suture  the  columella  to  an  appropriate 
point  on  the  new  upper  lip.     Excise  the  submaxillary  lymph  nodes. 

Method  4. — The  disease  is  extensive.     Excise  the  whole  upper  lip. 

Nelaton-Ombredanne  Operation. — Trace  the  flap  ABCDE  on  each  side  of  the 
defect  (Fig.  179).  "The  side  AB  is  formed  by  the  border  of  the  defect  and  in 
length  is  a  little  more  than  one-half  the  transverse  diameter  of  the  defect. 
Perpendicular  to  this  side,  we  trace  the  line  BC  slightly  concave  upwards  and 
shorter  than  the  vertical  diameter  of  the  defect.  The  result  of  this  will  be  that 
the  flap  when  transposed  will  be  a  little  too  long  and  not  quite  deep  enough  but 
the  elasticity  of  the  skin  will  permit  a  sufficient  gain  in  the  depth  at  the  expense 
of  the  length  of  the  flap  when  sutures  are  being  inserted.  Mark  the  point  E, 
2  to  23^^  cm.  (3^  to  I  inch)  horizontally  outwards  from  the  angle  of  the  mouth; 
between  and  equidistant  from  the  points  C  and  E  choose  the  point  D  which 
must  be  about  i  cm.  external  to  an  imaginary  line  uniting  C  and  E.  Join  CD 
by  a  line  slightly  concave  externally.  Join  DE  by  a  straight  line.  This 
completes  the  tracing  of  the  flap. 

The  cuts  AB  and  DE  penetrate  into  the  mouth.  The  cuts  BCD  penetrate 
to  the  bone.     Divide  the  reflection  of  the  mucous  membrane  between  the  jaw 


ANGIOMATA    FACE 


^33 


and  cheek;  and  dissect  the  flap  BCD  from  the  bone.  The  flap  ABC D  is  covered 
with  mucosa  except  at  its  point.  Along  the  edge  AB  suture  the  mucosa  to  the 
skin  so  as  to  form  a  red  edge  for  the  new  lip,  if  necessary  excising  a  few  milli- 
meters of  skin  to  make  the  mucosa  more  prominent.  Suture  the  edge  BC  to  its 
homologue  on  the  opposite  side  (Fig.  i8o) ;  the  incision  BC  being  slightly  concave 


^>  y_  I  4^^ 


^^"^^^  L .  ^«3^^ 


Fig.  179. — {Nelaton  and  Omhredanne.) 


Fig.   iSo. — (Xelalon  and  Omhredanne). 


its  suture  makes  a  little  prominence  on  the  free  border  of  the  new  lip.  When 
inserting  the  sutures  begin  with  those  in  the  mucosa.  The  curve  of  the  inci- 
sion CD  fits  it  well  for  its  new  position  under  the  nose.  In  closing  the  resultant 
defect  DC'D'E  do  not  try  to  unite  the  two  sides  of  the  rectangle  which  are 
closest  to  each  other;  this  would  deform  the  new  lip  giving  it  a  horrible  fixed 
sneer.  Suture  the  point  5  to  the  point  ^  so  as  to  form  a  sort  of  star  into  the 
branches  of  which  a  few  sutures  may  be  inserted. 

ANGIOMATA  OF  THE   FACE 

Angiomata  of  the  face  when  small  may  require  no  treatment;  when  larger 
they  may  be  treated  by  the  application  of  "dioxide"  snow  or  by  excision;  when 
superficial  and  extensive  their  owner  may  treat  them  with  resignation  but  when 
pulsatile  or  very  large,  deforming  and  threatening  to  life,  more  active  treatment 
may  be  necessary.  Excision  is  often  too  dangerous  and  disfiguring.  Ligation 
is  inefficient.  Injection  of  coagulating  materials  is  commonly  insufficient  and 
involves  grave  dangers  from  embolism.  Morestin  (Rev.  de  Chir.,  Feb.,  1914)  lias 
injected  solutions  of  formalin  to  kill  or  "fix"  the  diseased  tissues  but  precedes 
the  injections  by  ligating  the  principal  afferent  and  efferent  vessels.  The  tem- 
porary cessation  or  lessening  of  the  local  circulation  lessens  the  dangers  from 
embolism  and  increases  the  efficiency  of  the  injections.  Morestin's  formalin 
solution  consists  of  equal  parts  of  formalin,  90  per  cent,  alcohol  and  glycerine, 
of  which  any  amount  from  i  c.c.  to  12  c.c.  or  more  may  be  injected  according 
to  circumstances.  The  injections  may  require  to  be  repeated  several  times  but 
no  new  injection  should  be  made  until  the  reaction  from  the  pre\ious  one  has 
subsided. 

The  Operation. — A  general  anesthetic  is  necessary  in  the  first  operation;  if 
the  injections  require  to  be  repeated  the  tissues  are  so  altered  that  no  anesthetic 
is  required  in  the  later  operations. 


134  HARE-HP 

Step  I. — Ligation  of  the  ]'essels. — According  to  the  case  ligation  is  practised 
on  one  or  both  sides.  Bilateral  ligation  is  proper  when  the  lesion  is  very  exten- 
sive, passes  over  the  middle  line  and  is  pulsatile. 

Make  an  oblique  transverse  incision  whose  center  is  on  the  anterior  margin 
of  the  sternomastoid  muscle  one  finger's  breadth  below  the  angle  of  the  jaw. 
Retract  the  sternomastoid.  Penetrate  cautiously  between  the  facial  and  ex- 
ternal jugular  veins.  According  to  the  site  and  extent  of  the  lesion  tie  the  facial 
vein,  or  the  facial  and  external  jugular  or  even  the  internal  jugular  (this  last  of 
course  only  on  one  side).  It  is  best  to  place  the  ligatures  around  the  veins  but 
not  to  tie  them  until  after  the  arteries  have  been  tied. 

Recognize  the  external  carotid  artery  opposite  the  tip  of  the  greater  horn  of 
the  hyoid.  Pass  a  ligature  round  the  artery ;  expose  its  principal  branches  (facial 
superior  thyroid,  lingual)  and  tie  them  separately.  Unless  these  branches  are 
tied,  anastomosis  is  so  quickly  established  as  to  render  useless  the  ligation  of  the 
main  artery.     Close  the  wound. 

Step  2. — Charge  a  syringe  with  the  fixative  solution  and  arm  it  with  a  long, 
fine  needle.  Introduce  the  needle  through  the  skin  at  the  periphery  and 
push  it  through  the  tumor  mass.  Slowly  withdraw  the  needle  at  the  same  time 
expressing  the  contained  solution  drop  by  drop.  Do  not  inject  any  of  the 
solution  close  to  the  skin  or  mucous  membrane,  otherwise  sloughing  will  occur. 
Repeat  the  injection  until  the  whole  of  the  angioma  has  been  injected  (in  some 
very  large  tumors  it  is  better  to  inject  one  segment  of  the  tumor  at  a  time). 

Morestin  writes:  "In  pulsatile  angiomas  the  dose  of  solution  must  be  large 
even  although  it  may  cause  massive  sloughing;  the  dangers  from  the  disease 
justify  the  risk.  When  the  integument  is  diseased  it  is  difficult  to  obtain  a  cure 
without  greater  or  less  destruction  of  the  skin  but  in  these  cases  it  is  preferable 
not  to  attack  the  superficial  parts  of  the  disease  at  the  first  sitting,  they  may  be 
treated  later." 

"A  few  hours  after  operation  swelling  begins  and  increases  to  very  large 
proportions  during  three  or  four  days,  but  there  is  comparatively  little  discolora- 
tion. Pain  as  a  rule  is  slight  and  ephemeral.  General  symptoms  are  usually 
absent.  After  four  or  five  days  the  swelling  begins  to  diminish.  The  tumor 
itself  persists  for  a  time  as  a  hard  mass  but  little  by  little  this  softens  and  the 
tissues  may  become  quite  pliable." 


CHAPTER   XIV 
HARE-LIP 

Time  to  Operate. — On  the  whole,  it  may  be  taken  that  it  is  better  to  oper- 
ate after  the  patient  has  passed  the  first  two  months  of  life  than  at  an  earlier 
period,  although  many  surgeons  operate  by  choice  within  a  week  or  two  of 
birth. 

Position  of  Patient  and  Surgeon. — Chloroform  having  been  administered, 
the  patient  should  be  put  in  Rose's  position.  The  shoulders  being  supported  on 
a  pillow,  the  head  is  allowed  to  hang  backwards  over  the  end  of  the  table.  In 
this  posture  the  anterior  nares  are  at  a  lower  level  than  the  entrance  to  the 


PRINCIPLES    OF    OPERATION  1 35 

trachea,  and  thus  it  is  easier  for  blood  which  has  gathered  in  the  nose  or  pharynx 
to  escape  through  the  nares  than  to  be  aspirated  into  the  lungs.  For  the  same 
reason  much  trouble  caused  by  the  collecting  of  blood  in  the  pharynx  is  obviated. 
Trendelenburg's  position  has  the  same  advantages.  Ether  may  be  administered 
and  blood  and  secretions  removed  by  means  of  proper  apparatus  such  as  is  used 
in  operations  on  the  tonsils.  The  surgeon  sits  with  his  back  to  the  window 
opposite  the  patient's  head.  The  first  assistant  stands  beside  the  patient's 
left  shoulder. 

Fundamental  Principles  of  Hare-lip  Operations. — i.  Tension  must  be  re- 
lieved, so  that  the  function  of  the  sutures  is  practically  merely  to  hint  to  the 
edges  of  the  cleft  that  they  must  stay  in  apposition. 

2.  The  edges  of  the  cleft  must  be  freshened  so  that  union  can  take  place. 

3.  This  freshening  must  be  done  in  such  a  way  that  the  edge  of  the  upper  lip 
opposite  the  line  of  suture  is  made  to  project  below  the  normal  level  of  the  lip. 
The  object  of  this  is  to  avoid  the  occurrence  of  a  notch  on  the  lip  after  the  wound 
has  shrunk  when  healing  is  complete. 

4.  The  freshened  edges  of  the  cleft  must  be  brought  together  and  kept  to- 
gether. 

To  these  fundamental  principles  James  E.  Thompson  adds  the  following: 

5.  The  red  line  of  the  lip  must  extend  in  a  clean,  unbroken  curve  from  one 
side  of  the  newly  formed  lip  to  the  other. 

6.  The  depth  of  the  mucous  membrane  must  be  equal  on  each  side  of  the 
line  of  suture. 

7.  The  newly  formed  lip  must  not  be  too  short,  but  must  be  lengthened  so 
that  it  will  more  than  cover  the  gums. 

8.  The  nostril  must  be  reproduced  so  as  to  have  exactly  the  same  dimensions 
as  the  sound  nostril,  and  must  consist  of  tissue  of  the  same  texture  as  the  normal 
nostril. 

9.  There  must  be  no  flattening  of  the  nose  or  ala  nasi  on  the  afifected 
side. 

SINGLE   HARE-LIP 

Incomplete  Hare-lip. — The  cleft  in  the  lip  does  not  extend  into  the  nostril; 
it  is  often  a  mere  notch.  It  may  be  unnecessary  to  relieve  tension,  though  when 
the  cleft  is  at  all  extensive  or  wide  this  is  necessary  and  must  be  done  thoroughly. 
Malgaigne's  operation  gives  good  results,  but  Nelaton's  is  the  one  usually  recom- 
mended. These  operations  and  a  few  others  will  be  easily  understood  by  a 
glance  at  Figs.  i8i  to  i86. 

In  incomplete  hare-lip,  when  the  ala  of  the  nose  is  pulled  to  the  side  and  the 
nostril  much  widened,  C.  H.  Mayo  relieves  tension  very  thoroughly,  separating 
the  ala  of  the  nose  from  its  deep  connections;  then  he  makes  his  denudation  at  the 
floor  of  the  nostril  (Fig.  187,  A,  B),  and  by  pulling  the  lip  downwards  and  intro- 
ducing sutures,  converts  the  horizontal  wound  A,  B  into  a  vertical  one  (Fig.  188). 
The  rerult  is  obliteration  of  the  notch  in  the  lip  and  correction  of  the  deformed 
position  of  the  ala  of  the  nose. 


136 


HARE-LIP 


Figs.  i8n  and   182. — Malgaigne.     {Esmarch  and  Ko'xalzig.) 


Figs.   183  axd  184. — Xelaton.     (Esmarch  atid  Kowalzig.) 


Figs.  185  and  186. — Mirault.     {Esmarch  and  Kowalzig.) 


Figs.   187  and   \i 


^/i////>/..f..A... 

-C.   H.   Mayo's  operation. 


Fig.  180. — Relief  of  tension. 


Fig.  190. 

The  dotted  area  represents  the  extent  of  dissection 
that  is  commonly  required  for  the  rehef  of   tension. 


COLLIS     OPERATION 


137 


Complete  Single  Hare-lip. — Relief  of  Tension. — This  is  one  of  the  most  im- 
portant steps  of  all  hare-lip  operations.  Failure  to  relieve  tension  completely 
is  the  most  common  cause  of  bad  results. 

The  upper  lip  i"  -verted  and  pulled  upwards  and  outwards  by  the  fmger 
and  thumb  of  the  left  hand  (Fig.  189).  The  mucous  membratne  is  incised  at  its 
reflection  from  gum  to  lip,  and  divided  from  the  premolar  region  on  one  side  to 
the  premolar  region  on  the  other  side,  if  necessary.  Through  this  incision, 
with  knife  or  scissors,  one  separates  the  soft  parts  from  the  bones  (keeping  the 
instrument  close  to  the  bone).  Particular  attention  must  be  paid  to  the  sepa- 
ration of  the  ala  of  the  nose  from  the  bone  (Fig.  iqo). 

To  what  extent  must  the  soft  parts  be  separated  from  the  bone  ?  The  answer 
to  the  foregoing  question  is,  until  the  edges  of  the  cleft  in  the  lip,  when  placed 
together,  show  a  tendency  to  lie  in  apposition,  so  that  the  sutures  when  intro- 
duced may  be  tied  without  giving  rise  to  tension. 

Freshening  of  the  Edges  of  the  Cleft. — The  methods  of  freshening  the  edges  of 
the  cleft  are  legion. 


/    JSmdce* 


Figs.  191  and  192. — Collis'  operation. 

The  Collis  Operation  for  Single  Hare-lip. — Tension  having  been  relieved, 
make  the  incision  A,  B  (Fig.  191)  along  the  line  of  junction  between  mucous 
membrane  and  skin.  Dissect  the  mucous  membrane,  corresponding  to  that 
incision,  from  the  subjacent  tissues  until  the  whole  edge  A,  B  of  the  cleft  is  raw. 
The  mucous  membrane  may  be  entirely  removed  or  may  be  left  as  a  flap  (F, 
Fig.  192)  having  its  pedicle  posteriorly.  If  the  flap  is  left  attached  it  forms, 
when  the  operation  is  completed,  a  sort  of  valve 
covering  the  posterior  surface  of  the  wound.  In 
a  few  weeks  no  trace  of  it  will  be  found. 

On  the  external  edge  of  the  cleft  make  the 
incision  C,  E,  D  (Fig.  191)  through  the  whole 
thickness  of  the  lip.  At  the  point  E  divide  the 
flap  thus  formed  by  a  horizontal  incision.  This 
result?  in  the  formation  of  two  flaps,  C  e'  and  D 
e  (Figs.  191  and  192).  Stitch  the  raw  surface  of 
the  flap  C  e'  to  the  highest  possible  part  of  the 
raw  surface  A,  B.     This  brings  the  ala  of  the  nose 

into  good  position  and  provides  an  epithelial  covered  floor  to  the  anterior 
nares.  Turn  the  flap  D  e  (Fig.  193)  downwards  and  stitch  it  to  the  lowest 
possible  part  of  the  raw  surface  A,  B.  Stitch  the  point  E  (Fig.  193)  to  the 
middle  of  the  raw  surface  A,  B.  When  all  the  sutures  are  in  place  and  tied,  the 
wound  line  will  appear  as  represented  in  Fig.  193. 


Fig.    193. — Collis'    operation. 


138 


HARE-LIP 


This  operation  wastes  no  valuable  tissue  and  gives  a  particularly  long  upper 
lip.  Fig.  194  to  202  suffice  to  illustrate  some  other  well-known  methods  of 
operating. 

Sutures. — One  or  two  deep  sutures  involving  almost  the  whole  thickness  of 
the  lip  must  be  inserted.  The  best  material  for  these  is  silkworm-gut.  Hare-lip 
pins  have  been  discarded,  as  they  cause  too  much  scarring.  Usually  the  deep 
sutures  are  inserted  through  the  skin  and  give  rise  to  considerable  scarring  a^ 
their  points  of  entrance  and  emergence;  a  better  plan  is  to  introduce  the  deep 
sutures  from  the  mucous  surface  and  not  to  involve  the  skin  in   their  bite; 


Figs.  194, 195  and  196. — Giraldes.     {Esmarcli  and  Kou'alzig.) 


Figs.  197,  198  and  199. — Konig.     (Estnarch  and  Ko'walzig.) 


Figs.  200,  201  and  202. — Konig.     (Esmarch  and  Kowalzig.) 


when  this  is  done,  these  stitches  must  not  be  removed  until  healing  is  com- 
plete, when  they  will  generally  be  found  to  have  cut  their  own  way  out.  If  the 
surgeon  endeavors  to  remove  such  sutures  at  the  end  of  a  week,  he  requires  to 
evert  the  lip,  and  thus  jeopardizes  the  line  of  union.  Several  superficial  cu- 
taneous sutures  must  be  introduced;  the  best  material  for  these  is  horse-hair. 
Horse-hair  sutures,  because  of  their  elasticity,  leave  less  scar  than  any  others. 
All  cutaneous  sutures  (superficial  and  deep)  may  be  removed  by  the  seventh  day. 


DOUBLE   UNCOMPLICATED    HARE-LIP 

When  the  deformity  is  not  complicated  by  the  central  portion  of  the  lip 
being  carried  forwards  towards  the  tip  of  the  nose  by  the  intermaxillary  bone, 
the  following  operation  will  generally  be  found  satisfactory. 


DOUBLE    HARE-LIP 


139 


Make  the  incisions  A,  B,  C  and  D,  E,  F  (Fig.  203)  through  the  whole  thick- 
ness of  the  lip.  At  the  points  B  and  E  divide  each  of  the  flaps  thus  formed  into 
two.  The  edges  of  the  central  portion  of  the  lip  (Figs.  204,  205,  206)  are 
now  to  be  pared.     On  each  side  there  are  now  two  flaps,  an  upper  and  a  lower. 


Fig.  203. 


Fig.  204. 


The  raw  surfaces  of  the  upper  flaps  are  to  be  sutured  to  the  lateral  raw  surfaces 
of  G  as  high  up  as  possible.  Corresponding  to  the  lower  edge  of  G,  the  hori- 
zontal incisions  H  ajnd  I  (Figs.  204  and  205)  must  be  made  through  the  whole 
thickness  of  the  lip  on  each  side.     This  procedure  permits  the  easy  approxima- 


FiG.  205. 


Fig.  206. 


tion  of  the  edges  of  the  cleft  below  the  level  of  the  central  part  (G).  The  two 
lower  flaps  when  their  raw  surfaces  are  sutured  together  form  a  prominence  on 
the  edge  of  the  new  upper  lip.  The  appearance  of  the  wound  when  the  opera- 
tion is  completed  is  represented  in  Fig.  206.  Other  methods  of  operating  are 
suflSciently  illustrated  by  Figs.  207  to  215. 


Figs.   207,  208  axd  209. — Maas.     {Esmarch  and  Kon'alzig. 


James  E.  Thompson  ("Surg.,  Gyn.,  Obst.,"  May,  191 2)  good-naturedly 
laughs  at  many  of  the  operations  for  hare-lip  figured  in  this  and  other  books 
giving  diagrams  representing  what  the  true  results  must  be,  alongside  the  time- 
honored  figures  showing  the  results  as  imagined  by  the  inventors  of  the  opera- 


I40 


HARE-LIP 


tions.  To  insure  accuracy  in  making  his  incisions,  Thompson  uses  sharp- 
pointed  compasses  which  can  be  fixed  by  a  screw  and  with  them  makes  all 
necessary  measurements  and  marks. 

Thompson' s  Methods. — I.  Single  complete  hare-lip  without  much  divergence 
of  the  sides  of  the  cleft.  At  A  and  A',  Fig.  216,  i,  a  projection  or  shoulder  shows 
the  junction  of  the  cleft  and  the  nasal  margin.  With  compass  measure  the 
distance  from  Y  (midway  between  A  and  A')  to  Z  placed  on  an  imaginary  line 
KL  which  represents  the  natural  curve  of  the  upper  lip.  FLx  the  compasses 
so  that  their  points  will  remain  this  distance  (YZ)  apart.  Place  one  point  of 
the  compasses  at  A  and  the  other  at  B  on  the  skin  of  the  lip  close  to  the  red 
line  of  the  mucous  membrane.  Mark  the  point  B,  Fig.  216,  2,  by  pricking  the 
skin.     In  the  same  fashion  find  and  mark  the  point  B'.     The  line  AB  equals 


Figs.   210,   211   and  212. — Hagedorn.     {Esniarch  and  Kowalzig.) 


Figs.   213,   214   and   215. — Simon.     {Esmarch  and  Kowalzig.) 


in  length  the  line  A'B'.  Readjust  the  compasses  and  take  the  measurement 
BC,  the  point  C  being  on  the  free  margin  of  the  lip.  The  angle  ABC  is  usually 
about  60°  and  must  always  be  less  than  90°  if  a  projecting  prolabium  is  to  result 
from  the  completed  operation.  Mark  the  point  C  by  pricking  the  mucosa. 
In  the  same  fashion  find  and  mark  the  point  C .  The  line  BC  equals  in  length 
the  line  B'C  Pass  a  retaining  stitch  of  horse-hair  "through  each  side  of  the 
mucous  membrane  of  the  lip  close  to,  but  below,  C  and  C."  Suture  A  to  A', 
B  to  B',  C  to  C,  Fig.  216,  3. 

II.  The  sides  of  the  cleft  are  unsymmetrical.  Fig.  216,  4,  shows  how  the 
same  operation  gives  the  same  results  provided  that  the  cheeks  have  been  well 
mobilized  as  advised  on  p.  137. 

III.  Double  hare-lip.  In  Figs.  216,  5,  and  216,  6, "the  shoulders  marking  the 
margins  of  the  nostrils  are  shown  at  A  and  E,  and  at  A'  and  E'.  The  triangle 
E'DE  shows  the  line  of  incision  by  which  the  central  piece  of  skin  covering  the 
intermaxillary  bone  is  pared.  E  and  E'  are  placed  on  the  inner  margins  of  the 
nostrils.  The  sides  DE  and  DE'  are  usually  equal  in  length  to  one  another 
and  their  length  varies  according  to  the  depth  of  the  central  piece  of  skin.     It 


THOMPSON  S    METHODS 


141 


must  never  be  greater  than  AB  and  is  usually  much  less.  The  points  A  B 
and  C  and  A',  B'  and  C  are  chosen  as  described  previously  in  the  operation 
on  single  hare-lip.  Fig.  216,  6,  shows  the  final  appearance  of  the  lip  when  the 
flaps  have  been  cut  and  the  parts  approximated.     The  point  A  is  in  contact 


with  E,  A'  and  E';  the  apex  D  of  the  triangle  E'DE  lies  somewhere  along  the 
line  AB;  the  point  B  is  in  contact  with  B',  and  C  with  C. 

Two  essential  points  must  be  emphasized: 

I.  Under  no  circumstances  must  the  circumference  of  the  nostril  be  en- 
croached upon.  The  shoulders  that  represent  the  margins  of  the  nostril  must 
be  accurately  approximated. 


142 


HARE-LIP 


2.  The  points  B  and  B'  must  be  as  close  to  the  red  line  of  the  lip  as  possible, 
and  must  always  be  on  the  skin  (upper  side)  of  this  line." 

COMPLICATED    HARE-LIP 
A.  Single  complete  hare-lip.     The  alveolus  is  cleft  and  one  side  of  the 
cleft  is  much  more  prominent  than  the  other.     If  possible  push  the  protrud- 
ing part  into  alignment  with  the  rest  of  the  alveolus.     If  this  is  not  possible 
introduce  a  mattress  suture  of  wire  as  shown  in  Fig.  217, 
divide  the  bone  at  A,  push  the  mobilized  bone  into  proper 
position  and  fasten  it  with  the  wire. 

B.  Double  hare-lip  complicated  by  the  presence  of  the 
intermaxillary  bone  hanging  at  the  tip  of  the  nose. 

Some  surgeons  advise  that  the  misplaced  inter- 
maxillary bone  be  entirely  removed.  When  this  has 
been  done,  it  is  very  difficult  to  secure  union  between  the 
new-formed  upper  lip  and  the  column  of  the  nose.  Un- 
doubtedly it  is  wise  to  retain  the  bone  and  replace  it  in  its  proper  position.  An 
incision  (Fig.  218)  is  made  through  the  muco-periosteum  of  the  nasal  septum,  be- 
ginning immediately  behind  the  intermaxillary  bone  and  extending  backwards  for 
^  of  an  inch.  A  fine  periosteal  elevator  or  probe  is  passed  through  this  incision 
and  the  muco-periosteum  raised  on  each  side  of  the  septum  (Figs.  219  and  220) 
from  its  edge  up  to  the  root  of  the  nose.  With  a  strong  pair  of  scissors  a 
triangular  piece  of  the  septum  (Fig.  219)  is  now  excised.     This  permits  the 


Fig.  217. 


Fig.  218. 
(Esmarch  and  Kowalzig.) 


Fig.  219. 
{Esmarch  and  Kowalzig.) 


Fig.  220. 
{Esmarch  and  Kowalzig.) 


intermaxillary  bone  to  be  easily  pushed  back  into  position.  It  is  not 
absolutely  necessary  to  trim  off  the  mucous  membrane  covering  the  inter- 
maxillary bone  and  those  portions  of  the  superior  maxilla  with  which  it  is 
in  contact,  though  it  is  advisable  to  do  so,  as  union  can  then  take  place  with 
rapidity.  If  any  developing  teeth  are  encountered,  remove  such.  Teeth  which 
appear  later  in  bad  position  are  to  be  treated  by  a  dentist.  Suture  of  the 
bone  in  position  is  unnecessary.  The  cleft  in  the  lip  should  be  united  at  the 
same  sitting. 

Sometimes  instead  of  excising  a  wedge  from  the  septum  it  is  sufficient  to 
make  a  vertical  cut  through  it  and  slide  that  portion  of  the  septum  anterior  to 
the  cut  back  alongside  the  posterior  portion  (Fig.  220).  Lane  thoroughly  dis- 
approves of  all  these  attempts  to  replace  the  intermaxillary  bone. 


AFTER    TREATMENT 


143 


If  the  intermaxillary  bone  has  been  dislocated  backwards  by  any  of  the 
means  described,  Reich  ("Zent.  fur  Chir.,"  1911,  No.  25)  remarks  that  it  forms 
"a  blunt  and  bull-dog  nose."     He  has  endeavored  to  overcome  this  error. 

Reich'' s  Operation.  Step  i. — Dissect  the  philtrum  from  the  intermaxillary 
bone  and,  in  doing  so,  expose  the  edge  of  the  cartilaginous  septum  immediately 
above  the  intermaxillary  bone.  With  straight  scissors  divide  the  nasal  septum 
obliquely  upwards  and  backwards  as  high  as  possible  (Fig.  221).  This  cut 
divides  the  mucosa,  periosteum  and  perichondrium,  cartilaginous  septum  and 
the  perpendicular  plate  of  the  ethmoid  and  leaves  in  front  of  it,  and  separate 
from  the  rest  of  the  septum,  a  plate  of  bone  and  cartilage  reaching  from  the 
root  to  the  tip  of  the  nose,  guaranteeing  its  profile. 

Step  2. — Subperiosteally  excise  a  wedge  of  the  septum  as  in  the  preceding 
operation  but  much  farther  back.  Push  the  intermaxillary  bone  into  correct 
position. 

Step  3. — Close  the  hare-lip  in  the  usual  manner,  using  the  philtrum  nasi  to 
form  the  cutaneous  septum  of  the  nose  (Fig.  222). 


Figs.  221  and  222. — i.  Point  of  Nose.     2.  Philtrum  of  nose.     3.  Intermaxillary  bone. 
4.  Oblique  section  of  septum.     5.  Wedge  of  septum  removed. 


DRESSINGS   AFTER  OPERATIONS   FOR  HARE-LIP 


Should  tension  on  the  sutures  be  feared,  a  strip  of  adhesive  plaster  may  be 
placed  from  cheek  to  cheek  across  the  upper  lip,  in  such  a  way  as  to  relieve 
tension.  If,  however,  the  soft  parts  of  the  lip  and  cheeks  have  been  sufl&ciently 
separated  from  the  bones  at  the  beginning  of  the  operation,  then  such  a  measure 
is  unnecessary  and  undesirable,  as  it  simply  irritates  the  already  irritable  patient. 
It  is  not  necessary  to  apply  any  dressing  to  the  wound,  as  nature  soon  seals  it 
with  dried  blood-clot.  Until  the  sutures  are  removed  there  should  be  as  little 
interference  with  the  wound  as  possible.  If  it  is  going  to  heal,  it  wiU  heal  under 
the  scab,  and  the  best-intentioned  endeavors  to  clean  the  wound  will  merely 
interfere  with  nature's  work  and  do  no  good,  as  cleanliness  can  never  be  attained 
in  such  cases.  Care  must  be  taken  so  to  fix  the  little  patient's  arms  that  scratch- 
ing of  the  wound  is  rendered  impossible. 

When  it  is  desired  to  close  the  cleft  in  the  palate,  which  almost  invariably 
accompanies  extensive  hare-lip,  such  closure  ought  to  be  effected  either  at  the 
same  time  as  the  intermaxillary  bone  is  replaced  or  at  a  former  operation. 


144 


CLEFT   PALATE 


CHAPTER   XV 


CLEFT   PALATE 


The  proper  time  to  operate  for  cleft  palate  is  when  the  patient  is  under 
three  months  of  age;  Brophy's  method  of  operating  is  inapplicable  in  children 
of  over  six  months.  Brophy  has  operated  on  2u  cases  of  cleft  palate  in  babies 
younger  than  six  months  without  a  single  death,  yet  the  operation  is  un- 
doubtedly not  without  risk.  The  operation  should  be  performed  before  the 
closure  of  the  concomitant  hare-lip.  Brophy  gives  the  following  reasons  for 
the  above  practice:  (i)  The  existence  of  the  hare-lip  gives  more  room  in  which 
to  work.  (2)  ,There  is  less  nervous  shock  after  an  operation  on  a  child  of  a 
few  weeks  of  age  than  when  the  babe  is  older.  (3)  The 
bones  are  soft.  (4)  After  operation  the  child  will  be 
better  nourished.  (5)  The  muscles  of  the  palate  are  given 
an  opportunity  to  develop  instead  of  atrophy,  and  the 
patient  does  not  get  into  the  habit  of  articulating  through 
the  cavern  of  the  nose. 

Before  operating  see  that  the  patient's  general  health 
is  good  and  that  no  local  conditions  exist  which  might 
interfere  with  repair.  If  adenoids  are  present,  they  must 
be  removed.  For  a  few  days  prior  to  operation  it  is  well 
to  cleanse  the  mouth  and  nasal  cavity  with  a  saturated 
solution  of  boracic  acid  in  glycerin. 

Brophy's  Operation. — Applicable  in  children  younger 
than  three  months;  generally  possible,  though  not  so  easy, 
in  children  up  to,  but  not  beyond,  the  sixth  month.  The 
only  special  instruments  required  are  two  of  Brophy's 
strong  needle?  (Fig.  223);  a  few  strands  of  No.  20  silver 
wire;  lead  plates  No.  17,  American  gage.  No  special 
mouth-gag  is  necessary,  the  assistant's  fingers  being  sufficient  to  keep  the 
mouth  open  and  the  tongue  depressed.  Immediately  before  operating  the 
writer  swabs  the  parts  with  adrenalin  solution.  This  lessens  hemorrhage. 
During  operation  bleeding  is  easily  controlled  by  pressure  with  pledgets  of 
gauze  wrung  out  of  hot  water. 

The  Operation. — i.  Anesthetize  the  patient.  Place  in  Rose's  or  the  Tren- 
delenburg position.  Pass  a  stout  thread  through  the  anterior  end  of  the 
tongue  as  a  traction  suture.     This  is  a  great  convenience. 

2.  With  a  knife  pare  thoroughly  the  edges  of  the  cleft  in  the  hard  palate, 
cutting  away  a  little  of  the  bone  itself  to  insure  thoroughness.  Either  pare  or 
horizontally  split  the  edges  of  the  cleft  in  the  soft  palate.  If  split  thoroughly, 
the  edges  of  the  split  retract  and  so  a  good  raw  surface  is  left  without  any  loss 
of  .tissue. 

3.  Thread  a  Brophy  needle  with  a  strong  silk  or  celluloid  hemp.  Raise  the 
cheek  and  pass  the  threaded  needle  through  the  superior  maxilla  from  without 


Fig.       223. — {Brophy, 
^^  Dental    Cosmos.") 


BROPHY  S    OPERATION 


145 


inwards  at  a  point  just  back  of  the  malar  process  and  high  enough  to  be  above 
the  palate  (Fig.  224).  When  the  needle  appears  in  the  cleft,  pick  up  the  thread, 
which  it  carries,  with  hook  or  forceps.  Withdraw  the  needle,  leaving  the  loop 
of  thread  in  situ.  Catch  the  ends  of  the  thread  in  a  hemostat.  Through  a 
corresponding  part  of  the  opposite  bone  pass  a  loop  of  thread  in  the  same 
manner.  Pass  this  second  loop  of  thread  through  the  first  and  pull  the  latter 
out,  carrying  with  it  the  former.  We  now  have  a  loop  of  thread  passing  through 
both  superior  maxillary  bones  above  the  palate,  and  when  necessary  through 
the  nasal  septum.  By  means  of  this  thread  pull  a  strand  of  very  strong  silver 
wire  through  the  same  track. 


Fig.  224. — {Brophy,  "Denial  Cosmos.") 


4.  In  the  same  manner  introduce  one  or  sometimes  two  other  silver  wires 
through  the  anterior  portion  of  the  maxilla  above  the  level  of  the  palate  (Fig, 
224,  A). 

5.  Pass  the  ends  of  the  silver  wire  through  holes  in  lead  plates  moulded  to 
fit  the  convexity  of  the  buccal  surfaces  of  the  bones  (one  plate  on  each  side). 
Draw  the  wires  tight  and  twist  them  together — i.e.,  twist  the  "right  end  of 
the  anterior  wire  to  the  right  end  of  the  posterior  wire  and  the  same  on  the 
left  side"    (B,   Fig.    224). 

6.  With  the  thumbs  forcibly  press  the  two  maxillary  bones  together  until 
the  cleft  is  completely  closed.  Twist  the  wire  once  more  so  as  to  hold  the 
bones  firmly  together. 

7.  Close  the  soft  palate  by  sutures.  The  state  of  the  patient  may  necessitate 
this  step  being  delayed  until  another  day.  Do  not  close  the  hare-lip  until 
the  palate  is  completely  closed  and  the  patient  has  recovered. 

Note. — If  closure  of  the  cleft  by  mere  compression  proves  impossible,  division  of  the 
malar  process  may  be  practised.  Make  a  very  small  incision  through  the  mucous  mem- 
brane over  the  malar  process  of  the  superior  maxilla.  Through  this  divide  the  process  hori- 
zontally, i.e.,  parallel  to  the  alveolar  edge,  either  with  a  knife  or  a  s  mail  chisel,  such  as 
dentists  use. 

After-treatment  consists  in  as  great  cleanliness  of  mouth  and  nose  as  can  be 
attained;  in  the  use  of  stimulants,  if  necessary;  and  in  feeding  by  means  of  a 
spoon.     The  plates  and  wire  sutures  remain  in  place  from  two  to  four  weeks. 
10 


146 


CLEFT  PALATE 


Fig.  225. 


In  unilateral  cleft  palate  the  palatal  process  of  one  side  has  united  with  the 
septum  of  the  nose.  In  such  cases  the  septum  is  often  very  much  curved,  and 
its  lower  portion  seems  a  continuation  of  the  palatal  process  to  which  it  is  united. 
If,  in  the  course  of  operation,  it  is  difficult  to  bring  the  edges  of  the  two  palatal 
processes  together,  we  may  cut  a  groove  in  the  septum  at 
the  point  X  (Fig.  225)  and  bring  the  freshened  edge  of  the 
ununited  palatal  process  (P',  Fig.  225)  into  apposition  with 
it,  thus  using  a  part  of  the  septum  to  close  the  defect. 

Uranoplasty  (Arbuthnot  Lane's  Operation). — For  many 
reasons  the  operation  should  be  performed  as  early  as  possi- 
ble after  birth.  Before  the  milk  teeth  erupt  there  is  plenty 
of  material  present  to  permit  the  closure  of  almost  any  defect  no  matter  how 
wide  it  may  be.  The  large  surfaces  of  bare  bone  left  after  Lane's  operation 
heal  very  rapidly. 

Instruments  required: 

1.  Lane's  mouth-gags  with  sharp  teeth  which  bite  into  the  gums.  These 
are  sold  in  pairs  of  proper  sizes  (Figs.  226  and  227). 

2.  Lane's  needle  holder  with  very  small  needles  (Figs.  228  and  229).  This 
was  originally  devised  for  suture  of  the  bile  ducts. 

3.  One  small  strong  knife.  A  Jones'  teno- 
tome will  serve  admirably. 

4.  Fine  sharp-pointed  scissors. 

5.  One  strong  hemostat  with  mouse  teeth 
at  the  point. 

6.  Fine  strong  silk  or  hemp. 

7.  A  good  mouse- tooth  dissecting  forceps 
suitable  for  catching  the  tissues  or  the  end  of 
a  needle. 

Type  A. — The  cleft  in  the  hard  palate  is 
unilateral.  The  septum  is  continuous  with  the 
hard  palate  on  one  side.  The  alveolus  and  the 
soft  palate  are  also  cleft. 

Step  I. — Formation  of  reflected  flap.  Make  the  incision  7,  5,  6,  8  through 
the  muco-periosteum  to  the  bone  (Fig.  230).  In  order  to  obtain  plenty  of  tissue 
that  part  of  the  incision  represented  by  the  line  from  5  to  6  is  made  on  the  outer 
surjace  of  the  alveolus  near  the  reflection  of  the  mucosa  from  the  alveolus  to  the 
cheek.  Make  the  incision  through  the  mucosa  of  the  soft  palate,  but  do  not 
injure  the  musculature.  Reflect  the  outlined  flap  7,  5,  6,  8.  The  pedicle  or 
hinge  of  the  flap  corresponds  to  the  edge  of  the  cleft  in  the  palate. 

In  separating  the  muco-periosteum  from  the  bone  as  the  posterior  palatine 
foramen  is  approached,  an  elevator  pressed  in  between  the  flap  and  the  bony 
palate  causes  the  posterior  palatine  vessels  and  nerves  to  protrude  for  a  con- 
siderable length  in  a  tube  of  periosteum.  This  is  readily  grasped  by  an  efficient 
hemostat,  which  is  left  in  place  until  hemostasis  is  assured. 

That  portion  of  the  flap  taken  from  the  soft  palate  consists  of  mucosa  and 
submucosa.     It  is  important  not  to  injure  the  muscles  of  the  palate.     The 


Fig.  226. — {Lane.) 


LANE  S    OPERATION 


147 


reflected  flap  is  formed  on  the  side  of  the  cleft  which  is  not  attached  to  the 
septum. 

Slep  2. — On  the  side  of  the  cleft  attached  to  the  septum  proceed  as  follows: 
With  forceps  pull  the  uvula  and  soft  palate  forwards  so  as  to  expose  its  nasal 
surface.  Divide  the  mucosa  along  the  posterior  edge  of  the  soft  palate  (4,  3, 
Fig.  230).     Continue  the  incision  across  the  nasal  surface  of  the  soft  palate  to 


Fig.  227. — {Lane.) 

thd  point  where  the  soft  and  hard  palates  meet  at  the  edge  of  the  cleft  (3,2,  Fig. 
230).  Continue  the  incision  forwards  along  the  edge  of  the  hard  palate  (2,  i) 
and  across  the  alveolus  (1,9).  The  part  of  the  incision  affecting  the  hard  palate 
and  the  alveolus  penetrates  the  whole  thickness  of  the  muco-periosteum.  The 
part  of  the  incision  affecting  the  soft  palate  only  penetrates  the  mucosa  and 
submucosa.  Reflect  the  mucous  flap  (2,  3,  4)  outlined  on  the  nasal  surface  of 
the  soft  palate.  Introduce  an  elevator  through  the  incision  9,  i,  2  (Fig.  230) 
and  separate  the  muco-periosteum  from  the  hard  palate  and  to  a  slight  extent 
from  the  alveolus  near  the  point  9.  Divide  the  attachments  of  the  soft 
palate  to  the  hard  palate  along  the  posterior  edge  of  the  latter,  leaving  intact 
the  mucosa  on  the  oral  side  of  the  palate.  During  Step  2  the  posterior 
palatine  artery  remains  uninjured. 


148 


CLEFT  PALATE 


Step  3. — Turn  the  flap  5,  7,  8,  6  so  that  its  epithehal-covered  surface 
is  directed  towards  the  nose  and  its  raw  surface  towards  the  mouth.  Tuck 
the  edge  of  flap  5,  7,  8,  6  well  under  flap  9,  i,  2,  3,  4,  and  fix  it  in  position 
by  two  rows  of  fine  sutures  (Figs.  231  and  233). 

Type  B. — The  cleft  is  wide;  the  septum  is  not  attached 
to  the  palate;  the  alveolus  is  not  cleft. 

Step  I. — Make  the  flap  i,  2,  3  (Fig.  234)  as  in  Type  A. 

Step  2. — On  the  opposite  side  make  the  incision  6  through 
the  muco-periosteum  along  the  edge  of  the  cleft.  Make  the 
incision  7  and  8  on  the  nasal  surface  of  the  soft  palate  and 
reflect  a  flap  of  mucosa  from  the  soft  palate  as  in  Type  A. 
Separate  the  muco-periosteum  from  the  hard  palate  and  di- 
vide the  attachments  of  the  soft  to  the  hard  palate  along  the 
posterior  edge  of  the  latter,  leaving  intact  the  mucous  mem- 
brane on  the  oral  surface. 

Step  3. — Turn  flap  i,  2,  3  over,  with  its  epithelial  surface 
directed  towards  the  nasal  cavity,  so  as  to  cover  the  cleft. 
Tuck  the  free  edge  of  this  flap  well  under  the  flap  10,  6,  7,  8. 
The  triangular  portion  of  this  latter  flap  which  was  obtained 
from  the  nasal  surface  of  the  soft  palate  assists  greatly  in 
providing  a  thick  new  velum  palati. 

Step  4. — Suture  the  edge  of  flap  i,  2,  3  to  the  base  of  flap 
10,  6,  7,  8  (Fig.  235).  Suture  the  edge  of  flap  of  10,  6,  7,  8 
to  the  raw  surface  of  flap  i,  2,  3  (Fig.  235). 

Note. — If  the  lower  or  free  edge  of  the  nasal  septum  extends  to  the  level 
of  the  cleft,  attach  it  to  flap,  1,  2  and  3  in  the  following  manner  after  com- 
pleting Step  2  as  described:  Make  an  incision  (4,  Fig.  234)  through  the 
mucosa  and  periosteum  or  perichondrium  along  the  middle  line  of  the 
Fig.  228.  {Lane.)  septum  with  two  small  transverse  incisions  (5)  at  either  end,  and  turn 
down  laterally  the  narrow  flaps  so  formed,  leaving  the  cartilage  or 
bone  bared  and  exposed.  By  placing  flap  i,  2,  3  in  correct  position,  the  line  along  which 
it  will  rest  on  the  septal  margin  can  be  readily  defined.  Along  the  line  of  contact  with 
the  septal  margin  denude  the  surface  of  flap  i,  2,  3  with  a  sharp  knife.  By  a  series  of  sutures 
perforating  flap  i,  2,3  and  the  margin  of  the  septum  if  it  be  not  too  hard,  or  the  flaps  of  muco- 
periosteum  if  the  edge  be  bony,  securely  fix  the  flap  to  the  septum  (i,  Fig.  235).  Proceed  to 
Step  3. 

Type  C. — Double  cleft  palate.  Premaxillary  bone  (P,  M, 
Fig.  236)  well  in  front  of  the  alveolar  arch  and  fixed  to  the  under 
surface  of  the  nose;  the  mesial  segment  (L)  of  lip  is  fixed  to  the 
anterior  surface  of  the  premaxilla.  Operation  by  means  of  re- 
flected and  pivoting  flaps.  (The  following  description  is  in 
Lane's  own  words.) 

"The  reflected  flap  is  obtained  by  an  incision  extending  from 
I  along  the  outer  aspect  of  the  alveolus,  through  2,  and  on  to  3, 
when  it  bends  inwards  along  the  free  margin  of  the  soft  palate  to  the  uvula  4. 
The  pivoting  flap  is  obtained  by  an  incision  from  5,  along  the  outer  aspect  of 
the  alveolus,  through  6,  along  the  margin  of  the  cleft  in  the  hard  palate  from 
7  to  8,  along  the  upper  surface  of  the  soft  palate  9,  and  then  to  10. 


Fig.  229. — 

(Lane.) 


lane's  operation 


149 


Fig.  230. — Lane's  uranoplasty. 


Fig.  231. — Lane's  uranoplasty. 


Fig.  233. — Lane's  uranoplasty. 


I50 


CLEFT  PALATE 


Fig.  235.— (/.awe  ) 


lane's  operation 


I  =51 


Fig.  236. — (Lane.) 


Fig.  237. — (Lane.) 


I>2 


CLEFT   PALATE 


"The  area  of  mucous  membrane  corresponding  to  the  triangle  8,  9  and  10, 
is  raised  and  reflected  inwards.  The  area  of  muco-periosteum  included  in 
5,  6,  7  and  8  is  raised  from  the  subjacent  bone,  except  at  the  point  of  entry  of 
the  posterior  palatine  vessels  and  nerves,  which  form  the  pivot  on  which  this 
flap  rotates.  The  mucous  membrane  is  striped  from  the  premaxilla  and  trom 
the  free  edge  of  the  septum  in  the  manner  indicated  by  the  dotted  lines,  showing 
incisions  in   the  diagram. 

"Large  flaps  are  cut  from  the  portions  of  lip  forming  the  edges  of  the  cleft, 
and  great  care  is  taken  that  they  have  an  extensive  attachment  at  their  bases. 
The  mucous  membrane  covering  the  lateral  and  lower  aspects  of  the  piece  of 
lip  lying  in  the  front  of  the  premaxilla  is  removed  (L). 

"The  reflected  flap  is  first  put  in  position;  the  mucous  membrane,  where  it 
comes  into  contact  with  the  under  surface  of  the  septum,  having  been  rendered 
raw,  is  secured  to  it  by  sutures.  The  pivoting  flap  is  then  moved  inwards  upon 
the  reflected  flap,  to  which  it  is  united  firmly  by  a  double  row  of  sutures.  Finally 
the  soft  palate  is  closed  in  a  similar  manner.     This  is  represented  in  Fig.  237. 


Fig.  238. — (Lane.) 

"After  this  the  triangular  areas  of  muco-periosteum  which  were  reflected 
from  the  premaxilla  are  fixed  in  position  (see  Fig.  240),  where  these  are  indicated 
by  Y.  The  flaps  from  the  lips  shown  as  F,  F  are  arranged  with  their  raw  sur- 
faces upwards.  These  are  united  to  the  raw  surfaces  of  the  flaps  from  the 
premaxilla  and  of  the  reflected  flap,  and  are  also  sutured  by  their  margins  to 
one  another  and  to  the  free  edge  of  the  pivoting  flap  (see  Fig.  238). 

"Lastly,  the  ala  of  the  nose  is  cut  away  from  the  cheek  on  either  side  and  is 
displaced  inwards  where  it  is  united  by  sutures  to  the  septum,  and  is  sewn  to 
the  cheek  in  its  new  position.  This  I  have  attempted  to  indicate  in  the  same 
diagram.  Having  brought  the  edges  of  the  lip  into  accurate  position  by 
means  of  separate  sutures,  two  sutures  of  linen  thread  are  passed  in  the  manner 
indicated  in  Fig.  239.  The  needle  perforates  the  lip  from  behind,  and  is 
made  to  re-enter  the  anterior  aspect  of  the  lip  through  the  same  hole,  and  after 
traversing  the  lip  transversely  it  again  emerges  and  enters  through  the  same 
hole,  the  needle  passing  directly  backwards  through  the  lip.  When  this  thread 
k  made  taut  and  tied  the  opposing  raw  surfaces  of  lip  are  held  in  accurate 


lane's  operation 


D^ 


Fig.  239. — (Lane.) 


Fig.  240. — {Lane  \ 


Fig.  241. — {Lane.) 


154 


CLEFT   PALATE 


position,  and  no  scar  whatever  results  from  the  presence  of  these  deep  sutures, 
which  can  be  readily  removed  when  they  have  served  their  purpose.  In  Fig. 
239  only  one  cleft  in  the  lip  is  represented." 

Type  D. — Wide  cleft  of  soft  palate. 

Step  I. — Reflect  the  flap  i,  5,  6,  7,  8  (Fig.  241)  with  its  base  at  the  edge  of 
the  cleft. 

The  flap  consists  partly  of  muco-periosteum  from  the  hard  palate  and 
laveolus  and  mostly  of  mucous  membrane  from  the  soft  palate  and  cheek. 
The  flap  must  be  large  enough  to  easily  cover  the  defect.  Do  not  injure  the 
musculature  of  the  soft  palate. 


Fig.  242. —  {Lane.) 

Step  2. — From  the  nasal  surface  of  the  soft  palate  on  the  opposite  side  of 
the  cleft  reflect  the  flap  i,  2,  3,  4  with  its  base  at  the  edge  of  the  cleft. 

Step  3. — Suture  the  two  flaps  together  one  over  the  other  in  an  overlapping 
fashion  (Fig.  242). 

After  the  milk  teeth  have  erupted  some  modification  of  Lane's  methods  or 
the  following  classical  operation  may  be  selected. 

The  patient  having  been  anesthetized,  placed  in  Rose's  position,  and  a 
traction  thread  passed  through  the  tongue,  a  suitable  gag  is  introduced.  Of 
the  numerous  gags  invented,  probably  Lane's  or  Whitehead's  is  the  best,  but 
the  writer  finds  that  a  piece  of  wood  about  ^^  inch  thick  answers  every  purpose, 
and  consequently  rarely  uses  anything  else. 

I.  Denudation. — Seize  the  end  of  the  uvula  on  one  side  with  a  sharp  hook  or 
forceps  (Fig.  243).  With  a  sharp  knife  or  tenotome  remove  a  strip  of  mucous 
membrane  from  the  whole  edge  of  the  cleft.  In  cutting,  do  so  obliquely,  re- 
moving rather  more  membrane  from  the  oral  than  from  the  nasal  side  of  the 
palate.  This  gives  a  more  extensive  raw  surface,  which  is  a  great  advantage. 
When  the  soft  palate  is  very  thick,  its  edge  may  be  split  instead  of  pared. 
Repeat  the  process  on  the  other  side  of  the  cleft. 


URANOPLASTY 


155 


2.  With  a  suitable  periosteotome  or  knife  divide  the  muco-periosteum  along 
the  edge  of  the  cleft  in  the  hard  palate.     Separate  all  the  muco-periosteum 


from  the  hard  palate  up  to  the  alveolar  process  (Fig.  244).     For  this  procedure 
Brophy's  periosteotomes  (Fig.  245)  are  convenient,  but  a  suitable  instrument 
is  easily  extemporized  from  a  dental  spatula  or  even  an  aneurysm  needle. 
3.  The  soft  palate  may  be  said 

to  consist  of  three  layers :     (a)  The 

nasal  mucous   membrane;    (b)    the 

tissues   attached   to    the   posterior 

edge  of   the  hard  palate;    (c)    the 

oral  mucous  membrane. 

Leaving  intact  the  oral  mucous 

membrane,  which  is  continuous  from 

hard  to  soft  palate,  divide  trans- 
versely with  fine  curved  scissors  both  the  nasal  mucous 
membrane  and  the  tissues  attached  to  the  posterior 
edge  of  the  hard  palate.  This  is  one  of  the  most 
important  steps  in  the  operation,  allowing  the  muco- 
periosteal  flap  obtained  from  the  hard  palate  to  drop 
towards  the  mouth,  and  with  it  the  soft  palate 
(Fig.  249).  Repeat  this  procedure  on  the  opposite 
side.  Commonly  the  raw  edges  of  the  flaps  thus 
obtained  will  come  into  apposition  without  tension. 
If  they  do  not,  it  is  necessary  to  make  a  lateral  incision  through  the  muco-peri- 
osteum parallel  and  close  to  the  alveolus  (Fig.  247)  on  one  or  both  sides  of  the 


Fig.  245. — (Brophy,  "Dental 
Cosmos.") 


i=;6 


CLEFT  PALATE 


mouth,  and  extending  from  the  lateral  incisor  back  to  the  posterior  margin  of  the 
hard  palate.  If  this  is  insufficient  to  relieve  tension,  Billroth 's  procedure  may  be 
adopted  as  follows:  Pass  a  fme  chisel  through  the  posterior  angle  of  the  lateral 
incision,  direct  it  obliquely  inwards  and  upwards  against  the  hamular  process, 
and  with  a  light  blow  from  the  hand  make  it  divide  that  bone.  The  dislocation 
of  the  hamular  process,  increased  if  necessary  by  the  use  of  an  elevator,  gives 


Fig.  246. 


Fig.  247. 


Fig.  248. 


perfect  relaxation  of  the  velum  palati  and  does  not  injure  its  musculature. 
Incisions  through  the  soft  palate  dividing  its  muscles  were  formerly  considered 
necessary;  now  they  are  never  admissible. 

C.  H.  Mayo  considers  it  important  to  make  lateral  incisions  (Fig.  247)  on 
both  sides.  Outside  the  posterior  palatine  foramina,  these  do  not  merely  relieve 
tension,  but  permit  the  use  of  a  relaxation  tape.     Having  prepared  the  parts 


Fig.  24g. 
N.  M.  Nasal  mucosa.      H.  P.    Hard  palate.      O.  M.  Oral  mucosa.      S.  P.  Soft  palate.      S.  Line  of  section. 

for  the  insertion  of  sutures,  and  having  made  two  lateral  incisions  close  to  the 
alveoli,  he  introduces  a  narrow  tape  which  surrounds  the  right  and  left  muco- 
periosteal  flaps  (Fig.  247).  Traction  on  the  ends  of  the  tape  brings  the  flaps 
towards  the  operator,  steadies  them,  and  facilitates  the  introduction  of  the 
ordinary  sutures.  When  the  sutures  are  in  place  and  tied,  Mayo  crosses  the 
free  ends  of  the  tape  and  fixes  them  by  tying  a  ligature  around  them  at  this 


^m 


Fig. 


point  (Fig.  248),  cuts  off  the  superfluous  portions  of  the  tape,  and  lastly  slides 
the  w^hole  tape  until  that  part  fastened  by  the  ligature  lies  in  the  nasal  instead 
of  in  the  oral  cavity.  The  tape  fastened  as  above  acts  as  an  elflcient  relaxation 
suture  or  support;  it  also  drains  secretions  from  the  nasal  cavity  into  the  mouth. 
It  is  remarkable  how  this  very  simple  contrivance  facilitates  the  operation, 
Harry  Sherman  smears  the  tape  with  Mosetigs  bone  wax  and  fastens  its  free 
ends  together  by  sutures. 


URANOPLASTY 


157 


4.  Suture.  Many  special  needles  have  been  devised  to  overcome  the 
diflSculties  met  with  in  closing  palatal  defects.  Of  these,  the  Deschamps 
(Fig.  250)  is  perhaps  the  best,  although  it  is  usually  made  too  large.  The 
writer  finds  that  he  can  discard  such  special  instruments  by  using  very  small, 
full  curved  needles,  grasped  in  a  long-necked  needle-holder,  and  passing  each  end 
of  the  thread,  armed  with  a  needle,  from  the  nasal  to  the  oral  side  of  the  palate, 
i.e.,  from  within  outwards.  The  usual  method  of  suturing  is  to  begin  at 
the  uvula  and  work  forwards,  being  careful  to  evert  the  edges  of  the  wound  when 
the  flaps  from  the  hard  palate  are  being  united.  Silk  or  waxed  linen  are  the 
materials  used.  If  the  soft  palate  has  been  split  instead  of  pared,  Sherman 
sutures  the  nasal  surface  first  (knots  being  on  the  nasal  side)  and  then  the  oral 
surface. 


Fig,  251. — [Brophy,  "  Dental  Cosmos.") 


Fig.  252. —  {Brophy,  '' Dental  Cosmos.") 


Harry  Sherman  (Journ.  A.  M.  A.,  Dec.  i,  1917)  as  a  preliminary  measure 
endeavors  to  narrow  the  cleft  by  means  of  pressure  applied  as  follows: 

From  a  point  opposite  the  top  of  the  ear  apply  a  strip  of  adhesive  plaster 
on  the  cheek  to  a  point  on  the  upper  lip  just  external  to  the  side  of  the  nose. 
Do  this  on  both  cheeks.  Have  a  hook  on  the  outer  surface  of  the  anterior 
end  of  each  adhesive  strip.  By  an  elastic  band  uniting  the  two  hooks  it  is 
easy  to  compress  the  superior  maxillae.  Other  surgeons,  e.g.,  Brown  (Oral  Dis- 
ease and  Malformation)  apply  adhesive  tape  across  the  lip  from  cheek  to  cheek 
and  by  this  means  obtain  narrowing  of  the  cleft  and  even  reposition  of  the  pro- 
truding premaxillary  bone  in  double  cleft  palate.  As  soon  as  elastic  pressure 
has  caused  the  ends  of  the  broken  alveolar  arch  to  overlap  (single  cleft  palate) 
Sherman  considers  the  child  ready  for  operation.  He  uses  the  Langenbeck 
method  for  closure  of  the  soft  palate  but  splits  instead  of  paring  the  edges. 
The  posterior  half  of  the  hard  palate  is  closed  by  the  Langenbeck  method  also, 
but  mattress  sutures  are  employed  so  that  the  edges  of  the  wound  are  turned 


158 


TONGUE 


down  into  the  mouth  thus  providing  broad  contact  of  raw  surfaces.  Lateral 
incisions  and  a  waxed  tape  relaxation  band  are  used  as  already  described.  At 
a  later  date  the  anterior  part  of  the  cleft  is  repaired  by  Lane's  method. 

Brophy  puts  in,  as  a  preliminary,  tension  sutures  of  No.  22  silver  wire, 
fixing  these  on  lead  plates  (Figs.  251  and  252).  He  claims  that  the  use  of 
these  obviates  the  necessity  of  lateral  incisions,  and  that  the  lead  plates  act  as 
a  splint,  securing  rest,  and  hence  better  results.  The  fact  that  numbers  of 
Brophy's  cases  have  passed  the  supreme  test  of  successfully  reading  aloud  be- 
fore professional  societies  makes  his  opinions  and  procedures  worthy  of  the 
gravest  consideration.     C.  H.  Peck  recommends  the  use  of  a  dental  plate  to 

protect  the  united  palate.     The  plate  must  of  course 
be  removed  frequently  for  the  sake  of  cleanliness. 

After-treatment. — ^Liquid  or  soft  food  is  alone  per- 
missible. Antiseptic  sprays  may  be  used  if  not 
annoying  to  the  patient.  The  patient  should  get  out 
of  bed,  and  in  suitable  weather,  out  of  doors  as  soon 
as  possible.  The  sutures  must  not  be  removed  earlier 
than  the  seventh  day  after  operation. 

Partial  Cleft  Palate. — When  there  is  a  cleft  of 
the  soft  palate  alone  and  the  edges  can  be  brought 
together  without  tension,  one  is  content  to  pare  the 
edges  and  apply  sutures.  When  the  cleft  in  the  soft 
palate  reaches  close  to  the  hard  or  when  the  latter 
is  partially  cleft,  it  is  absolutely  necessary  to  relieve 
tension.  This  is  done  in  the  same  fashion  as  in  complete  cleft  palate  by  di- 
viding the  attachments  of  the  velum  to  the  hard  palate  and  by  separating  the 
muco-periosteum  from  the  bone  to  as  great  an  extent  as  may  be  necessary 
(Fig.  253). 


Z  and  0.  Line  of  separation 
of  attachments  of  velum  to  hard 
palate.  X,  Y,  Z,  Q.  Area  in 
which  muco-periosteum  (con- 
tinuous with  the  velum)  is 
separated  from  the  bone. 


CHAPTER  XVI 


TONGUE 


Butlin's  Marginal  Resection  of  the  Tongue. — This  operation  is  suitable 
where  the  tongue  is  originally,  or  has  become,  too  large  for  the  mouth  and 
where  its  lateral  margin  in  contact  with  the  teeth  shows  dangerous  or  annoying 
irritability.  The  effects  of  the  operation  are:  (a)  diminution  in  the  size  of  the 
tongue  without  impairment  of  mobility  or  speech,  {h)  the  teeth,  instead  of  being 
in  contact  with  an  irritable  papilla-bearing  surface,  now  lie  in  contact  with  smooth 
mucous  membrane  derived  from  the  inframarginal  surface  of  the  tongue. 

Butlin's  operation  (Burghard's  Op.  Surg.  II,  209)  has  been  modified  by  Samp- 
son Handley  (Brit.  Journ.  Surg.  I,  42)  so  as  to  do  away  with  the  necessity  of 
laryngotomy. 

An  anesthetic  should  be  administered  exactly  as  in  operating  for  cleft 
palate. 

Step  I. — Transfix  the  tongue  far  back  by  a  strong  silk  suture  for  purposes 


butlin's  operation 


159 


of  traction  and  control.     Seize  the  tip  of  the  tongue  with  a  volsellum  and 
pull  it  forwards. 

Step  2. — On  the  dorsum  make  a  more  or  less  transverse  incision  parallel  to  the 
end  of  the  tongue  and  about  i>^  inches  long.     On  the  undersurface  of  the 


Fig.  254. — First  stage  of  operation.     (By  permission  from  the  British  Journal  of  Surgery.) 

tongue  make  a  corresponding  incision.  Through  these  two  incisions  cut  out 
a  wedge-shaped  segment  of  the  tongue  but  leave  (Fig.  254)  the  segment  attached 
by  its  two  ends  to  the  tongue. 


t,   ^J\ 


Fig.  255. — Second  stage.     (By  permission  from  the  British  Journal  of  Surgery.) 

Step  3. — PulHng  the  mobilized  segment  away  from  the  tongue,  close  the 
wedge-shaped  wound  with  sutures.     This  stops  bleeding. 

Step  4  — Step  by  step  continue  the  wedge-shaped  excision  along  the  edge 
of  the  tongue  and  apply  sutures  to  stop  bleeding.  When  the  level  of  the  last 
molar  tooth  is  reached  finish  the  dissection  on  that  side  (Fig.  255).  In  similar 
fashion  resect  the  opposite  side  of  the  tongue. 


i6o 


TONGUE 


The  lower  incision  should  be  at  the  junction  of  the  smootli  mucosa  of  the 
undersurface  of  the  tongue  with  the  papillary  mucosa  of  the  dorsum.  The 
dorsal  incision  must  be  made  internal  to  the  tissue  it  is  desired  to  excise. 
The  smooth  infralingual  mucosa  being  preserved  makes  an  excellent  flap  for 
the  reconstruction  of  the  margins  of  the  tongue  (Fig.  256). 


L^   J' 


Fig.  256. — The  operation  completed.     (By  permission  from  the  British  Journal  of  Surgery.) 


When  a  small  tumor  exists  near  the  tip  of  the  tongue,  it  may  be  removed 
by  means  of  a  V-shaped  incision. 

Dieffenbach's  Operation. — ^Local  anesthesia  usually  sufi&ces.  If  a  general 
anesthetic  is  used,  the  mouth  must  be  kept  open  during  the  operation  by  a 
mouth-gag.     Pull  the  tongue  forwards  by  means  of  a  volsellum  or  a  stout 


Fig.  257. 


thread  passed  through  its  tip.  At  a  point  on  each  side  of  the  tumor  and  about 
^  inch  from  it,  pass  a  long  silk  thread  through  the  whole  thickness  of  the 
tongue  in  such  a  manner  that  the  loop  of  the  thread  is  under  the  tongue, 
while  its  two  free  ends  emerge  from  punctures  on  the  dorsum  (Fig.  257). 

Excise  the  tumor  and  a  wedge-shaped  portion  of  the  whole  thickness  of  the 
tongue  by  the  converging  incisions  A  B,  A  C  (Fig.  257).  The  excision  is  most 
easily  effected  with  the  scissors.  The  bleeding  is  now  liable  to  be  sharp. 
Tighten  and  tie  the  suture  which  has  already  been  introduced.  This  stops  all 
•hemorrhage.  Introduce  a  few  more  stitches  so  that  the  wound  is  neatly 
closed  (Fig.  258). 


EXCISION   TONGUE  l6l 

The  only  after-treatment  required  is  frequent  cleansing  of  the  mouth  with 
non-poisonous  antiseptic  washes. 

Excision  by  Elliptical  Incisions. — Small  tumors  of  the  tongue  may  be  ex- 
cised under  local  anesthesia  by  means  of  elliptical  incisions  surrounding  them. 
As  soon  as  the  neoplasm  is  removed,  bleeding  is  stopped  by  the  application  of 
a  few  sutures  which  at  the  same  time  close  the  wound. 

The  treatment  of  lingual  thyroids  is  discussed  on  page  216. 

COMPLETE   REMOVAL  OF  THE  TONGUE 

As  a  preliminary  to  any  operation  for  extirpation  of  the  tongue  it  is  necessary 
to  clean  the  mouth.  The  mouth,  especially  in  cases  of  cancer,  is  a  filthy  cavern. 
The  teeth,  usually  decayed,  are  covered  with  tartar  and  other  abominations. 
The  mouth  should  be  thoroughly  washed  with  antiseptic  solutions,  the  teeth 
vigorously  brushed,  or,  better,  cleansed  by  a  good  dentist,  and  loose  teeth  should 
be  removed.  Very  many  methods  of  operating  have  been  devised,  but  only 
a  few  of  them  will  be  described. 

I.  Whitehead's  Operation.— The  following  description  is  taken  almost 
entirely  from  an  article  by  Whitehead: 

1.  The  patient  should  be  placed  in  a  sitting  posture;  the  head,  firmly  held, 
should  be  inclined  forwards  so  that  the  blood  may  escape  easily.  The  light  must 
be  good  and  have  direct  access  to  the  mouth.  The  patient's  mouth  and  the 
surgeon's  axilla  should  be  at  about  the  same  level. 

2.  During  the  first  stages  of  the  operation  anesthesia  should  be  complete, 
but  afterwards  only  partial  insensibility  should  be  maintained. 

3.  A  good  gag  is  essential.  It  must  be  one  which  will  not  slip  and  will  not 
embarrass  respiration.  [Whitehead's  gag,  with  the  tongue  depressor  absent, 
is  probably  the  best.]     With  this  the  mouth  is  opened  as  widely  as  possible. 

4.  A  strong  ligature  should  be  passed  through  the  tip  of  the  tongue  for  the 
purpose  of  traction. 

5.  The  tongue  is  retained  within  the  mouth  principally  by  means  of  the 
frenum  and  the  attachments  to  the  anterior  pillars  of  the  fauces.  These  and 
the  reflection  of  the  mucous  membrane  between  the  tongue  and  jaw  must  be 
divided  with  scissors.  Should  any  spouting  vessels  be  seen,  they  must  at  once 
be  caught  in  forceps  and  twisted;  general  oozing  of  blood  may  be  neglected, 
because  as  soon  as  the  main  arteries  are  discovered  and  twisted  all  bleeding 
ceases.  "There  is,  in  reality,  no  difficulty  in  determining  the  actual  position 
of  the  lingual  arteries,  as  they  are  practically  invariably  found  in  the  same 
situation  and  it  requires  very  little  experience  to  seize  them  with  a  pair  of  for- 
ceps before  dividing  them."  The  rest  of  the  tongue  may  be  cut  away  without 
difficulty.  Before  completely  removing  the  tongue  it  is  wise  to  pass  a  Hgature 
through  the  glosso-epiglottidean  fold.  This  ligature  may  be  left  in  place  for 
twenty-four  hours,  and  permits  one  to  pull  forwards  the  epiglottis  should 
respiration  be  interfered  with  at  any  time.  Traction  on  this  ligature  of  itself 
arrests  hemorrhage  and  makes  it  an  easy  matter  to  secure  any  bleeding  vessel. 

6.  Wash  the  wound  with  an  antiseptic  solution. 
11 


l62 


TONGUE 


7.  Paint  the  wound  with  iodoform  styptic  varnish.  The  varnish  is  made 
by  substituting  for  the  alcohol  ordinarily  used  in  the  preparation  of  Friar's 
balsam  a  saturated  solution  of  iodoform  in  ether  9  volumes,  and  turpentine  i 
volume. 

After-treatment. — Encourage  the  patient  to  sit  up  and  move  about  even 
as  early  as  the  day  following  the  operation.  Give  liquid  food  by  the  mouth 
as  early  and  freely  as  possible.  If  necessary,  supplement  oral  feeding  by  the 
use  of  nutrient  enemata.  The  mouth  is  frequently  washed  and  the  varnish 
is  reapplied  daily. 

In  the  hands  of  Whitehead  this  operation  has  had  remarkable  primary 
results.     Up  to  1891  he  had  performed  it  66  times  with  but  three  deaths. 

When  it  is  necessary  to  remove  only  one-half  of  the  tongue,  the  operation 
is  practically  the  same  as  above,  except  that  the  organ  is  split  in  the  middle 
line  and  the  diseased  half  alone  excised. 

n.  Regnoli-Billroth  Operation. — Step  i.— Pass  a  stout  thread  through  the 

tongue  for  purposes  of  traction. 

Step  2. — Make  an  incision  through  the 
skin  and  subcutaneous  tissue  from  the 
anterior  margin  of  one  masseter  muscle  to 
the  anterior  margin  of  the  other  masseter. 
This  incision  follows  the  lower  edge  of  the 
lower  jaw  (Fig.  259).  Reflect  the  skin-flap 
thus  outlined.  The  submaxillary  region  now 
lies  exposed.  If  more  room  is  desired,  the 
posterior  ends  of  the  original  incision  may 
be  extended  backwards  to  the  angles  of 
the  lower  jaw. 

Fig.  259. — Regnoli-Billroth  operation.        Step  3. — With  scissors  or  knife  penetrate 
{Esmarch  and  Ko'^'dzig.)  ^^^  mouth  from  below  upwards  immediately 

behind  the  symphysis.  Be  careful  not  to  injure  the  periosteum.  Separate 
the  structures  composing  the  floor  of  the  mouth  from  the  lower  jaw 
as  far  back  as  the  anterior  pillars  of  the  fauces.  Any  bleeding  vessels  are 
caught  up  by  forceps  and  either  twisted  or  ligated.  The  tongue  with  its  trac- 
tion thread  is  pulled  out  through  the  sub-mental  wound  and  its  posterior 
connections  divided  with  scissors. 

Step  4.— If  there  is  hemorrhage  from  the  stump  and  it  is  not  easy  to 
locate  the  bleeding  point,  hook  the  forefinger  into  the  pharynx  and  pull 
forwards.  This  simple  manoeuvre  brings  the  whole  stump  within  reach  and 
the  hemorrhage  is  easily  controlled  by  forceps  or  suture,  A  few  sutures  of 
silk-worm-gut  judiciously  inserted  lessen  the  extent  of  raw  surface. 

Step  5. — Put  an  iodoform  gauze  drain  in  place  and  close  the  remainder 
of  the  wound  with  interrupted  silkworm-gut  sutures. 

During  this  operation  all  affected  or  suspected  lymphatic  tissue  must  be 
removed  from  the  submaxillary  region. 

m.  Sedillot's  Operation. — In  cases  of  Ungual  cancer  where  the  floor  of  the 
mouth  and   the  jaws  are  not  affected,   Kocher   ("Operationslehre,"   fourth 


sedillot's  operation  163 

edition)   strongly  advocates  Sedillot's  operation.     The   only  disadvantage  of 
the  procedure  is  that  excision  of  affected  or  suspected  lymph-glands,  etc., 
if  done  at  the  same   time  as   the  primary  operations,  leaves  too   large  and 
irregular  a  wound,  so  that  infection  can  scarcely  be 
avoided.     Kocher  recommends  that  the  glands  be 
excised  at  a  second  operation.     Supposing  that  the 
disease  affects  the  edge  of   the  tongue   posteriorly 
and  has  spread  to  its  base,  to  the  anterior  pillar  of 
the  fauces,  the  soft  palate,  and  the  lateral  wall  of 
the  pharynx,  the  operation  is  carried  out  as  follows: 
Median  division  of  the  lower  lip,  chin,  and  skin 
in  submental  region  as  far  as  the  hyoid  bone  (Fig.         .        ^  nn^       v\\ 
260).     Hemostasis.     Division  of  the  lower  jaw  in  \ 

the  middle  line.  Separation  of  the  divided  halves  Fig.  260. — Excision  of  tongue. 
of  the  jaw  with  sharp  hooks.     Median  division  of 

the  geniohyoid  and  genioglossal  muscles.  By  means  of  a  traction  thread 
pull  the  tongue  out  and  towards  the  sound  side.  Divide  the  mucous  mem- 
brane of  the  floor  of  the  mouth  backwards  at  the  margin  of  the  tongue. 
This  exposes  the  lingual  vein,  running  backwards  and  outwards  over  the 
lateral  surface  of  the  hyoglossus;  also  the  lingual  nerve  near  the  border  of 
the  tongue,  immediately  under  the  mucous  membrane.  The  hypoglossal 
nerve  is  exposed  at  the  outer  surface  of  the  hyoglossus,  over  which  it  runs  in- 
wards and  forwards.  Between  the  hyoglossus  and  genioglossus  lies  the  lingual 
artery,  easily  recognized  and  tied.  Divide  the  hyoglossus  with  the  cautery 
(Kocher  divides  all  the  muscles  around  the  tumor  with  the  cautery).  Put 
great  traction  on  the  tongue  and,  using  the  cautery,  divide  the  mucous  mem- 
brane posteriorly,  along  a  line  remote  from  the  disease.  If  the  disease  extends 
to  the  palate  and  pharynx,  divide  the  styloglossus  muscle,  and  with  it  the  glosso- 
pharyngeal nerve.  After  dividing  the  mucous  membrane  in  front  of  the  tonsil 
it  can  be  lifted  up  by  blunt  dissection,  even  when  diseased,  until  the  internal 
pterygoid  muscle  is  exposed.  Divide,  with  the  cautery,  the  soft  palate  so  far 
as  it  is  diseased,  and  with  it  the  tensor  and  levator  palati  muscles.  Now  divide 
the  mucous  membrane  on  the  posterior  wall  of  the  pharynx  as  far  as  the  longus 
colli  muscle  and  forwards  to  the  base  of  the  tongue.  All  this  can  be  done  under 
full  guidance  of  the  eye.  Lastly,  with  the  cautery,  divide  the  tongue  itself, 
remote  from  the  disease,  and  sever  its  nerves,  muscles,  and  vessels  (after  apply- 
ing ligatures),  or  such  of  these  as  penetrate  the  neoplasm.  Preserve  as  many 
nerves  and  muscles  as  possible  so  as  to  interfere  with  deglutition  to  the  minimal 
extent.  Ability  to  swallow  is  the  greatest  preventive  against  subsequent 
pneumonia.  Rub  the  wound  with  a  small  amount  of  xeroform.  Wire  the 
divided  jaw.  Do  not  elevate  the  periosteum  when  drilling  the  bone.  Close  the 
wound  in  the  soft  parts,  providing  for  gauze  drainage  immediately  in  front  of 
the  hyoid  bone.  If  the  patient  is  placed  in  the  Trendelenburg  position,  the 
operation  can  be  done  under  a  general  anesthetic  without  any  preHminary 
tracheotomy.  The  operation  is  suitable  for  all  cases  except  those  in  which  the 
jaw  is  affected. 


164 


TONGUE 


After-treatment. — Until  the  patient  is  able  to  sit  up,  he  should  be  kept  in 
Trendelenburg's  position.  On  the  day  following  the  operation  he  should  try 
to  sit  up  and  attempt  to  swallow  tea  or  wine  with  water.  Nourishment  must 
be  administered  through  an  esophageal  tube. 

IV.  Von  Langenbeck's  method  of  excising  the  tongue  is  very  similar  to 
that  of  Sedillot,  and  thus  requires  no  special  description,  except  as  regards  the 
incision.  On  the  side  corresponding  to  the  disease  make  an  incision  from 
the  corner  of  the  mouth  vertically  downwards  to  the  border  of  the  lower  jaw, 
and  continue  it  downwards  to  the  side  of  the  hyoid  bone  (Fig.  260).  The 
upper  portion  of  the  cut  divides  the  lower  lip  and  gum,  penetrating  to  and 
exposing  the  lower  jaw;  the  lower  or  submental  portion  at  first  penetrates  only 
the  skin  and  superficial  fascia.  Through  the  lower  part  of  the  incision  excise 
all  suspected  glands  (lymphatic  and  salivary)  and  ligate  the  lingual  artery. 
Divide  the  jaw  along  the  line  of  incision  after  boring  holes  for  subsequent 
wiring.  With  strong  hooks  separate  the  segments  of  the  jaw.  The  tongue 
and  floor  of  the  mouth  are  well  exposed  by  this  procedure  and  can  be  dealt  with 
according  to  the  principles  already  laid  down. 

V.  Kocher's  Method. — In  certain  cases  of 
extensive  carcinoma,  and  always  when  the  disease 
involves  the  lower  jaw,  Kocher  advises  the  following 
operation: 

Step  I. — Put  the  patient  in  Trendelenburg's  posi- 
tion. Pass  a  stout  thread  through  the  tongue  for 
purposes  of  traction. 

Step  2. — Beginning  immediately  below  the  sym- 
physis of  the  lower  jaw,  make  an  incision  downwards 
to  a  point  a  little  above  the  hyoid  bone;  from  here  cut 
backwards  to  the  anterior  margin  of  the  sterno- 
mastoid.  Once  more  change  the  direction  of  the  incision  and  continue 
it  upwards  along  the  margin  of  the  sternomastoid  to  a  point  near  the  level 
of  the  lobe  of  the  ear  (Fig.    261). 

Step  3. — Reflect  upwards  the  skin-flap  thus  outlined. 
Step  4. — Excise,  en  masse  if  possible,  all  the  enlarged  glands  under  the  upper 
end  of  the  sternomastoid  and  under  the  angle  and  horizontal  ramus  of  the  jaw. 
Carefully  dissect  free  the  anterior  border  of  the  sternomastoid,  exposing  the 
carotid  packet  of  vessels  and  the  great  horn  of  the  hyoid.  Excise  the  glands 
in  this  region. 

Step  5. — If  the  cancer  affects  the  floor  of  the  mouth,  the  fauces,  or 
jaw,  it  is  wise  to  ligate  the  facial  vein  and  the  external  carotid  artery. 

Step  6. — Expose  clearly  the  anterior  belly  of  the  digastric  through  its  whole 
length,  and  ligate  the  veins  under  it.  From  below  upwards  dissect  free 
the  packet  of  glands  exposed  until  the  entire  posterior  belly  of  the  digastric 
and  the  stylohyoid  muscles  lie  free  in  the  posterior  inferior  part  of  the  wound. 
Detach  the  mass  of  glands  (lymphatic  and  salivary)  from  the  lower  jaw. 

Step  7. — At  the  posterior  end  of  the  great  horn  of  the  hyoid  divide  the  in- 
sertion of  the  hyoglossus  muscle.  This  exposes  the  lingual  artery.  Tie  the 
artery,  but  preserve  the  hypoglossal  nerve. 


Fig.     261. — Kocher's 
operation. 


butlin's  operation  165 

Step  8. — The  lower  surface  of  the  mylohyoid  muscle  now  lies  exposed  and 
on  it  the  mylohyoid  nerve.  At  the  posterior  margin  of  the  muscle  penetrate 
the  mouth  (guided  by  a  finger  in  the  mouth)  after  once  more  noting  the 
extent  and  limits  of  the  disease.  Beginning  at  this  opening,  divide  the  oral 
mucous  membrane  along  a  line  remote  from  the  disease.  Attend  to 
hemostasis. 

Step  g. — Divide  the  lingual  muscles  at  the  hyoid  and  remove  all  infiltrated 
tissue.  It  is  easy  to  pull  the  tongue  out  through  the  wound  as  soon  as  the 
oral  mucous  membrane  has  been  divided. 

If  a  preliminary  tracheotomy  has  been  done,  the  entrances  to  the  larynx 
should  be  packed  with  sterile  gauze  as  soon  as  the  pharynx  is  opened. 

_  After-treatment. — 'Leave  the  lower  part  of  the  wound  open  so  that  the  laryn- 
geal pack  may  be  changed  frequently.  Every  time  the  dressings  are  changed 
(and  this  must  be  done  very  frequently)  administer  plenty  of  nutritious  food 
by  means  of  an  esophageal  tube.  As  long  as  the  mechanism  of  deglutition  is 
seriously  disturbed  keep  the  patient  in  more  or  less  of  the  Trendelenburg 
position  except  when  he  stands  or  sits  up.  As  long  as  deglutition  is  poor  the 
patient  must  not  lie  horizontally;  he  must  either  sit  up  or  lie  with  his  head  and 
shoulders  low.  The  object  of  this  care  is,  of  course,  to  avoid  pneumonia  from 
the  entrance  of  secretions  into  the  air  passages. 

The  question  as  to  whether  the  last-mentioned  operation  should  or  should 
not  be  preceded  by  a  tracheotomy  is  much  discussed.  Kocher  and  Jacobson 
are  strong  advocates  of  this  as  a  preliminary. 

The  advantages  of  tracheotomy  are  the  possibility  of  easy  anesthetization; 
of  plugging  the  pharynx  with  gauze,  thus  avoiding  inspiration  of  blood,  and 
of  greater  freedom  in  operating. 

Butlin  advocates  preliminary  laryngotomy  as  a  safe  and  convenient  sub- 
stitute for  tracheotomy. 

When  removal  of  the  whole  base  of  the  tongue  is  not  necessary  Crile  passes 
closely  fitting  rubber  tubes  through  the  nares  into  the  pharynx,  to  a  point 
opposite  the  epiglottis,  pulls  the  tongue  well  forwards  and  then  closely  packs 
the  pharynx  with  gauze.  The  two  tubes  after  emerging  from  the  anterior 
nares  are  connected  by  a  Y,  of  glass  or  metal,  to  a  single  tube  and  through 
this  the  anesthetic  is  administered. 

The  opponents  of  preliminary  tracheotomy  believe  that  this  operation, 
while  decreasing  the  danger  of  pneumonia  from  inspiration  of  blood,  yet  makes 
the  patient  subject  to  a  greater  danger  of  contracting  pneumonia  from  other 
causes.  If  tracheotomy  is  decided  on,  it  should  be  performed  several  days 
before  the  tongue  is  attacked,  to  permit  the  patient  to  become  accustomed  to 
the  new  conditions  of  respiration  before  his  powers  are  taxed  by  the  very 
severe  operation  he  is  to  undergo. 

VI.  Butlin's  Method.* — (A)  The  disease  does  not  involve  the  floor  of  the 
mouth. 

Perform  a  preliminary  laryngotomy  (p.  232). 

Pack  the  pharynx  to  prevent  blood  gravitating  into  the  larynx. 

Step  I. — By  Whitehead's  method  or  some  modification  thereof,  remove  the 

*Butlin,  "Op  Surg.  Malignant  Dis.,"  second,  ed.,  "Brit.  Med.  Jour.,"  Feb.  15,  1905. 


1 66 


TONGVE 


local  disease  with  ^i  inch  of  apparently  healthy  tissues  around  it  in  every 
direction.  Where  the  disease  is  on  the  border  of  the  tongue,  it  is  best  to  remove 
that  half  of  the  tongue  to  an  inch  behind  the  cancer. 

After  about  nine  days,  when  the  patient  is  able  to  take  plenty  of  liquid  food, 
proceed  to  Step  2. 

Step  2. — Make  an  incision  along  the  anterior  border  of  the  sternomastoid 
from  near  the  mastoid  process  to  the  sternoclavicular  articulation.  Make  an 
incision  from  the  symphysis  menii  to  meet  the  previous  incision,  just  above 
the  thyroid  cartilage.  Reflect  the  two  triangular  flaps  of  skin  thus  outlined 
and  expose  the  platysma  myoides  and  fat  of  the  anterior  triangle  of  the  neck. 

Step  3. — Beginning  below,  expose  the  sternomastoid  and  retract  it  back- 
wards. Expose  the  carotid  packet  of  vessels,  dissecting  from  below  upwards, 
and  separate  from  it  every  particle  of  fat,  whether  superficial  or  deep,  anterior 


Fig.  262. — Butlin's  method  for  excision  of  the  tongue. 
Sketch  indicating  the  position  of  the  most  important  lymph  nodes,  all  of  which  are  supposed  to  have  been 
dissected  out  and  removed,     i.  Location  of  submental  group  lymph  nodes.     2.  Location  of  submaxillary 
group  lymph  nodes.     3.  Location  of  parotid  group  lymph  nodes.     4.  Location  of  carotid  group  lymph 
nodes. 

or  posterior.  Be  careful  to  remove  the  fat  between  the  parotid  and  the  vessels. 
All  this  fat  ought  to  be  left  attached  to  that  of  the  rest  of  the  anterior  triangle, 
otherwise  the  operation  is  liable  to  be  incomplete  (Fig.  262).  Working  from 
the  region  of  danger  (carotid  packet)  and  from  below  upwards,  remove  en 
masse  all  the  fat  in  the  anterior  triangle  and  with  it  the  submaxillary  salivary 
gland,  leaving  the  muscles  quite  bare.  In  the  submental  region  complete  the 
dissection  by  searching  between  the  geniohyoid  muscles,  lest  a  gland  be  over- 
looked. 

If  the  disease  involves  the  contents  of  the  carotid  packet,  these  must  also 
be  removed.  The  internal  jugular  vein  more  often  requires  removal  than  does 
the  carotid  artery. 

Step  4. — Place  one  strip  of  gauze  in  the  submaxillary  triangle  beneath 
the  jaw  and  another  between  the  parotid  and  the  vessels.     Bring  the  ends  of 


butlin's  results  167 

the  gauze  out  at  the  lowest  part  of  the  wound.  Provide  tubular  drainage  also. 
Close  the  wound.  Damage  to  the  parotid  will  permit  a  leakage  of  saliva,  but 
this  ceases  in  a  few  days. 

The  principles  of  Butlin's  operation  are:  (i)  Operation  in  two  stages  is 
much  safer  than  in  one.  (2)  The  glands  are  involved  very  early  in  lingual 
cancer,  but  the  lymphatic  vessels  between  the  primary  lesion  and  the  secondary 
seem  to  escape. 

Mr.  Butlin's  results  have  been  so  remarkable  that  no  apology  is  necessary 
for  reproducing  the  statistics  of  seventy  cases  in  which  he  was  permitted  to 
complete  the  operation  in  the  manner  he  advocates.  A  study  of  Butlin's 
specimens  and  drawings  gives  great  encouragement  in  the  treatment  of  cancer 
of  the  tongue  even  when  apparently  advanced: 

Analysis  of  seventy  cases  in  which  the  contents  of  the  anterior  triangle 
were  removed: 

Died  of  the  operation 6 

Lost  sight  of  after  operation i 

Died  of  recurrence  in  the  mouth 9 

Died  of  recurrence,  uncertain  where  (in  one  of  these  the  glands  could  not  be  entirely  re- 
moved ;  operation  abandoned) 7 

Died  of  recurrence  in  the  glands  (in  one  of  these  the  submaxillary  salivary  gland  was 
left,  and  the  disease  recurred  beneath  it;  in  the  other  seven  cases  the  glands  were 
enlarged  at  the  time  of  their  removal,  and  in  five  of  these  they  were  demonstrably 

cancerous) 8 

Died  of  cancer  on  the  opposite  side  of  the  tongue i 

Died  of  affection  of  glands  on  opposite  side  of  neck 2 

Died  of  other  disease  within  three  years i 

Cases  not  countable  (operation  too  recent) 11 

Successful  cases, , 24 

Total 70 

The  successful  cases  are  calculated  on  the  seventy  cases,  after  deducting 
cases  not  countable  (11),  the  patient  who  died  within  three  years  of  another 
disease  (i),  and  the  patient  who  was  not  traced  after  the  operation  (i),  leaving 
fifty-seven  cases,  with  twenty-four  successful  cases  =  42.01  per  cent. 

The  age  of  the  patients  operated  on  showed  that  ten  of  them  were  over  65 
years  of  age,  and  one  over  70  years  (77). 

The  causes  of  death  from  operation  were: 

Hemorrhage,  etc.  (both  from  mouth  and  neck  in  a  badly  alcoholic  patient) i 

Suffocation  (from  the  sudden  falling  back  of  the  root  of  the  tongue  some  days  after 

operation) i 

Septic  pneumonia 4 

Total 6 

(B)  The  disease  involves  the  floor  of  the  mouth  to  such  an  extent  that  the 
intrabuccal  operation  is  impossible. 

Remove  the  tongue  by  any  of  the  methods  abeady  described,  and  according 
to  the  condition  of  the  patient  remove  the  glands  of  the  neck  either  at  the  same 
or  at  a  subsequent  seance. 


1 68 


TONGUE 


Whatever  operation  is  chosen  for  removal  of  lingual  cancer,  it  is  always 
of  prime  importance  to  remove  en  masse  the  whole  of  the  related  lymphatic 
territory,  even  if  the  primary  lesion  appear  trivial  and  the  lymphatics  show 
no  macroscopic  involvement. 

Crile  ("Journ.  Am.  Med.  Assoc,"  Dec.  i,  1906)  reports  remarkably 
favorable  results  from  an  operation  similar  to,  but  more  extensive  than  Butlin's. 


A 

^^■i 

B 

^1^1 

c             m 

fm 

E 

/JIM 

w^     "        ^ 

^^ 

.*L.. 
c 

k.mi 

Fig.  263. — [Crile.) 
The  entire  mass  of  lymphatic  gland  bearing  tissue  is  excised  en  bloc,  and  handled  as  little  as  possible 
This  dissection  becomes  easy  when  followed  in  the  deep  plane.  The  entire  block  of  tissue  is  finally  divided 
above,  including  the  vein.  A,  splenius.  B,  hypoglossus  descendens.  C,  spinal  accessory.  D,  elevator 
ang.  scapuii.  E,  pneumogastric.  F.  scalenus  posticus.  G,  internal  jugular.  H.  facial  vein  and  artery . 
I,  submental.  J,  submaxillary.  K,  digastric.  L,  mylohyoid.  M,  sternohyoid.  N,  omohyoid.  O, 
thyroid  gland.     P,  thyrohyoid.     Q.  carotid. 


When  lymph  nodes  are  palpably  enlarged,  further  metastasis  is  sure  to  be 
irregular,  therefore  Crile  removes  the  whole  lymphatic-bearing  tissue  on  the 
affected  side;  when  there  are  no  palpably  enlarged  glands  he  only  removes  the 
lymphatics  next  in  order. 

In  operating  on  the  former  class  of  cases  Crile  temporarily  compresses 
the  common  carotid  with  his  special  clamp,  doubly  ligates  and  divides  the 
internal  jugular  vein  low  down  in  the  neck  and  excises  the  vein  along  with 
the  lymphatic  tissues,  and  the  muscles  of  that  side  of  the  neck  (Fig.  263). 


maitland's  operation  169 

George  E.  Armstrong  performs  what  is  practically  the  Eutlin  operation. 
He  begins  by  exposing  the  cervical  lymphatic  territory  on  both  sides  of  the 
neck,  ligating  both  external  carotid  arteries  and  excising  the  lymphatics  exactly 
as  does  Butlin.  After  providing  for  drainage  and  closing  the  large  cervical 
wounds  he  immediately  proceeds  to  excise  the  tongue.  When  only  one  lateral 
half  of  the  tongue  is  removed  he  finds  it  very  advantageous  to  stitch  the  re- 
maining half  to  the  floor  of  the  mouth.  In  this  way  nearly  all  the  raw  surfaces 
are  covered. 

Vn.  Maitland's  Operation.— Maitland  ("The  Australasian  Med.  Gazette," 
Oct.  20,  1906,  describes  a  thorough  operation  which  has  given  him  much  satis- 
faction and  which  he  practises  in  all  except  very  early  and  very  late  cases.  Fig. 
264  shows  Maitland's  incisions.  The  following  paragraphs  are  copied  from 
the  article  to  which  reference  has  been  made. 

^^  Dissection  of  the  Digastric  Triangle. — A  clean  dissection  is  then  made  of 
this  triangle,  beginning  at  the  point  of  the  chin  and  working  outwards  and 
upwards,  paying  particular  attention  to  the  spaces  between  the  outer  edge  of 
the  mylohyoid  and  the  hyoglossus,  as  glands  are  easily  overlooked  in  these 
situations.  The  anterior  layer  of  the  outer  portion  of  the  deep  cervical  fascia, 
which  here  forms  a  compartment  for  the  submaxillary  gland,  is  opened,  the 
glands  pulled  forwards,  the  facial  artery  tied  and  divided,  the  common  facial 
and  anterior  division  of  the  temporo-maxillary  veins  having  been  previously 
tied  and  divided.  The  dissection  of  this  anterior  portion  of  the  digastric 
triangle  is  then  completed  by  carrying  the  dissection  well  up  over  the  body  of 
the  mandible,  so  as  to  remove  the  lower  of  the  facial  glands.  That  portion  of 
the  digastric  triangle  posterior  to  the  stylo-maxillary  ligament  containing  the 
parotid  is  next  cleared  and  the  lower  portion  of  the  parotid  is  removed.  This 
dissection  is  carried  sufficiently  deep  to  remove  the  deep  parotid  glands;  this 
step  has  been  insisted  on  by  Butlin.  I  have  regularly  carried  it  out  for  some 
years. 

^'Division  of  the  Sternomastoid. — Before  this  step  in.  the  operation  is  per- 
formed the  dissection  of  the  anterior  triangle  is  begun  from  before  backwards 
till  the  anterior  border  of  the  sternomastoid  is  reached.  The  muscle  is  then 
divided  at  the  level  of  the  omohyoid,  the  lower  portion  being  turned  down. 

^^  Dissection  of  the  Anterior  and  Posterior  Triangles. — The  dissection  of  these 
two  triangles  is  then  proceeded  with  from  below  upwards,  cleaning  all  the 
fascia  off  the  vessels.  The  dissection  is  carried  on  right  up  beneath  the  parotid, 
the  dissection  being  completed  by  removing  the  sternomastoid  muscle  at  its 
insertion,  together  with  the  contents  of  the  anterior  and  posterior  triangles. 
By  this  means  the  whole  of  the  deep  descending  cervical  chain  of  glands  is 
removed. 

"Removal  of  Internal  Jugular  Vein. — This  is  done  as  the  last  step  of  the 
operation;  if  it  be  done  earlier  in  the  operation  much  valuable  time  is  lost  in 
stopping  venous  hemorrhage.  I  am  firmly  of  opinion  that  only  by  removing 
the  sternomastoid  muscle  can  the  deep  cervical  chair  of  glands  be  thoroughly 
removed.  The  internal  jugular  vein  I  do  not  always  remove,  as  with  the 
removal  of  the  sternomastoid  muscle,  as  I  suggest,  the  vein  can  be  more  thor- 
oughly cleared  both  on  its  anterior  and  posterior  aspects. 


170 


TONGUE 


"r/te  Effect  of  Removal  of  the  Sternomastoid  Muscle. — All  the  mo\-ements 
of  the  head  are,  as  I  show  you  from  these  cases,  thoroughly  carried  out  by  the 
post-rotators,  and  the  removal  of  the  muscle  practically  in  no  wise  interferes 
with  the  head  movements.  The  text-books  advise  preservation  of  the  muscle, 
because  of  the  supposed  interference  with  the  movements  of  the  head;  but  this 
view  I  know  to  be  erroneous. 

"77/e  Division  of  the  Spinal  Accessory. — This  is  done  in  nearly  every  case, 
and  only  in  two  instances  have  I  seen  drooping  of  the  shoulders;  the  third  and 
fourth  cervical  are  sufficient  to  preserve  the  function  of  the  muscle. " 

VIII.  A.  P.  C.  Ashhurst's  operation  is  sufficiently  described  by  illustrations 
264,  265  and  266  (Annals  of  Surg.,  Aug.,  1915). 


Fig.  264. — Maitland.     {Australasian  Med.  Gaz.) 


IX.  Spischamy's  Suprahyoid  Operation.  (Archiv  flir  klin.  Chir.,  xcii, 
p.  121 2). — Step  I.— Make  a  transverse  incision  above  the  hyoid  bone  from  one 
sternomastoid  to  the  other.  If  necessary  enlarge  the  wound  b)/  longitudinal 
incisions  along  the  sternomastoid  muscle.  Remove  the  lymphatic  glands 
and  with  them  the  submaxillary  salivary  glands,  if  the  floor  of  the  mouth  is 
affected.  Ligate  and  divide  both  lingual  arteries.  Divide  both  hypoglossal 
nerves. 

Step  2. — Separate  the  root  of  the  tongue  from  the  hyoid  bone  and  open  the 
pharynx  in  the  angle  between  the  tongue  and  the  epiglottis  (Fig,  267).  All 
the  diseased  structures  (even,  if  required,  the  tonsils,  pillars  of  the  fauces  and 
floor  of  the  mouth)  can  now  be  isolated  under  guidance  of  the  eye. 

Step  3. — Open  the  mouth  and  through  it  divide  the  anterior  attachments 
of  the  tongue.     Remove  the  tongue. 

Step  4. — Suture  together  the  remnants  of  muscles  attached  to  the  chin  and 
the  hyoid  bone.  Carefully  reunite  the  digastric  muscles  to  the  hyoid.  Close 
the  wound  leaving  a  narrow  canal  to  the  pharynx  for  purposes  of  drainage. 

Pass  a  soft  oesophageal  catheter  through  the  nose  into  the  oesophagus  to 
permit  feeding  during  the  first  few  days. 

Spischarny  states  that  preliminary  tracheotomy  is  unnecessary  if  the  opera- 
tion is  performed  in  Rose's  position. 

X.  Vallas'  Transhyoid  Operation. — When  cancer  is  limited  to  the  base  of 
the  tongue  near  the  epiglottis,  or  when  it  affects  the  epiglottis,  Vallas'  operation 
of  transhyoid  pharyngotomy  gives  good  access  to  the  parts.     This  operation  is 


FXCISION    TONGUE 


171 


Fig.  266. — After  removal  of  tongue,  floor  of  mouth  is  covered  partially  by  suturing  mucosa 
of  cheek  across  alveolus  to  stump  of  tongue.  A  hemostat  is  on  the  right  lingual  artery  in  the 
floor  of  the  mouth.     {Ashhurst,  Annals  of  Surgery.) 


Fig.  267. 


172 


TONGUE 


also  suitable  for  the  removal  of  foreign  bodies  and  the  treatment  of  sj^ihiHtic 
strictures.     Preliminary  tracheotomy  is  not  essential. 

The  Operation.  Step  i. — Make  a  median  incision  through  the  skin  and 
subcutaneous  tissue  from  the  symphysis  of  the  lower  jaw  to  the  superior  angle 
of  the  thyroid  cartilage. 

Step  2. — With  blunt  or  sharp  dissection  separate,  in  the  middle  line,  the 
fibres  of  the  mylohyoid  muscles  in  such  fashion  as  to  expose  the  upper  border 
of  the  hyoid  bone  in  the  median  line. 

Step  3. — With  scissors  or  bone  forceps  divide  the  hyoid  bone  in  the  middle 
line.  Retract  the  halves  of  the  bone  along  with  the  fibres  of  the  mylohyoid 
muscle.     This  gives  us  a  space  i3^  inches  in  width. 

Step  4. — The  lower  part  of  the  wound  is  separated  from  the  phar>'n.x  by  the 
thyrohyoid  membrane,  the  upper  part  by  the  mucosa.  To  reach  the  pharynx, 
divide  the  thyrohyoid  membrane;  to  reach  the  base  of  the  tongue  or  floor  of  the 
mouth,  cut  upwards.  Access  has  now  been  gained  to  the  seat  of  the  disease. 
It  is  unnecessary  here  to  describe  over  again  the  removal  of  the  neoplasm; 
it  must  be  done  freely  on  the  principles  already  enunciated.  Having  completed 
the  excision,  close  the  wound,  pro\'iding  drainage  at  its  lower  end.  No  special 
suture  of  the  hyoid  is  required. 

XI.  Abadie's  Operation. — The  carcinoma  afiFects  the  floor  of  the  mouth 
superficially — has  spread  to  the  tongue  and  to  the  alveolar  mucosa  anteriorly 


Fig.  268. — {Journ.  de  Chir.) 


the  muscles  of  the  floor  of  the  mouth  are  not  involved.  Abadie's  operation 
may  be  valuable  ("Arch,  provinciales  de  Chir.,"  xx,  725;  Ref.  "Journ.  de  Chir.," 
April,  191 2).  Fig.  268  shows  diagrammatically  a  case  suitable  for  the  operation 
and  the  lines  of  incision. 

Step  I. — Make  an  incision  along  the  lower  border  of  the  inferior  maxilla 
from  one  masseter  to  the  other.  Dissect  upwards  so  as  to  separate  all  the  soft 
parts  from  the  front  of  the  jaw  until  the  mouth  is  freely  opened  along  the  line 
of  reflection  of  the  mucosa  from  the  jaw  to  the  lips.  Reflect  upwards  as  a  visor 
the  flap  thus  formed. 

Step  2. — According  to  the  extent  of  the  lesion  select  the  two  extreme  points 
of  the  line  of  section  of  the  bone  (A  and  B,  Fig.  269).     At  these  points  perforate 


PAROTID    TUMORS 


173 


the  bone  with  a  drill.  With  an  amputation  saw  divide  the  bone  along  the  line 
AB.  Pass  a  Gigli  saw  through  the  perforation  at  B  and  divide  the  alveolus 
along  the  line  BC.     Do  the  same  at  perforation  A. 

Step  3. — Seize  the  mobilized  segment  of  bone  with  lion-jawed  forceps  and 
pull  it  upwards  and  forwards.  With  scissors  cutting  horizontally  from  before 
backwards,  dissect  up  the  disease  on  the  floor  of  the  mouth,  then  cutting  up- 
wards and  forwards  excise  the  disease  from  the  tongue  along  the  lines  shown  in' 
Fig.  268.     Attend  to  hemostasis. 


Fig.   269. — {Journ.  de  Chir.) 

Step  4. — Close  the  wound  in  the  tongue  with  sutures.  Unite  the  mucosa  of 
the  tongue  to  that  of  the  lip.  Replace  the  visor-shaped  flap  of  lip  and  suture 
the  skin  wound  after  providing  for  drainage.  Before,  during,  or  after  Abadie's. 
operation,  the  lymphatic  territory  ought,  of  course,  to  be  cleared  of  its  glands 
and  fat  as  in  any  other  operation  for  cancer  of  the  tongue. 


CHAPTER  XVII 

PAROTID  GLAND 

From  the  standpoint  of  operative  surgery  tumors  of  the  parotid  may  be 
divided  into  two  classes: 

1.  Those  which  are  encapsulated  inside  the  gland.  This  encapsulation 
may  not  be  perfect,  but  there  is  no  general  infiltration  of  the  gland  by  the  disease. 
Such  tumors  are  the  adenomata  and  the  mixed  tumors  of  feeble  malignancy. 

2.  Those  tumors  which  filtrate  the  gland  substance.  Such  are  the  sar- 
comata and  carcinomata. 

The  principles  of  operation  which  may  be  applied  to  both  classes  of  tumors 
alike  are:  (a)  early  operation;  {h)  free  exposure  of  the  growth  by  suitable 
incisions;  (c)  careful  hemostasis. 


174 


PAROTID    GLANU 


When  the  tumor  is  one  of  those  encapsulated  within  the  gland,  it  should, 
if  possible,  be  enucleated  with  its  capsule,  leaving  the  gland  as  little  injured 
as  is  practicable.  When  the  capsule  cannot  be  removed  with  the  growth,  it 
should  be  removed  afterwards  as  thoroughly  as  circumstances  permit.  The 
facial  nerve  must  be  preserved.  An  incomplete  operation  often  gives  good 
results,  but  completeness  must  always  be  the  aim.  When  the  tumor  is  of  the 
infiltrating  type,  the  whole,  gland  with  its  fascial  coverings  or  capsule  must  be 
removed,  and  with  it  any  adherent  skin.  Little  attention  may  be  given  to  the 
facial  nerve;  its  destruction  is  almost  certain.  T.  Carwardine  and  Gunn  have 
each  preserved  the  facial  nerve  in  such  operations.  The  necessary  dissection 
must  take  very  much  time  and  in  feeble  patients  this  constitutes  no  mean 
risk.  As  in  the  case  of  cancers  located  elsewhere,  too  much  rather  than  too 
little  must  be  done.  If  the  surgeon  believes  that  the  whole  growth  cannot 
be  removed,  it  is  better  to  abstain  from  operation.  An  incomplete  operation 
is  worse  than  useless. 

I.  Enucleation  of  Parotid  Tumors. — (A)  The  tumor  is  small,  mobile 
and  apparently  easily  removed:  Make  a  horizontal  incision  over  the  promi- 
nent portion  of  the  growth,  parallel  to  the  course  of  the  fibres  of  the  facial  nerve 
and  of  length  sufficient  to  permit  of  removal  of  the  tumor  under  guidance  of 
the  eye  and  without  bruising  of  the  wound.  Incise  the  gland  substance  so  as 
to  expose  the  tumor,  which  must  now  be  shelled  out.  Attend  to  hemostasis; 
in  doing  this,  suture-ligatures  involving  the  gland  substance  should  be  avoided, 
as  they  are  liable  to  constrict  branches  of  the  facial  nerve  and  salivary  ducts. 
Close  the  wound  with  or  without  drainage. 

(B)  The  tumor  is  not  large  and  not  suitable  for  the  simple  procedure  de- 
scribed above: 

Step  I. — Beginning  at  the  tip  of  the  mastoid  process,  make  an  incision 
downwards  along  the  anterior  edge  of  the  sternomastoid,  to  the  level  of  the 
angle  of  the  lower  jaw;  from  this  point  cut  forwards  and  upwards,  in  a  curve, 
over  the  ascending  tamus  of  the  jaw,  until  a  flap  is  outlined  which  when  elevated 
will  expose  most  of  the  tumor.  The  flap  consists  of  skin  and  superficial  fascia 
alone;  no  deeper  structures  must  be  involved  because  of  the  facial  nerve. 

Step  2. — The  growth  of  the  tumor  inevitably  pushes  aside  and  spreads 
out  the  glandular  tissue  in  which  it  lies.  Examine  the  exposed  surface  for 
that  part  least  covered  by  glandular  tissue.  The  tumor  capsule  will  generally 
be  seen  at  once;  if  not,  expose  it  by  dividing  horizontally  any  overlying  glandular 
substance.  If  the  capsule  is  strong,  proceed  to  do  an  extracapsular  enucleation 
by  blunt  dissection.  Any  bands  of  tissue  passing  to  the  capsule  from  its  sur- 
rounding must  be  doubly  ligated  and  divided.  First  free  the  anterior  border 
of  the  tumor,  then  the  posterior,  and  dissect  free  its  deep  surface /^-ow  below 
upwards  so  as  to  gain  early  control  of  the  vascular  supply.  Proceeding  in  this 
fashion,  it  is  often  possible  to  enucleate  the  tumor  en  masse,  but  often  enough 
some  deeply  seated  fragments  are  left  behind;  such  must  now  be  removed 
individually. 

If  the  capsule  is  weak  and  the  tumor  soft,  extracapsular  enucleation  is  im- 
possible. Under  these  circumstances  freely  incise  the  capsule,  clean  out  its 
contents,  and  remove  the  capsule  bit  by  bit  as  thoroughly  as  possible.     This 


EXCISION    PAROTID  I  75 

apparently  very  imperfect  operation  often  gives  excellent  results.  With  re- 
gard to  enchondromata  of  the  salivary  glands  Jacobson  writes:  "It  is  not 
uncommon  for  branches  of  the  facial  nerve  to  be  in  relation  with  the  capsule  of 
the  tumor,  and  if  this  had  been  much  handled,  or  treated  by  counter-irritation, 
they  may  very  likely  be  firmly  adherent.  In  either  case  injury  to  the  nerve  may 
be  best  avoided  by  slitting  up  the  capsule  and  shelling  out  the  enchondroma 
first.  The  capsule  should  then  be  examined  to  see  if  any  nerve  branches  are 
adherent  to  it;  after  these  have  been  separated,  the  capsule  itself  should  be 
removed.  This  should  always  be  done  to  prevent  any  recurrence,  as  the 
peripheral  part  of  these  enchondromata  is  often  adherent  to  the  capsule 
itself.''     (''Operations  of  Surgery,"  i,  340.) 

Step  3. — Attend  to  hemostasis.     Close  the  wound  by  sutures.     Drain  dead 
spaces.     Dress. 

II.  Excision  of  the  Parotid.- — Excision  of  the  parotid  is  necessary  in  cases 
of  malignant  neoplasms,  such  as  carcinoma  or  sarcoma.  As  these  tumors  are 
infiltrating  in  character,  enucleation  is  impossible  and 
useless;  the  whole  gland  must  be  removed,  whether 
evidently  affected  or  not. 

Step  I. — Make  a  h- -shaped  incision  (Fig.  270)  of 
sufl&cient  extent,  through  the  skin.  Reflect  the  skin  so 
as  to  expose  all  the  parotid  covered  by  its  fascia. 

Step  2. — Mobilize  the  anterior  edge  of  the  gland 
and  tumor.  Doubly  ligate  and  divide  the  vessels 
situated  here  and  Steno's  duct.  Forceps  may  be  used 
instead  of  ligatures  during  the  dissection.  Separate  the 
gland  from  the  masseter,  working  from  before  backwards.  Fig.  270. — Excision  of 
doubly  ligating  all  vessels  before  dividing  them.  P^^°  ^ 

Step  3. — Separate  the  lower  edge  of  the  gland  (submaxillary  portion)  from 
its  surroundings  by  blunt  dissection,  doubly  ligating  and  dividing  the  vessels. 
Step  4. — Expose  the  upper  end  of  the  anterior  portion  of  the  sternomastoid, 
open  its  sheath,  and  retract  the  muscle  backwards.  That  portion  of  the 
sheath  adherent  to  the  fascia  covering  the  parotid  must  be  removed  with  the 
tumor. 

Step  5. — By  blunt  dissection,  working  from  below  upwards  and  elevating  the 
lower  edge  of  the  gland,  expose  the  external  carotid  artery  as  it  passes  under  the 
stylohyoid  and  digastric  muscles.  Doubly  tie  and  divide  the  artery.  Mobilize 
the  tumor  and  gland  up  to  the  level  of  the  styloid  process. 

Step  6. — Separate  by  blunt  dissection  all  connections  between  the  tumor  and 
the  temporo-maxillary  joint.  Ligate  and  divide  the  temporal  vessels  at  the 
level  of  the  zygoma. 

Step  7. — Pull  the  gland,  etc.,  backwards,  expose  the  numerous  veins  which 
run  along  with  the  internal  maxillary  artery,  from  behind  the  neck  of  the 
lower  jaw  into  the  gland.  Doubly  ligate  this  leash  of  vessels  and  divide  them. 
Step  8.— Separate  by  blunt  dissection  the  posterior  and  pharyngeal  con- 
nections of  the  gland,  doubly  ligating  or  clamping  all  vessels  before  dividing 
them.  In  making  this  last  dissection  be  on  the  lookout  for  and  avoid 
injury  to  the  internal  jugular  vein. 


176 


PAROTID    GLAND 


Step  9. — Attend  to  hemostasis.  Close  the  wound  with  sutures  after 
providing  for  drainage. 

Any  enlarged  lymphatic  glands  near  the  parotid  ought  to  be  removed 
along  with  the  tumor.  The  operation  is  a  difficult  one,  and  ought  not  to  be 
attempted  by  the  inexperienced. 

Zarraga's  Method.  ("Journ.  de  Chir.,"  Sept.,  1912). — i.  From  the  tip  of 
the  mastoid  make  an  incision  downwards  along  the  anterior  edge  of  the  sterno- 
mastoid  to  a  point  a  little  below  the  angle  of  the  lower  jaw.  Continue  the 
incision  forwards  immediately  below  and  parallel  to  the  lower  jaw  until  the 
anterior  border  of  the  masseter  is  reached.  Continue  the  incision  upwards 
along  the  anterior  edge  of  the  masseter  to  terminate  on  the  zygoma. 


Fig.  271. — (Jojini.  de  Chir.) 

2.  Reflect  upwards  the  skin  flap  thus  outlined.  This  exposes  the  sterno- 
mastoid,  the  facial  nerve,  the  parotid,  the  masseter  and  the  lower  jaw  in  front 
of  it,  the  facial  artery,  the  zygoma. 

3.  With  elevator  and  knife  bare  the  bone  of  the  lower  jaw  just  in  front  of 
the  masseter  and  divide  it  with  Gigli's  saw.  Divide  the  masseter  at  its  zygo- 
matic insertion.     Divide  Steno's  duct. 

4.  Grasp  the  ascending  ramus  of  the  jaw  with  lion-jawed  forceps  and  dis- 
locate it  outwards  and  backwards,  at  the  same  time  dividing  the  internal 
pterygoid  muscle,  ligating  the  inferior  dental  vessels  and  dividing  the  tendon 
of  the  temporal  muscle  (Fig.  271). 

5.  Ligate  the  external  carotid  immediately  before  it  enters  the  parotid; 
ligate  the  internal  maxillary  as  it  passes  behind  the  condyle  of  the  inferior 
maxilla.    Ligate  the  superficial  temporal  and  the  posterior  auricular  arteries. 


SALIVARY   FISTULA  177 

6.  Remove  the  gland  and  the  ascending  ramus  of  the  jaw  together.  One 
at  this  time  can  see  if  the  pharyngeal  prolongation  of  the  parotid  is  adherent 
to  the  carotid  packet  and  if  necessary  separate  the  adhesions. 

Salivary  Fistula.— A  salivary  fistula  most  commonly  results  from  disease  or 
injury  of  Steno's  duct.  In  some  cases  a  stricture  is  present  distal  to  the  fistula 
and  if  this  is  dilated,  the  fistula  either  closes  spontaneously  or  after  its  orifice 
has  been  stimulated  by  the  cautery  or  revivified  and  sutured.  When  the  above 
simple  treatment  is  inappropriate  or  has  failed,  operation  becomes  necessary. 

I.  The  fistula  is  anterior  to  the  masseter  muscle. 

(A)  Von  Langenbeck's  Operation. — Make  the  proximal  portion  of  the  duct 
(i.e.,  the  segment  of  duct  next  to  the  parotid  gland)  prominent  by  passing  a 
probe  into  it,  through  the  fistula.  With  a  knife  or  scissors  separate  the  fistula, 
and  duct  from  their  surroundings,  leaving  them  attached  to  the  gland.  In  a 
convenient  location  pass  the  knife  from  the  wound  into  the  mouth,  perforating 
the  buccal  mucosa.  Pull  the  free  end  of  the  mobilized  duct  into  the  mouth 
through  the  perforation  in  the  mucosa  and  fix  it  there  with  sutures.  Close  the 
external  wound.  When  applicable,  the  above  is  the  best  operation  for  salivary 
fistula,  but  unfortunately  it  is  not  often  available,  as  the  unnatural  orifice  is 
usually  far  back  near  the  origin  of  Steno's  duct  behind  the  anterior  margin  of  the 
masseter. 

(B)  Degiiise^s  Operation. — From  the  fistula  make  two  perforations  into  the 
mouth,  about  }4.  inch  apart.  Through  these  openings  pass  the  two  ends  of  an 
elastic  ligature,  a  piece  of  lead  wire,  or  a  stout  silk  suture.  Fasten  together 
the  ends  of  the  ligature  in  the  mouth  so  as  to  exercise  pressure  on  the  included 


ft. 

Figs.  272  and  273. — Deguise's  operation. 

tissues.  Necrosis  of  the  tissues  follows  and  a  permanent  opening  into  the 
mouth,  is  assured.  Freshen  the  edges  of  the  cutaneous  fistula  and  unite  them 
by  sutures.  The  elastic  ligature  or  lead  wire  may  best  be  introduced  through  a 
cannula  which  is  made  to  perforate  the  cheek  from  within  outwards  (Figs.  272, 
273).  A  silk  suture  is  best  inserted  from  without  inwards  by  means  of  a  needle 
at  each  end. 

(C)  Kaufmann's  Operation. — Pass  a  cannula  (about  J4  inch  in  diameter) 
from  the  fistula  into  the  mouth  and  through  it  introduce  a  rubber  tube  or  seton. 
Remove  the  cannula,  leaving  the  seton  in  place.  Whenever  the  track  of  the 
seton  has  become  covered  with  epithelium,  remove  the  seton  and  close  the 
cutaneous  orifice  of  the  fistula. 

11.  The  fistula  is  situated  in  the  masseteric  portion  of  Steno's  duct. 
12 


178 


PAKOTID    GLAND 


(A)  Either  Kaufmann's  seton  or  Deguise's  method  of  double  puncture  may 
be  used,  but  neither  the  seton  nor  the  constricting  ligature  must  j)erforate  the 
masseter.  The  puncture  or  punctures  must  pass  from  the  lisUila  to  the  mouth 
by  tunnelling  between  the  masseter  and  the  skin. 

(B)  Von  Langenbeck's  method  may  be  used  if  a  sufficient  length  of  duct 
remains  attached  to  the  gland.     In  this  method  it  is  necessary  to  puncture  the 

masseter  and  pull  the  mobilized  portion  of  duct  through 
the  puncture  into  the  mouth.  Instead  of  being  punc- 
tured, the  masseter  may  be  divided  transversely,  and 
if  necessary  a  portion  of  the  ascending  ramus  of  the 
lower  jaw  may  be  cut  away  with  rongeurs  so  that  the 
defective  duct  may  gain  access  to  the  mouth. 

(C)  Plastic  formation  of  a  new  duct  (Braun's  opera- 
tion): Make  the  incision  A,  B  (Fig.  274).  Mobilize  the 
fistulous  orifice  by  dissecting  it  free  from  the  skin. 
The  incision  penetrates  all  the  tissues  of  the  cheek  except  the  mucosa  and 
masseter.  Retract  the  edges  of  the  wound,  exposing  the  outer  surface  of 
the  mucosa  (Fig.  275).  From  the  mucosa  construct  a  flap  with  its  pedicle  at 
the  edge  of  the  masseter,  of  length  sufficient  to  reach  from  the  masseteric  edge 


^'^r, 


*/^ 


Fig   274. — Braun's 
operation. 


275. — Braun's  operation. 

to  the  fistula.  Turn  this  flap  back  over  the  masseter;  suture  its  free  end  to  the 
fistula;  suture  its  upper  and  lower  edges  together  so  as  to  form  a  tube  lined  with 
epithelium  (Fig.  276).     Close  the  skin-wound. 

(D)  Grouse's  Operation. — This  operation  is  very  similar  to  that  of  Braun 
but  is  simpler  and  of  wider  application. 


270. 


Step  I. — Make  a  3  cm.  (i34  in.)  incision  through  the  skin  and  fat  straight 
downwards  from  a  point  2  cm.  below  the  zygoma  and  2  cm.  in  front  of  the  ear. 
This  avoids  injury  to  nerves  and  vessels.  Expose  the  fascia  covering  the  parotid 
and  make  a  i  cm.  incision  in  it. 


CROUSE  S    OPERATION 


179 


Fig.  277. — {Croiise,    ^arg.,   Gyn.    &   Ubsl.) 


Fig.  278. — {Crouse,  Surg.,  Gyn.  b"  Ohsl.) 


l8o  PAROTID   GLAND 

Step  2. — Grasp  the  lip,  turn  the  cheek  out  and  reflect  a  flap  of  mucosa,  about 
]/i  inch  wide  and  thick  enough  (^g  in.?)  to  be  reHably  viable,  beginning  near 
the  vermilion  line  of  the  upper  lip  and  running  back  to  slightly  behind  the 
level  of  the  second  upper  molar.     The  pedicle  of  this  flap  is  posterior. 

Step  3. — Introduce  a  curved  hemostat  through  the  external  incision  on  the 
cheek  and  pass  it  forwards  hugging  the  surface  of  the  masseter  and  force  it  into 
the  mouth  just  in  front  of  the  pedicle  of  the  intra-oral  flap  (Fig.  277).  Open  the 
forceps  and  dilate  the  tunnel.  Grasp  the  end  of  the  flap  in  the  forceps  and  pull 
it  through  the  tunnel.  Pass  a  No.  o  chromic  gut  suture  in  the  Lembert  fashion 
through  the  mucous  surface  of  the  flap  near  its  free  end  (Fig.  278)  and  through 
the  posterior  edge  of  the  incision  in  the  parotid  fascia.  Tie  the  suture  but  leave 
its  ends  long.  Pass  a  fine  forceps  from  the  external  wound  through  the  tunnel 
into  the  mouth  and  catch  with  it  the  middle  of  a  ligature  of  No.  5  chromic  gut. 
Pull  this  thread  through  the  wound  and  tie  the  long  ends  of  the  fine  suture  to 
its  loop  leaving  the  long  ends  of  the  coarse  ligature  in  the  mouth.  The  mucosal 
flap  assumes  a  tubular  form  around  the  coarse  ligature.  Close  the  external 
wound.  Grouse  has  used  his  operation  five  times  with  success  (Surg.,  Gnti. 
and  Obst.,  May,  191 5). 

Anastomosis  between  the  Parotid  and  Submaxillary  Glands. — In  cases  in 
which  lesions  of  Steno's  duct  seriously  interfere  with  excretion  from  the  parotid 
Ferrarini  (Zent.  f.  Ghir.,  13,  June,  19 14)  has  shown  the  possibility  of  estabhshing 
drainage  through  a  parotid-submaxillary  anastomosis. 

Expose  the  submaxillary  gland  by  an  incision  parallel  to  and  below  the 
horizontal  ramus  of  the  lower  jaw.  Continue  the  incision  back  to,  and  around 
the  angle  of  the  jaw  so  as  to  freely  expose  the  lower  part  of  the  parotid.  Open 
the  capsule  of,  and  mobilize  bluntly,  the  submaxillary  gland.  Isolate  and 
mobilize  the  lower  end  of  the  parotid  behind  the  angle  of  the  jaw.  Make 
incisions  in  or  pare  off  corresponding  portions  of  the  two  glands  and  suture  the 
raw  surface  of  one  gland  to  the  raw  surface  of  the  other.  Close  the  external 
wound.  This  operation  has  been  an  experimental  success  but  has  not  been 
used  clinically. 

lanni  (Internat.  Abst.  of  Surg.,  ^lay,  1919)  advises  Leriche's  resection  of 
the  auriculotemporal  nerve  to  prevent  secretion  from  the  Parotid  in  old  cases 
of  fistula  where  plastic  operation  is  improper.  After  the  auriculotemporal 
nerve  has  passed  around  the  posterior  surface  of  the  neck  of  the  lower  jaw  it 
enters  the  substance  of  the  upper  part  of  the  parotid  and  passes  upwards  in 
front  of  the  auditory  meatus  behind  the  temporal  arterj^  and  vein  "in  a  fibrous 
sheath  which  renders  its  exposure  difficult  and  its  isolation  troublesome'* 
(Poirier  and  Charpy).  In  this  part  of  its  course  besides  supplying  branches 
to  the  gland  it  gives  off  branches  which  anastomose  with  the  superior  terminal 
branches  of  the  facial  nerve. 

The  Operation. — Beginning  at  the  Zygoma  make  a  vertical  incision  3  cm. 
(i^^  in.)  long  immediately  in  front  of  the  tragus,  and  so  expose  the  temporal 
artery.  Note  the  extra-glandular  portion  of  the  nerve  parallel  to  and  behind 
the  artery.  Follow  the  nerve  downwards  into  and  through  the  gland  tissue. 
When  it  is  fully  isolated,  the  portion  of  the  nerve  trunk  freed  from  its  surround- 
ings is  about  4.5  cm.  (1%  in.)  long  and  the  small  secretory  branches  which 


INTRANASAL   TUMORS  l8l 

Stimulate  the  gland  are  visible.     Evulse  the  central  end  of  the  nerve.     Secretion 
ccmtinues  for  some  days  after  operation. 

Olivier  (Lyon  Chir.,  XVI,  No.  2)  had  perfect  results  in  three  cases.  He 
writes  that  the  operation  is  easy  but  that  the  resection  must  be  extensive  enough 
to  get  all  the  parotid  branches.  These  branches  leave  the  nerve  trunk 
behind  and  a  little  internal  to  the  neck  of  the  condyle  so  that  the  dissection 
must  be  deej). 


CHAPTER  XVIII 

OPERATIONS  UPON  THE  NOSE 
EXCISION   OF  INTRANASAL  MALIGNANT  TUMORS 

DENKER'S   TRANSM AXILLARY   METHOD* 

Step  I . — With  blunt  hooks  pull  the  angle  of  the  mouth  and  the  upper  lip 
upwards  and  outwards.  Beginning  opposite  the  wisdom  tooth  on  the  affected 
side  make  an  incision  through  the  gum  of  the  upper  jaw  to  a  point  near  the 
frenum  of  the  upper  lip.  The  incision  should  be  slightly  curved  upwards.  With 
an  elevator  separate  the  soft  parts  from  the  upper  jaw  until  that  bone  is  exposed 
nearly  to  the  lower  margin  of  the  orbit  and  the  pyriform  aperture  of  the  nose 
is  laid  bare. 

Step  2. — With  a  fine  elevator  or  dissector,  beginning  at  the  pyriform  aper- 
ture, separate  the  mucous  membrane  from  the  outer  wall  of  the  lower  and  mid- 
dle sinuses  of  the  nose  and  partly  from  the  floor  of  the  nose.  Continue  this 
separation  backwards  to  the  posterior  limits  of  the  antrum  of  Highmore.  If 
the  lower  turbinated  bone  is  not  involved  in  the  tumor,  remove  it  with  strong 
scissors.     Temporarily  pack  with  gauze  for  hemostasis. 

Step  3. — With  chisel  and  rongeur  remove  the  external  bony  wall  of  the 
antrum  of  Highmore.  If  the  mucosa  lining  the  interior  surface  of  this  wall  is 
healthy  incise  it  freely  so  as  to  gain  free  access  to  the  sinus;  if  it  is  involved  in 
the  growth,  extirpate  it  with  the  growth.  With  chisel  and  rongeur  remove 
completely  the  inner  or  nasal  wall  of  the  antrum,  both  the  bone  and  the  mucosa. 

Step  4. — With  scissors  or  probe-pointed  knife  remove  the  mucosa  of  the 
outer  wall  of  the  nose  (already  separated  in  Step  2).  If  the  tumor  has  arisen 
from  the  middle  sinus  of  the  nose  it  generally  will  come  away  with  the  nasal 
mucous  membrane.  Free  access  is  now  attained  to  the  ethmoidal  and  sphe- 
noidal sinuses  which  can  be  treated  according  to  circumstances. 

Step  5. — Pack  the  wound  with  gauze.  Suture  the  oral  wound.  Keep  the 
mouth  clean  with  washes.     Remove  the  pack  after  three  or  four  days. 

The  above  operation  is  not  suitable  for  cases  of  tumors  arising  from  the 
nasopharynx,  retro-maxillary  or  pterygo-palatine  fossae. 

*  "Aliinchener  med.  Wochenschrift,"  1906,  No.  20. 


182 


OPERATIONS  UPON  THE  NOSE 


RHINOPHYMA    (ACNK    HYPKRTROPHICA) 

This  deforming  disease  must  be  treated  by  ojjeration.  If  the  tumors  are 
pedunculated  their  removal  requires  no  special  description,  if  they  are  extensive 
and  non-pedunculated  proceed  as  follows: 

Give  a  general  anesthetic. 

Step  I. — Through  the  anterior  nares  introduce  gauze  strips  and  so  plug  the 
posterior  two-thirds  of  the  nose,  leaving  the  anterior  portion  free.  This  pre- 
vents the  inflow  of  blood.     Plugging  of  the  posterior  nares  will  do  as  well. 

Step  2. — Put  the  forefinger  of  the  left  hand  into  one  nostril  as  a  guide. 
Make  an  incision  down  to  but  not  into  the  cartilage,  all  round  the  growth  from 
the  middle  line  outwards  (Fig.  279). 

Be  sure  to  leave  as  much  skin  as  possible  near  the  opening  of  the  nares  to 
avoid  subsequent  stricture. 


js: 
Figs.  279  and  280. 


-Rhinophyma.     (Laurens.) 


Step  3, — Seize  the  median  edge  of  the  tumor  mass  with  forceps  and  entrust 
these  to  the  assistant  (Fig.  280).  With  knife  or  scissors  shave  off  all  the  dis- 
eased tissues  within  the  circle  of  the  incision.  Attend  to  hemostasis  with 
forceps,  ligature,  pressure  with  hot  pads  or  the  thermo-cautery. 

Step  4. — Repeat  Steps  3  and  4  on  the  opposite  side. 

Step  5. — Remove  the  nasal  plugs.  Introduce  short  drainage  tubes  into 
each  nostril.  Cover  the  wounds  with  rubber  tissue,  perforated  oiled  silk  or 
silver  foil.  Apply  compressive  dressings.  Field  (Journ.  A.  M.  A.,  June  14, 
1919)  operates  in  two  sittings — excising  first  one-half  and  later  the  other.  He 
uses  skin  grafts.  The  results  in  time  are  very  good.  Skin  grafting  is  rarely 
necessary.  Major  Seelig  heartily  condemns  skin  grafts  as  unnecessary  and 
the  cause  of  subsequent  disfigurement.  He  urges  that  the  redundant  tissue 
be  not  shaved  off  too  deeply,  otherwise  all  sebaceous  gland  rests  are  removed 
and  no  nidusus  of  epithelium  left  for  formation  of  new  skin. 

Angioma  of  Nose. — Angiomata  of  the  nose  are  not  uncommon  and  may 
require  no  treatment.  Often,  however,  they  are  so  disfiguring  as  to  pre- 
vent their  possessors  from  earning  a  livelihood. 


EPITHELIOMA    NOSE 


183 


When  small,  angiomata  may  be  treated  by  freezing  (liquid  air,  carbon- 
dioxide  snow),  by  electrolysis,  by  application  of  nitric  acid,  by  ignipuncture, 
etc.,  but  a  large,  pulsating  tumor  demands  excision.  In  the  patient  shown  in 
Figs.  281  and  282  ("Lancet,''  March  23,  1912),  Mr.  Battle  ligated  the  external 
carotid,  the  superior  thyroid  and  the  facial  arteries  on  both  sides  and  then  cut 
away  the  nasal  disease  leaving  the  bony  and  cartilaginous  framework  of  the 
nose  exposed.  About  three  weeks  later  the  central  portion  of  the  lip  was  excised 
and  later  the  nasal  wound  was  covered  by  a  flap  taken  from  the  forehead  in 
the  Indian  method.     The  result  was  gratifying. 


Fig.  2&i.~{Bdtlle:) 


Fig.  282.— [Battle.) 


Epithelioma  of  Nose. — In  order  to  excise  not  merely  the  tumor  but  at  least 
^  inch  of  apparently  healthy  tissue  all  around  and  in  one  piece  with  the 
lymphatic  nodes  next  in  order  Henry  Curtis  (Trans.  Royal  Soc.  Med.  Clin. 
Sect.,  April,  1914)  operated  as  follows:  (The  tumor  w^as  situated  on  the  left 
side  of  the  tip  of  the  nose,  the  submaxillary  glands  were  small  and  hard);  the 
incision  1-6  (Fig.  283)  was  made.  On  the  columella  the  cut  penetrated  to  the 
cartilage;  elsew^here  it  reached  the  bone  or  penetrated  the  nose  and  mouth. 
From  the  beginning  of  the  original  cut  in  the  median  line  of  the  upper  lip,  a 
second  incision  was  made  (1-7)  just  skirting  the  red  margin  of  the  lip  to  the 
left  angle  of  the  mouth,  and  then  vertically  down  (7-8)  to  reach  the  lower  bor- 
der of  the  mandible.  The  flap  outlined  by  the  cuts  8-7-1-2-3-4-5-6  included 
the  entire  left  nostril,  the  w^hole  thickness  of  the  cheek  and  exposed  both  the 
nasal  and  oral  cavities. 

An  incision  penetrating  the  skin  alone  was  now  made  between  the  points 
6  and  8  and  the  cheek  flap  was  removed  with  the  lymphatics  and  glands  en 
masse.  "Those  removed  consisted  of  the  left  maxillary  glands,  just  below  the 
orbit,  the  lymphatic  vessels  (and  ?  glands)  in  the  left  buccinator  region,  both 
submaxillary,  salivary  and  lymphatic  glands,  both  submental  glands,  and  the 


1 84 


OPERATIONS    UPON    THE   NOSE 


left  superficial  and  deep  cervical  glands."  To  expose  the  glands  below  the  jaw 
and  to  provide  a  flap  to  repair  the  defect  in  the  nose  and  cheek  the  incisions 
8,  5',  4',  3',  2'  were  made  and  the  outlined  flap  was  fixed  by  sutures  into  its 
new  bed.  A  split  made  in  the  flap  (Fig.  283  insert  2'-2"-x)  aided  in  fashion- 
ing the  new  nostril.  The  wound  in  the  neck  was  easily  closed.  The  result 
was  satisfactory  after  some  subsidiary  patching  operations  had  been  done. 


•.# 


...r 


Fig.  283. — Curtis'    operation.     {After   Curtis.) 


RHINOPLASTY 


Rhinoplasty,  or  the  reconstruction  of  the  nose,  is  called  for  in  cases  where 
the  nose  has  been  destroyed  by  disease  or  operation.  The  character  of  the 
operative  interference  required  varies  with  the  location  and  extent  of  tissue 
destruction. 

I.  The  destruction  is  confined  to  the  soft  structures  of  the  nose  but  the 
osseous  and  a  part  of  the  soft  structures  of  the  nose  remain. 

A.  A  relatively  small  portion  of  the  soft  parts  has  been  destroyed.  Figs. 
284,  285,  286,  287  sufficiently  e.xplain  the  correction  of  this  defect. 

1.  The  defect  is  confined  to  one  ala.  Fritz  Konig  ("Berlin,  klin.  Woch.," 
1902,  No.  7),  after  thoroughly  freshening  the  nasal  defect,  implanted  into  it  a 
properly  shaped  segment  consisting  of  the  whole  thickness  of  the  concha  of  the 
ear.     The  result  was  excellent. 

2.  The  defect  extends  beyond  the  ala  but  is  still  lateral. 

Langenbeck's  Operation. — From  the  sound  side  of  the  nose  reflect  a  skin- 
flap,  which  has  its  base  near  the  inner  angle  of  the  yee  of  the  affected  side 
(Figs.  288  and  289).  Suture  the  flap  thus  obtained  to  the  edges  of  the  defect, 
which  have,  of  course,  been  vivified  immediately  before.  Cover  the  raw  surface 
left  by  the  elevation  of  the  flap  with  Thiersch's  skin-grafts. 

Nelaton's  Operation. — This  is  similar  to  the  preceding,  but  the  flap  is  ob- 
tained from  the  cheek  (Fig.  290). 

3.  The  septum  is  absent. 


RHINOPLASTY 


i8s 


Dieffenbach's  Operation.— Make  a  flap  as  outlined  in  Fig.  291,  consist- 
ing of  the  whole  thickness  of  the  upper  lip.     Freshen  the  distal  end  of  the  flap, 


Figs.  284,  285,  286  and  287. — (Esmarch  and  Kowalzig.) 


Figs.    288,    28Q    and    2^0.— {Esmarch    and    Kowalzig.) 


Figs.  291  and  292. — {Esmarch  and  Kowalzig.) 


Figs.  293  and  294. — {Esmarch  and  Kowalzig.) 

turn  it  forwards,  and  suture  it  to  a  vivified  area  on  the  anterior  edge  of  the 
nasal  opening  (Fig.  292).     Close  the  wound  in  the  lip. 

Langenbeck  makes  a  flap  from  the  skin  of  the  upper  lip,  leaving  the  deeper 
structures  intact  (Figs.  293  and  294). 


i86 


OPERATIONS   UPON   THE   NOSE 


Both  of  the  above  methods  are  faulty  in  that  use  is  made  of  very  hairy 
skin,  and  annoyance  is  sure  to  result. 


Fig.   295. — Lexer's  operation. 

Lexer  makes  a  flap  from  the  mucous  and  submucous  structures  of  the  upper 
lip,  leaving  the  skin  intact  except  for  a  perforation  through  which  the  flap  is 


Fig.  296. — Lexer's  operation. 

brought  into  position  (Figs.  295  and  296).     Hueter  uses  a  flap  of  skin  obtained 
from  the  nose  itself  (Figs.  297  and  298). 


Figs.  297  and  298. — Hueter's  operation.     {Esmarch  and  Kowalzig.) 


4.  Much  of  the  end  of  the  nose  has  been  destroyed  as  well  as  the  cutaneous 
septum  and  much  of  the  cartilaginous  septum:  The  alae  nasi  are  drawn  up- 


CABOCHE  S    OPERATION 


187 


wards  meeting  in  a  mass  of  scar  tissue  attached  to  the  ends  of  the  nasal  bones. 
(La  Pr.  Med.  23,  Jan.,  191Q.) 

Caboche's  Operation. — Slop  i. — -Free  the  remains  of  the  alas  nasi  by  an 
incision  parallel  to  and  about  ^g  i'"'ch  from  their  lower  or  free  margin 
(Fig.  299),  and  penetrating  the  nasal  cavity.  Where  the  alae  were  ad- 
herent to  the  nasal  bones  there  is  much  scar  tissue.     Excise  the  scar  tissue. 


"wiTirrm'^ 


""'^Tnt^ 


Fig.   299. — {Cahoclie,  La  Pr.  Med.) 

The  result  is  the  formation  of  two  alar  flaps  (Fig.  302,)  with  external 
pedicles  and  a  considerable  wound  due  to  the  excision  of  all  the  scar  tissue  at 
the  level  of  the  lower  part  of  the  nasal  bones. 

Step  2. — Formation  of  new  septum:  (a)  Much  of  the  cartilaginous  septum 
is  present  and  on  it  is  part  of  the  cutaneous  septum.  Puncture  the  septum  at 
a  point  slightly  behind  the  future  pedicle  (Fig.  300).  From  this  puncture  divide 
the  septum  close  and  parallel  to  the  floor  of  the  nose  until  the  vomer  is  reached 


Fig.  300. — (Caboche,  La  Pr.  Med.) 


Fig.  301. — (Caboclie,  La  Pr.  Med.) 


as  demonstrated  by  increased  resistance  to  the  passage  of  the  Septotome. 
Separate  the  cartilage  from  the  vomer  for  a  sulflcient  distance  by  hitting  the 
handle  of  the  costotome  a  few  blows  with  the  heel  of  the  hand.  Divide  the 
cartilage  from  a  point  near  the  nasal  bones  downwards  and  backwards  to  reach 
the  incision  already  made — meeting  it  at  an  angle  of  about  45  degrees  (Fig.  300). 


1 88  OPERATIONS   UPON   THE   NOSE 

Pull  the  point  of  the  septal  flap  forwards  and  upwards  and  suture  it  to  the  peri- 
osteum of  the  nasal  bones. 

(b)  Only  the  bony  septum  is  present.  At  the  anterior  inferior  part  of  the 
septum  separate  the  muco-periosteum  on  both  sides  backwards  for  i  cm.  and 
upwards  for  2  cm.  Continue  the  separation  of  this  muco-periosteum  from  the 
floor  of  the  nose  outwards  as  far  as  possible.  This  forms  a  submucous  pocket 
on  each  side  of  the  septum,  open  anteriorly  and  bounded  internally  by  the 
denuded  septum,  inferiorly  by  the  denuded  floor  of  the  nose.  The  postero- 
superior  external  boundaries  are  formed  by  the  mobilized  muco-periosteum. 
Divide  the  periosteum  along  its  posterior  line  of  adhesion  to  the  floor  of  the 
nose  thus  forming  on  each  side  of  the  septum  a  rectangular  pedicle  capable  of 
nourishing  the  vomer  after  it  is  mobilized.  Divide  the  vomer  from  before 
backwards  along  the  floor  of  the  nose  for  a  sufficient  distance.  This  is  best 
done  with  an  electric  saw.  Divide  the  septum  from  a  point  near  the  nasal 
bones  to  the  posterior  extremity  of  the  incision  already  made  parallel  to  the 
nasal  floor.  Pull  the  point  of  the  flap  upwards  and  forwards  (Fig.  301,) 
to  be  inserted  between  the  nasal  bones  which  have  been  previously  separated 
from  each  other  by  a  forceps.  Perforate  the  nasal  bones  and  end  of  septal 
flap,  introduce  a  wire  suture  and  so  fix  them  together  (Fig.  301).  As  the  whole 
of  the  operation  is  very  bloody  it  is  wise  to  have  the  pharynx  packed  and  to 
provide  for  respiration  and  anesthesia  by  means  of  a  preUminary  laryngotomy 
(Butlin's)  or  the  use  of  a  pharyngeal  tube. 


Fig.  302. — {Caboche,  La  Pr.  Med.) 


Fig.  303. — {Caboche,  La  Pr.  Med.) 


Step  3. — Make  two  flaps  from  the  cheeks  (Figs.  302  and  303,)  sufficient  in 
size  to  more  than  cover  the  nasal  defect.  Usually  the  lower  end  of  these  flaps 
will  reach  to  the  level  of  the  angles  of  the  mouth  while  their  upper  ends  or 
pedicles  may  be  near  the  orbito-nasal  angles.  The  upp^  portions  of  the  flaps 
should  have  as  much  subcutaneous  fat  on  them  as  possible.  Do  not  suture 
the  lower  ends  of  the  flap  into  position  for  some  days.  Do  not  insert  any  drain 
or  pack  into  the  nose  lest  the- flaps  be  compiressed.  Divide  the  pedicles  after 
about  six  weeks.  Of  course  as  in  all  rhinoplasties,  one  or  more  secondary  or 
modeling  operations  may  be  required. 

B.  Practically  all  the  soft  structures  of  the  nose  are  absent. 

I.  Indian  Method. — In  this  operation  a  pedunculated  flap  is  taken  from 
the  forehead  and  sutured  to  the  nasal  defect. 


RHINOPLASTY  189 

The  Operation. — With  oiled  silk  make  a  model  of  the  flap  required.  Figs. 
304  to  311  represent  variously  shaped  flaps  which  have  been  used. 

Step  I. — Place  the  anesthetized  patient  in  the  Rose  or  Trendelenburg  pos- 
ture. Thoroughly  freshen  the  edges  of  the  nasal  defect  down  to,  but  not 
beyond,  the  points  into  which  the  new  alae  of  the  nose  are  to  be  inserted.  When 
considerable  skin  exists  over  the  bridge  of  the  nose,  Step  i  may  be  modified 
advantageously  as  follows:  From  the  nasal  bridge  reflect  the  flap  of  skin  A, 
B,  C  (Fig.  313)  and  turn  it  down  with  its  epidermal  surface  directed  towards 
the  nasal  cavity.  Freshen  or  pare  the  edges  of  the  nasal  defect  as  already  de- 
scribed. When  in  Step  3  the  forehead  flap  is  turned  down,  its  raw  surface  lies 
in  contact  with  the  raw  surface  of  the  flap  from  the  nasal  bridge,  an  epidermal 
lining  is  provided  for  the  new  nose,  and  thus  shrinking  is  obviated. 

Step  2. — Place  the  oiled  silk  model  on  to  the  forehead,  in  an  oblique  position, 
and  with  its  pedicle  so  placed  as  to  include  the  angular  artery.  Guided  by 
the  model  as  to  shape  and  size,  cut  a  flap  from  the  forehead.     The  flap  con- 

FiG.  304.  Fig.  305.  Fig.  306.  Fig.  307. 


Fig    308.  Fig.  309.  Fig.  310.  Fig.  311. 

Figs,  304  to  311. — {Esmarch  and  Kowalzig.) 

sists  of  all  the  structures  down  to  the  bone.  With  sutures  lessen  the  size  of 
the  defect  left  in  the  forehead;  cover  such  open  wound  as  may  be  left  with 
skin-grafts. 

Step  3. — Turn  the  forehead  flap  downwards  with  its  epidermal  surface  for- 
wards, being  careful  not  to  twist  the  pedicle  too  severely.  As  this  step  is  being 
carued  out  it  may  be  necessary  to  lengthen  the  lateral  incisions  which  bound 
the  pedicle.  Fig.  312  shows  a  well-designed  pedicle.  Attention  to  the  pedicle 
is  of  prime  importance  because  too  great  torsion  means  interference  with 
the  blood-supply,  and  more  particularly  with  the  drainage  of  the  flap.  It  is 
wise  to  make  numerous  shallow  scratches  through  the  epidermis  of  the  flap; 
these  permit  of  lymphatic  drainage.  (See  chapter  on  Plastic  Operations.) 
Fold  on  itself,  laterally,  that  portion  of  the  flap  which  is  to  form  the  new  septum 
of  the  nares  and  maintain  this  fold  by  one  or  two  stitches  (Fig,  314).  Fold 
on  themselves  the  two  lower  angles  of  the  flap  which  are  to  form  the  alae  of  the 
nose  and  maintain  the  folds  by  means  of  mattress  sutures. 

Step  4. — Suture  the  raw  edges  of  the  new  alae  of  the  nose  into  their  proper 
position  in  the  nasal  defect.     Do  the  same  with  the  new  nasal  septum.     Suture 


IQO 


OPERATIONS    UPON    THE    NOSE 


Fig.  312. — {Esmarch  and  Kowalzig.) 


Fig.  313. 


Fig.  314. 


Fig.   315. — {Esmarch  and  Kowalzig 


Figs.   316    and    317. — (Monod   and    Vanverts.) 


RHINOPLASTY 


191 


the  rest  of  the  flap  in  position  (Fig.  315).  Do  not  use  too  many  sutures  near 
the  pedicle,  and  in  attempts  at  esthetic  effect  do  not  jeopardize  the  vitahty  of 
the  flap,  which  depends  on  the  freedom  of  the  pedicle.  If  the  flap  lives  and 
unites  in  its  new  position,  any  defects  in  the  appearance  of  the  root  of  the  nose 
may  be  safely  attended  to  subsequently.  Keep  the  newly  formed  nasal  open- 
ings patent  by  means  of  dressed  rubber  tubes  or  cigarette  drains. 

2.  French  Method. — In  this  operation  pedunculated  flaps  taken  from  the 
cheekb  are  used  to  repair  nasal  defect.  Figs.  316  and  317  sufficiently  describe 
the  operation  as  performed  by  Nelaton. 

3.  Italian  Method. — Skin  for  the  repair  of  the  nasal  defect  is  obtained 
from  the  anterior  and  inner  aspects  of  the  upper  arm. 

Slep  I. — Dissect  from  the  upper  arm  a  flap  of  skin,  with  its  pedicle  pointing 
towards  the  elbow.  Flex  the  shoulder  and  bring  the  free  end  of  the  flap  in 
contact  with  the  vivified  edges  of  the  nasal  defect.  Unite  the  flap  to  the  nasal 
defect  by  means  of  sutures.  With  suitable  apparatus  (Fig.  318)  fix  the  head 
and  arm  so  that  they  maintain  a  constant 
relationship  to  each  other  until  union  has 
taken  place. 

Step  2. — When  the  flap  is  firmly  united 
to  the  edges  of  the  nasal  defect,  divide  its 
pedicle  and  complete  the  rhinoplasty  by 
forming  the  alae  and  septum  of  the  nose  out 
of  the  lower  portion  of  the  flap. 

II.  The  destruction  of  tissue  involves 
both  the  soft  parts  and  the  osseous  and  car- 
tilaginous supports  of  the  nose. 

A.  The  tip  of  the  nose  with  its  alae  and 
septum  are  intact  [Konig  (see  p.  200),  Israel 
(see  p.  201)]. 

B.  The  tip  of  the  nose  has  been  destroyed.     ^  „     /,r      ^      ^  rr 

.  fiG.  318. — {Monod  and  Vanverts.) 

Finger  Operation. — The  bony  framework 

of  the  nose  is  absent  and  the  soft  structures  are  more  or  less  destroyed  (Fig.  319). 

1.  By  paring  and  splitting  the  tissues,  vivify  the  edges  of  the  nasal  defect. 
Preserve  as  flaps  all  tissues  which  may  be  of  use  in  forming  the  new  nose. 
Vivify  the  bone  at  the  root  of  the  nose.     Apply  warm  gauze  to  the  wounds. 

2.  A.  Make  an  incision  through  the  skin  on  each  side  and  the  whole  length 
of  the  middle  finger  of  the  left  hand,  carefully  avoiding  injury  to  the  vessels. 
Reflect  the  skin  forwards  on  the  palmar  side  of  the  wounds  for  a  short  distance 
so  as  to  form  a  skin  flap  on  each  side  of  the  finger.  These  flaps  are  reflected 
only  from  the  sides  of  the  finger;  the  skin  on  the  palmar  surface  of  the  finger 
is  left  intact.  Form  similar  flaps  on  the  dorsal  side  of  the  wounds.  Through 
the  original  incisions  excise  the  carpo-phalangeal  articulation  and  divide  the 
flexor  and  extensor  tendons  as  well  as  the  ligaments  of  the  excised  joint,  being 
careful  not  to  injure  the  vessels.  Excise  the  finger  nail.  Remove  the  skin 
from  the  tip  of  the  finger.     Cut  off  the  distal  end  of  the  last  phalangeal  bone. 

B.  If  there  is  a  sufficiency  of  suitable  tissue  at  the  nasal  defect  to  form  an 
epithelial  lining  for  the  new  nose  then,  instead  of  the  lateral  incisions  on  the 


192 


OPERATIONS   UPON   THE   NOSE 


finger,  make  one  median  incision  and  from  it  reflect  flaps  of  skin  towards  the 
sides  of  the  finger. 


Fig.  319. — (McWilliams.) 


Fig.  320. — {McWilliams.) 


FIRM 
^'ATTACHMENl 
TO  FRONTAL 
BONt 


Fig.  321. — {McWilliams.) 


Fig.  322. — {McWilliams.) 


3.  Apply  the  cut  surface  of  the  bone  of  the  distal  phalanx  to  the  vivified 
bone  at  the  root  of  the  nose  and  fix  it  there  with  sutures. 

A.  If  method  A  has  been  adopted  in  step  2,  suture  the  palmar  flaps,  with 
their  epidermal  surfaces  directed  towards  the  nasal  cavity,  to  the  deeper  parts 


RHINOPLASTY 


193 


of  the  skin  flaps  around  the  nasal  defect.  This  forms  an  epitheHal  lining  to 
the  new  nose.  Suture  the  dorsal  flaps  to  the  edges  of  the  skin  flaps  around  the 
nasal  defect  (Fig.  320).  Support  and  immobilize  the  hand,  arm  and  head  with 
plaster  of  Paris  as  shown  in  Fig.  322. 

B.  If  method  B,  step  2,  has  been  adopted,  use  the  remnants  of  tissue  around 
the  nasal  defect  to  form  the  epithelial  lining  for  the  new  nose  and  cover  with  the 
skin  of  the  finger. 

4.  After  about  two  or  three  weeks  ligate  the  vessels  on  one  side  of  the  base 
of  the  finger  through  the  existing  lateral  incision;  a  few  days  later  ligate  the 
vessels  on  the  other  side  of  the  finger  (Mc Williams). 

5.  About  four  or  six  weeks  after  the  first  operation  amputate  the  finger  at 
the  base  of  the  proximal  phalanx.  Trim  the  phalanx  suitably,  flex  it  and  suture 
its  raw  end  to  a  bed  prepared  for  it  at  the  middle  of  the  lower  edge  of  the 
nasal  defect  so  that  it  now  forms  the  columella. 


Fig.  323. — (McWilliams.) 


As  some  necrosis  of  the  proximal  phalanx  often  occurs  after  amputation  it 
may  be  wise  to  defer  trimming  and  implanting  it  in  the  nasal  defect  until 
viability  is  assured  (Fig.  323). 

6.  After  healing  of  the  implants  is  complete  it  may  be  necessary  to  perform 
a  number  of  minor  plastic  operations  to  make  the  new  prominence  or  proboscis 
approximate  the  form  of  a  human  nose.  Figs.  319  and  320  show  a  patient  of 
McWilliams  before  and  after  operation.  Fig.  321  shows  the  position  of  the 
phalanges  in  the  same  patient. 

Nekton's  Operation. — Ch.  Nelaton  has  devised  an  ingenious  method  of 
rhinoplasty  which  requires  no  description  other  than  that  afforded  by  Figs. 
324,  325,326,327. 

Ch.  Nekton's  Operation  with  Transplantation  of  Costal  Cartikge. — Pre- 
liminary Operation. — Step  i . — With  oiled  silk  make  a  model  or  pattern  of  the 

13 


194 


OPERATIONS    UPON    THE    NOSE 


flap  necessary  to  cover  the  new  nose  with  skin.  Lay  the  model  on  the  forehead 
and  mark  its  outlines  with  silver  nitrate.  The  best  shape  and  position  for 
the  flap  are  shown  in  Fig.  328. 


J 

^m                 JT         "**    v^^^B^t> 

5 

^^KT"^]^^ 

.^gH, 

m'm:  ■ 

W%\ 

^WiM^'-'         .  ..i 

Figs,   324   and   325. — Nekton's   operation.     (Monod   and    Vauvcrts.) 

Step  2. — Without  injuring  the  perichondrium  excise  by  sharp  dissection  rhe 
whole  cartilage  of  the  eighth  rib.  Close  the  wound.  With  a  knife  pare  about 
one  inch  of  one  end  of  the  cartilage  (the  rib  end)  until  it  is  not  more  than  3^ 


Figs.   326  and  327. — N^laton's  operation.     {Monod  and    Vanverls.) 


inch  (3  mm.)  thick.  This  thin  portion  is  destined  to  form  the  new  column 
of  the  nose.  Where  the  pared  portion  of  cartilage  joins  the  unpared  portion 
cut  a  notch  nearly  through  the  cartilage  so  that  it  may  be  later  bent  in  fashioning 
the  nose. 


RHINOPLASTY 


195 


Step  3. — At  the  middle  of  the  distal  end  of  the  flap  outlined  with  silver 
nitrate  on  the  forehead,  make  a  cut  down  to  the  bone.  With  a  director  burrow 
a  tunnel  under  the  periosteum  from  end  to  end  of  the  flap  (Fig.  328).  Pass 
the  graft  of  cartilage  into  this  tunnel  in  such  fashion  that  its  thin  or  pared 
end  lies  subperiosteally  near  the  skin  wound  and  the  notch  at  the  junction  of 
the  pared  and  unpared  portions  faces  towards  the  skin.  Close  the  skin  wound. 
Apply  dressings. 

After  about  two  months  the  second  stage  of  the  operation  may  be  under- 
taken. 

Second  Stage  in  the  Operation. — Step  i. — Make  an  incision  all  round  the 
nasal  defect  except  at  its  lower  side  (Fig.  328).  This  cut  penetrates  to  the 
bone.  Reflect  the  soft  parts  between  the  incision  and  the  nasal  defect  towards 
the  latter  (Fig.  328). 


Figs.   328  and  329. — Nelaton's  operation.     {Laurens.) 

Step  2. — Reflect  the  flap  which  was  outlined  on  the  forehead  at  the  pre- 
liminary operation.  (Of  course  the  original  marking  has  disappeared  but  the 
model  has  been  kept  and  the  flap  has  been  again  traced  out  with  silver  nitrate.) 
The  implanted  cartilage  is  an  integral  part  of  the  flap.  Model  the  distal  end 
of  the  flap  as  in  Figs.  314  and  329.  Gently  twist  the  flap  into  position  and  fix 
it  by  sutures  as  shown  in  Fig.  315.* 

Schimmelbusch's  Operation. — Practically  as  in  the  Indian  method,  make 
a  forehead  flap  to  cover  the  defect  in  the  nose,  but  here  the  flap  consists  of  the 
outer  table  of  the  skull  as  well  as  skin  (Fig.  330) .  Protect  the  flap  with  gauze 
and  close  the  forehead  defect,  preferably  by  sliding  forwards  and  inwards  large 
flaps  of  the  scalp,  as  shown  in  Figs.  330  and  331.  Examine  the  reflected  flap 
of  bone  and  skin.  If  the  bone  is  not  splintered,  cover  the  whole  raw  surface  at 
once  with  Thiersch's  grafts,  protect  the  grafts  with  silver-foil  or  rubber  tissue, 
and  apply  gauze  dressings.  With  bandages  support  the  flap  against  the  head  and 
wait  untn  the  grafts  have  become  mature.  This  period  of  waiting  is  of  value 
in  that  the  flap  becomes  accustomed  to  receiving  its  nourishment  through  the 
pedicle  before  the  pedicle  is  disturbed  by  twisting,  but  as  the  flap  inevitably 


'In  Fig.  315  the  flap  has  been  taken  from  a  different  part  of  the  forehead. 


196 


OPERATIONS    UPON   THE    NOSE 


shrinks  during  the  delay,  it  is  very  necessary  that  it  be  made  at  least  one-sixth 
larger  than  the  defect  to  be  filled.  If  on  examination  the  bone  in  the  flap  is 
found  to  be  splintered,  delay  the  skin  grafting  until  any  necrotic  bone  is  thrown 
off  and  the  remainder  is  covered  by  granulations  (four  to  eight  weeks).  When 
the  raw  surface  of  the  flap  is  satisfactorily  covered  with  epidermis,  make  an 
incision  with  a  fine  saw^  in  the  middle  line  through  the  bone  in  the  flap,  so  that 
the  flap  can  now  be  bent  into  a  A  shape  (Fig.  331).     Mobilize  the  pedicle  of  the 


Figs.   330   and   331. — Schimmelbusch's   operation. 


flap  and  twist  the  latter  into  position.  With  sutures  unite  the  edges  of  the  flap 
to  the  freshened  edges  of  the  nasal  defect.  When  freshening  the  edges  of  the 
nasal  defect,  it  is  easy  to  form  flaps  of  tissue  which  may  be  used  to  form  a  septum 
for  the  nostril  (Fig.  332). 

E.  Lexer's  Operation. — As  Schimmelbusch's  operation  is  based  on  Konig's 
so  is  Lexer's  on  Schimmelbusch's.  Lexer  ("Archiv  fiir  klin.  Chir.,"  xcii,  749) 
recognizes  that  after  complete  rhinoplasty  it  is  most  difl&cult  to  breathe  through 
the  nose  because  of  contraction  of  scar  tissue.  Before  opera- 
tion the  disease  causing  the  deformity  (sj^Dhilis,  tubercu- 
losis) has  caused  much  destruction  of  tissue  and  recovery 
has  taken  place  by  the  filling  in  of  ulcerations  and  defects 
with  granulation  tissue  which  has  contracted  until  the 
pyriform  opening  has  become  small  and  distorted  and  nasal 
respiration  is  poor.  Before  attempting  to  form  a  new 
external  nose  the  freedom  of  the  air  passage  must  be 
assured.     The  operation  is  performed  in  many  stages. 

First  Stage. — Step  i. — With  knife,  scissors  and  chisel 
cut  away  all  scar  tissue  which  deforms  the  pyriform  open- 
ing and  obstructs  respiration. 
Step  2. — From  the  skin  around  the  opening,  from  remnants  of  the  alae  of 
the  nose,  etc.,  form  pedunculated  flaps  and  with  these  cover  the  defects  resulting 
from  the  excision  of  scar  tissue  (Fig.  s^s)-  These  flaps  may  be  held  in  place 
by  gauze  tampons  until  they  become  united  to  their  new  beds.  No  flaps  may 
be  taken  from  the  root  of  the  nose  above  the  aperture;  the  skin  here  must 
be  preserved  intact  for  use  later. 


Fig. 


332- 


RHINOPLASTY 


197 


Second  Stage — Preparation  of  Flap  from  Forehead. — This  procedure  is 
identical  with  that  of  Schimmelbusch  except  that  Lexer  at  once  covers  the  bone 
in  the  flap  with  skin  by  folding  the  flap  on  itself  (Figs.  334  and  335).  The 
wound  in  the  forehead  should  be  covered  by  Thiersch  or  Wolf  skin  grafts. 

Third  Stage. — (Three  or  four  weeks  Xdiitx .)— Step  i. — Formation  of  pedicle 
for  the  forehead  flap. 


Fig.  2,^2,-— {Lexer.) 


Fig.  334.— (Lexer.) 


The  flap  on  the  forehead  formed  in  stage  2  was  provided  with  a  broad 
pedicle  whose  base  was  on  a  level  with  the  eyebrows  (Fig.  334)-  Lexer,  in 
several  sittings,  gradually  step  by  step  continues  the  cuts  which  outline  the 
forehead  flap  downwards  until  they  reach  on  one  side  the  inner  angle  of  the 
eye,  on  the  other  side  the  nasal  opening  (Fig.  336).  From  the  latter  incision 
he  separates  the  skin  of  the  root  of  the  nose  from  the  bone  until  the  middle 
hne  is  reached  (Fig.  337)  and  it  becomes  possible  to  twist  the  pedicle  and  bring 
the  flap  into  position  without  tension. 


Fig.  2,3$-— {Lexer. 


Fig.  336. — {Lexer.) 


Fig.  337. — {Lexer,  Archiv  fiir 
Klin.  Cliir.) 


Step  2. — From  the  under  surface  of  the  forehead  flap  reflect  a  narrow  flap 
of  skin  to  form  the  septum  or  philtrum  of  the  new  nose  (Fig.  337)  and  through 
the  wound  thus  made  divide  the  bone  in  the  flap  longitudinally  so  as  to  fold 
the  bone  on  itself  as  in  Schimmelbusch's  operation. 

Step  3. — Freshen  the  edges  of  the  nasal  aperture  and  suture  the  forehead 
flap  in  proper  position  as  in  Schimmelbusch's  method. 

Fourth  Stage. — After  several  weeks  divide  the  pedicle  using  its  remnants  to 
help  to  repair  the  defect  between  the  eyebrows.     It  is  better  to  delay  this 


198 


OPERATIONS   UPON  THE   NOSE 


Step  as  long  as  possible,  as  when  the  pedicle  is  divided  the  transplanted  bone 
may  atrophy,  especially  in  syphilitics. 

The  result  of  the  operation  so  far  is  to  provide  the  patient  with  a  hideous 
excrescence  which  an  Ananias  or  an  enthusiast  might  call  a  nose.  Lexer  next 
proceeds  to  fashion  a  nose  from  the  excrescence. 

Fifth  Stage. — This  stage  is  begun  a  few  weeks  after  the  pedicle  has  been 
divided. 

I.  Formation  of  a  Depression  Between  the  Forehead  and  the  Nose. — At  the 
level  of  the  eyes  divide  the  scars,  in  front  of  the  angle  of  the  eye,  down  to  the 
bone  excising  any  disfiguring  scar  tissue.  The  cuts  made  for  this  purpose 
are  about  2  cm.  long.  From  these  cuts  on  each  side  separate  the  soft  parts 
from  the  bone  and  cut  away  all  oedematous  and  thickened  connective  tissue 
(Fig.  338,  b). 


b  c 

Fig.  338. — (Lexer.) 


The  subcutaneous  excision  of  scar  tissue  leaves  a  superfluous  amount  of 
skin  and  hence  it  is  necessary  to  convert  the  lateral  linear  incisions  into  ellipses 
(Fig.  338,  b)  by  excising  a  little  skin  from  their  anterior  margins  before  closing 
them  with  sutures. 

2.  Formation  of  the  Point  of  the  Nose. — The  tissues  about  the  point  of  the 
nose  have  sunk  down  and  are  too  voluminous. 

On  the  under  surface  of  the  new  nose  make  a  semilunar  incision  which 
reaches  near  the  base  of  the  septum  nasi  already  constructed  (Fig.  339,  a). 
Through  this  incision  pass  an  elevator  and  raise  the  skin  of  the  tip  of  the 
nose  from  the  underlying  bone  (obtained  from  the  forehead).  Obtain  a  fresh 
piece  of  bone  from  a  rib  or  tibia  of  the  same  patient  or  from  some  other  person 
who  has  required  an  amputation  or  resection.  Model  this  fragment  of  bone 
into  an  oval  with  a  shallow  groove  on  its  «on-periosteal  side  and  with  some- 
what of  a  convexity  on  its  periosteal  side.  Push  this  fragment  into  the  bed 
prepared  for  it  at  the  tip  of  the  nose,  periosteum  towards  the  surface,  in  such 
a  manner  that  it  lies,  subcutaneously,  on  the  bony  support  of  the  new  nose 
and  forms  a  rounded  tip  to  it.     The  pushing  in  of  the  fragment  of  bone  makes 


RHINOPLASTY  I 99 

the  semilunar  incision  gape  somewhat  but  this  open  wound  will  heal  by  granu- 
lation satisfactorily  (Figs.  338,  c,  and  339,  b  and  c).  For  a  few  days  it  may  be 
necessary  to  leave  a  pin  in  situ  perforating  the  fragment  of  bone  and  keeping 
it  from  being  misplaced. 

3.  Formation  of  the  Ala  of  the  Nose. — The  curved  incision  used  for  the 
implantation  of  bone  to  form  the  point  of  the  nose  in  healing  contracts  and 
leaves  a  small  notch  which  when  seen  from  the  side  acts  as  an  anterior  margin 
to  the  lower  edge  of  the  alae.  To  make  this  notching  more  distinct  and  to 
make  the  clumsy  lower  edge  of  the  new  nose  thinner,  subcutaneously  excise 
through  the  curved  incision,  the  soft  tissues  on  the  inner  side  of  the  bony 
support  of  the  nose  and  with  fine  forceps  cut  out  a  notch  in  the  bone  on  each 
side  so  as  to  widen  the  nostrils  (Figs.  338,  c,  and  339,  b).  Last  of  all  fashion 
the  outer  side  of  the  alae  by  excising  a  small  amount  of  skin  as  in  Fig.  338,  d, 
but  in  suturing  this  wound  stitch  its  posterior  cutaneous  edge  not  to  its  anterior 
cutaneous  edge  but  to  the  subcutaneous  tissue  in  front  of  the  wound,  thus 
obtaining  a  more  or  less  sightly  indentation. 

III.  The  destruction  of  tissue  involves  only  the  osseous  and  cartilaginous 
framework  of  the  nose,  the  surface  being  left  intact. 


a  be 

Fig.  339. — (Lexer.) 

Finney's  Operation.- — Step  i. — Cut  away  the  nail  and  its  matrix  from  the 
ring  finger  of  the  left  hand.  Remove  the  skin  from  the  back  of  the  finger 
up  to  its  middle  joint.  Denude  the  tip  of  the  finger  completely,  leaving  the 
tip  of  the  bone  bare.     Stop  bleeding. 

Step  2. — Introduce  a  tenotome  into  the  nose  and  divide  all  the  cicatricial 
connections  between  the  retracted  tip  of  the  nose  and  the  frontal  and  superior 
maxillary  bones.  Pull  the  soft  parts  of  the  nose  forwards  into  the  best  possible 
position.  Do  not  cut  the  skin.  Vivify  the  inner  surface  of  the  dorsum  of  the 
nose  in  the  middle  line. 

Step  3. — Introduce  the  prepared  ring  finger  into  the  nose  in  such  fashion 
that  the  tip  of  the  exposed  phalanx  lies  in  contact  with  the  nasal  process  of 
the  frontal  bone  and  the  raw  surface  of  the  dorsum  of  the  finger  is  in  contact 
with  the  raw  median  surface  of  the  inside  of  the  dorsum  of  the  nose.  Hold 
the  finger  in  position  with  stitches  uniting  the  edges  of  the  finger  wound  to 
the  free  border  of  the  tip  of  the  nose. 

Step  4. — Hold  the  hand  in  position  by  means  of  adhesive  strips  and  plaster 
of  Paris  for  too  weeks. 

Step  5. — (Two  weeks  later).  Disarticulate  the  finger  at  the  metacarpo- 
phalangeal joint.     Apply  dressings. 

Step  6. — (One  week  later  than  Step  5).     Split  the  tissues  in  the  middle 


200 


OPERATIONS  UPON  THE  NOSE 


line  over  the  nasal  spine  of  the  superior  maxilla.  Flex  the  finger  at  the  proximal 
phalangeal  joint.  Insert  the  free  end  of  the  proximal  ])halanx  into  the  wound 
made  over  the  nasal  spine  of  the  superior  maxilla  and  fix  it  there  with  sutures. 
The  proximal  phalanx  forms  the  column  of  the  nose;  the  two  other  pha- 
langes form  the  dorsal  support.  Later  some  minor  operations  will  be  neces- 
sary to  narrow  the  new  column  of  the  nose  and  to  improve  appearances. 

Konig's  Operation. — This  operation  was  originally  devised  for  the  cor- 
rection of  saddle-nose,  but  it  is  also  of  great  value  in  the  treatment  of  cases 
where  the  soft  parts  are  absent  as  well  as  the  hard.  The  operation  as  here 
described  is  that  done  for  saddle-nose;  the  modifications  required  when  the 
soft  parts  are  absent  are  so  self-evident  that  they  will  not  be  mentioned. 

Step  I. — Make  a  transverse  incision  across  the  seat  of  the  saddle  (A,  B, 
Fig.  340).     Pull  the  tip  of  the  nose  down  into  correct  position. 


Figs.  340,  341  and  342. — Konig's  operation. 


Step  2. — From  the  forehead  turn  down  the  vertical  flap  D  CFigs.  341  and 
342)  and  suture  its  free  extremity  to  the  point  C  at  the  tip  of  the  nose.  This 
flap  is  3^  inch  wide  and  is  made  by  cutting  through  the  soft  parts  with  a  knife, 
introducing  a  chisel  through  the  upper  part  of  the  wound,  and  thus  elevating 
a  long  narrow  strip  consisting  of  skin,  periosteum,  and  the  outer  table  of  the 
skull.     The  bone  in  the  flap  gives  firmness  to  the  new  nose. 

Step  3. — After  the  Indian  fashion,  reflect  from  the  forehead,  a  skin-flap 
E,  F,  G  (Fig.  341),  and  turn  it  down  so  as  to  cover  the  nasal  defect  A,  B,  C 
(Figs.  341  and  342),  as  well  as  flap  D. 

The  results  obtained  from  this  operation  or  some  of  its  modifications  have 
been  very  satisfactory. 

Author's  Method. — This  is  suitable  in  cases  where  the  nasal  bones  and  the 
surface  structures  are  intact  but  all  the  cartilaginous  septum  has  been  destroyed. 

Step  I. — Without  injuring  the  perichondrium  excise  by  sharp  dissection 
thin  strips  of  cartilage  from  eighth  rib.     The  strips  should  be  about  i^i  inches 


RHINOPLASTY  20I 

long,  3-^  inch  wide  and  }  i,'  inch  thick.  Preserve  these  in  warm  salt  solution. 
Close  the  wound. 

Step  2. — With  a  tenotome  introduced  either  through  the  skin  or,  as  in  Finney's 
operation,  through  the  nose,  divide  the  cicatricial  connections  of  the  nose  to 
the  pyriform  aperture.     Pull  the  nose  forwards  into  as  good  position  as  possible. 

Step  3. — Introduce  a  tenotome  through  the  skin  in  the  middle  line  of  the 
nose  just  below  the  osseous  nasal  bridge.  From  the  puncture  make  a  tunnel 
between  the  skin  and  the  mucosa  on  each  side  down  to  the  junction  of  the 
nasal  alae  and  the  upper  lip,  where  the  skin  is  again  perforated.  With  an  eyed 
probe  or  a  forceps  pull  a  thread  and  by  means  of  the  thread  pull  a  strip  of 
cartilage  through  each  tunnel.  Do  not  permit  the  ends  of  the  cartilage  to 
protrude  through  the  skin  punctures.  The  strips  of  cartilage  act  as  splints  or 
braces  for  the  nose.  Of  course  it  is  easy  to  introduce  a  strip  of  cartilage  at  any 
place  where  it  will  do  most  good. 

Israel's  Operation. — This  is  merely  a  modification  of  Konig's  method, 
but  gives  better  cosmetic  results.  The  flap  D  (Fig.  342)  is  made  narrow, 
being  only  about  3^^  inch  wide,  and  when  turned  down  and  its  free  end  sutured 
in  place,  exactly  as  in  Konig's  operation,  it  is  left  uncovered  by  any  other 
flap.  After  a  short  time  the  raw  surface  of  the  flap  becomes  covered  by  granu- 
lation tissue  and  the  epidermis  spreads  over  it.  The  local  condition  is  now  the 
following. 

The  tip  of  the  nose  is  in  normal  position.  The  skin  and  bone  flap  D  (Fig. 
342)  bridges  over  the  defect  created  by  the  incision  A,  B  (Fig.  340),  and  also 
the  undivided  skin  at  the  root  of  the  nose.  Whenever  flap  D  has  become 
well  healed,  draw  it  slightly  to  one  side;  make  a  vertical  median  incision  through 
the  skin  at  the  root  of  the  nose  above  the  defect.  Elevate  this  skin  on  each 
side  of  the  median  incision,  bring  the  edges  up,  and  suture  them  to  the  vivified 
edges  of  the  new  nasal  bridge  (flap  D,  Fig.  342). 

Von  Mangold's  Operation. — Step  i. — Make  a  small  transverse  incision 
across  the  middle  line  through  the  skin  at  the  glabella.  With  a  Kocher  sound 
or  blunt  dissector  burrow  a  tunnel  under  the  skin,  in  the  middle  line  down  to 
the  point  of  the  nose. 

Step  2. — Expose  by  incision  the  seventh  or  eighth  costal  cartilage.  Excise 
a  plate  of  cartilage,  with  its  perichondrium,  about  i^^  inches  long,  %  inch  wide, 
and  3^  inch  thick. 

Step  3. — Push  the  excised  plate  of  cartilage  into  the  subcutaneous  tunnel 
prepared  on  the  nose.  The  side  of  the  graft  which  has  no  perichondrium 
ought  to  be  directed  towards  the  skin.     Close  the  little  wound  with  sutures. 

Step  4. — Make  a  small  incision  through  the  skin  in  the  grooves  to  the  out- 
side of  each  ala  of  the  nose.  Through  these  incisions  implant  a  thin  strip 
of  costal  cartilage  in  each  ala. 

Von  Mangold  was  able  to  form  good  nares,  to  correct  saddle  shape  and  to 
obtain  a  rectilinear  nose,  but  it  was  necessary  to  lengthen  and  improve  the 
shape  of  the  organ  at  a  second  operation  after  an  interval  of  five  months. 

Second  Operation. — Through  an  inverted  V-shaped  incision  (apex  of  V 
in  middle  line  at  root  of  nose,  legs  of  V  coming  down  on  each  side  of  the  nose) 
detach  the  soft  structures  of  the  nose  and  with  them  the  cartilaginous  graft. 


202 


OPERATIONS  UPON  THE  NOSE 


Fig.   343. — (Marshall,   Journ.   A.   M.   A.) 


FiG._344. — (Marshall,  Journ.  A.  M.  A.) 


MARSHALL  S   OPERATION 


203 


from   the  subjacent  structures.     Carefully  apply  the  upper  end  of  the  graft 

of  cartilage  into  the  angle  between  the  glabella  and  the  root  of  the  nose.     Suture 

the  wounds. 

External  lateral  deflections  of  the  nose  commonly  the  result  of  accidents  or 

blows  are  often  so  disfiguring  as  to  interfere  seriously  with  the  bearer's  chances 

of  earning  his  livelihood. 

Marshall's  Operation. — ("Journ.  A.  M.  A,,"  Jan.  18,  1913.) 

Step  I. — With  a  tenotome  puncture  the  skin  over  the  nasal  process  of  the 

superior  maxilla  where  the  elevation  which  makes  the  nasal  prominence  begins. 

Introduce  a  chisel  about  j^f  e  inch  wide,  through  the  puncture,  and  divide  the 


Fig.  345. — {Marshall,  Journ.  A.  M.  A.) 


process  without  injuring  the  nasal  mucosa  (Fig.  343).  The  division  of  bone  may 
be  accomplished  as  widely  as  necessary  without  enlarging  the  skin  incision. 
Apply  pressure  to  the  wound  for  purposes  of  hemostasis. 

Step  2. — Do  the  same  on  the  opposite  side. 

Step  3. — Introduce  one  blade  of  an  Ashe  septal  forceps  (better  a  heavier 
forceps  with  longer  blades)  into  the  nares,  the  other  blade  being  outside,  and 
complete  by  fracture  the  mobility  of  the  nasal  process  along  its  entire  line,  for 
the  upper  part  of  the  nasal  process  can  usually  be  made  mobile  at  the  sutures 
along  the  lacrimal  and  the  nasal  bones  on  the  corresponding  side. 

Step  4. — Do  the  same  on  the  opposite  side. 

Step  5. — If  there  is  a  nasal  obstruction  through  malposition  of  the  septum, 
seize  the  septum  with  the  same  forceps  and  force  it  into  correct  position. 


204  TORTICOLLIS.       WRY    NECK.       CAPUT    OBSTIPUM 

Step  6. — If  the  nose  is  not  yet  straight  the  defect  probably  lies  at  the  suture 
between  the  frontal  and  upper  extremities  of  the  two  nasal  bones  and  both  proc- 
esses of  the  superior  ma.\illa.  Straighten  this  faulty  angle  "by  a  sharp  stroke 
with  the  mallet  at  this  point  guarded  by  a  rubber-covered  lead  plate,  the  force 
being  directed  downwards  from  the  frontal  bone,  but  towards  the  obtuse  angle 
(that  is,  against  the  deflected  side).  Elevation  can  be  assisted  sometimes  to 
advantage  with  a  large  urethral  sound." 

Step  7. — Dress  the  wounds  with  collodion.  Occasionally  Marshall  inserts 
nasal  splints  for  24  hours.  The  nose  ought  to  remain  absolutely  straight  with- 
out being  held  in  position.  Do  not  use  apparatus  to  hold  the  nose  in  position, 
such  is  uncomfortable  and  gets  out  of  place  to  such  a  degree  as  to  do  more 
harm  than  good.  Marshall  instructs  his  patients  to  keep  a  moderate  pressure 
on  the  originally  deflected  side  for  several  days  so  as  to  obviate  any  tendency  to 
recurrence  of  the  deformity.  Figs.  344  and  345  show  a  patient  before  and  after 
operation. 


CHAPTER  XIX 

TORTICOLLIS.  WRY-NECK.   CAPUT   OBSTIPUM 

There  are  several  methods  of  operating  on  torticollis. 

(a)  Subcutaneous  tenotomy  of  the  sternal  and  cla\acular  portions  of  the 
sternomastoid.  This  operation  is  rarely  performed,  as  its  only  advantage 
lies  in  the  absence  of  scar,  while  its  disadvantages  are  danger  and  incom- 
pleteness. 

{h)  Open  section  of  the  same  structures,  plus  division  of  all  bands  of  fibrous 
tissue  which  obstruct  reduction  of  the  deformity. 

(c)  Tendon  lengthening. 

id)  Excision  of  the  degenerated  sternomastoid  (Mikulicz). 

WTien  the  torticollis  is  of  the  spasmodic  variety,  the  follo^\•ing  methods 
have  been  ad\-ised: 

{e)  Division  or  excision  of  the  spinal  accessor}-  nersx. 

(/)  Multiple   myotomy    (Kocher). 

Open  Tenotomy  of  Sternomastoid. — The  favorite  site  for  dividing  the 
muscle  is  J-^  to  ^^  inch  above  the  clavicle.  The  skin  incision  may  be  vertical, 
oblique,  or  transverse;  probably  the  oblique  is  best.  Beginning  at  the  outer 
edge  of  the  sternal  attachment  of  the  sternomastoid,  make  an  incision  i  to  i)^ 
inches  in  length,  passing  upwards  and  outwards  to  the  middle  of  the  anterior 
margin  of  the  cla\-icular  portion  of  the  muscle.  Retraction  of  the  woimd  ex- 
poses both  portions,  which  are  easily  isolated  and  divided  without  danger  toother 
structures.  Rotate  the  head  firmly  towards  the  sound  side,  keeping  the  shoulder 
of  the  affected  side  steady.  This  manoeuvre  puts  all  other  contracted  structures 
on  the  stretch.  Divide  all  such,  even  down  to  beside  the  carotid  packet  of 
vessels.  Attend  carefully  to  hemostasis.  Suture.  Dress.  Lorenz  advises 
forcible  overcorrection  before  the  patient  comes  out  of  the  anesthesia.  The 
corrected  or  overcorrected  position  must  be  retained  either  by  an  extension 
apparatus  or  by  means  of  a  proper  collar.     After  healing  has  taken  place,  massage, 


WRY    NECK  205 

exercise,  and,  for  a  time,  the  use  of  some  orthopedic  apparatus,  such  as  Sayre's, 
are  requisite. 

Muscle  Lengthening. — Thelwell  Thomas  ("Lancet,"  March  9,  1912)  has 
obtained  good  results  by  muscle  lengthening.  It  does  away  with  long  and  tire- 
some after-treatment  as  he  does  not  use  any  retentive  apparatus.  Make  a 
transverse  incision  over  the  lower  third  of  the  sternomastoid.  Expose  the 
sternomastoid  and  isolate  a  sufficient  segment  of  it.  Estimate  how  much  the 
affected  muscle  is  shorter  than  its  fellow.  Split  the  affected  muscle  longitudi- 
nally for  a  distance  equal  to  a  little  more  than  half  the  amount  of  the  shortening. 
At  the  lower  end  of  the  vertical  incision  divide  the  anterior  portion  of  the 
muscle  transversely.  At  the  upper  end  of  the  vertical  incision  divide  the  pos- 
terior portion  of  the  muscle.  Suture  the  ends  of  the  muscle  with  chromicized 
catgut.  Close  the  wound.  It  is  often  necessary  to  divide  bands  of  deep  fascia 
as  well  so  as  to  obtain  correction. 

Myomectomy. — Mikulicz's  Operation. — In  severe  cases  of  torticollis  Mikulicz 
advises  excision  of  the  lower  two-thirds  of  the  sternomastoid,  the  upper  one- 
third  being  preserved  so  as  to  avoid  injury  to  the  spinal  accessory  nerve. 

Expose  and  divide  the  sternal  and  clavicular  portions  of  the  muscle  as  in 
open  tenotomy.  Seize  the  divided  ends  in  forceps  and  pull  the  muscle  down- 
wards and  through  the  skin-wound;  as  this  is  done,  separate  it  from  its  sur- 
roundings by  blunt  and  sharp  dissection.  Avoid  injuring  the  external  jugular 
vein.  When  two-thirds  of  the  muscle  is  isolated,  divide  and  remove  it.  At- 
tend to  hemostasis.  Divide  all  cicatricial  bands  which  can  be  felt.  Close 
the  wound.  Apply  dressings  and  pressure  enough  to  obviate  dead  spaces. 
No  subsequent  orthopedic  treatment  is  required. 

Bruns  in  doing  this  operation  removes  only  one-third  of  the  muscle.  The 
chief  disadvantage  of  the  operation  is  cosmetic,  viz.,  the  loss  of  the  shapeli- 
ness of  the  neck.     It  should  be  reserved  for  severe  or  recurrent  cases. 

Division  of  the  Spinal  Accessory  Nerve. — The  spinal  accessory  nerve 
escapes  from  the  skull  through  the  jugular  foramen.  It  runs  obliquely  down- 
wards and  backwards  between  the  internal  jugular  vein  and  the  digastric  mus- 
cle, entering  the  sternomastoid  muscle  at  a  point  about  two  inches  below 
the  mastoid  process.  The  nerve  pierces  the  muscle  obliquely  and  proceeds, 
across  the  posterior  triangle  of  the  neck  to  supply  the  trapezius. 

The  Operation. — -Make  an  incision  23^^  to  3  inches  in  length  from  the  mastoid! 
process  downwards  along  the  anterior  border  of  the  sternomastoid.  Expose- 
the  anterior  border  of  the  muscle  and  divide  the  cervical  fascia.  Retract 
the  muscle  backwards.  With  the  finger  recognize  the  transverse  process 
of  the  atlas,  which  is  covered  by  the  digastric  muscle.  The  nerve,  after  pass- 
ing between  the  bony  process  and  the  muscle,  emerges  at  the  lower  edge  of 
the  latter  and  passes  to  the  sternomastoid.  Expose  the  nerve  and  either 
divide  it  or  excise  about  3^^  inch  of  it.  Close  the  wound  with  sutures.  Dress.. 
The  results  of  the  operation  are  usually  good;  the  danger  is  practically  nil. 

Nerve  Section  for  Spasmodic  Torticollis. — Division  of  the  posterior  pri-^ 
mary  divisions  of  the  cervical  nerves  was  first  carried  out  by  Gardner  of  Ade- 
laide and  Keen  of  Philadelphia  in  1888.  The  operation  is  only  suitable  for 
very  severe  cases  in  which  the  disease  has  rendered  life  a  burden.     The  object 


206  TORTICOLLIS.       WRY-NECK.      CAPUT   OBSTIPUM 

of  the  operation  is  to  paralyze  all  the  muscles  involved — e.g.,  when  the  spasm 
turns  the  head  to  the  right  and  extends  it  one  should  paralyze  the  left  sterno- 
mastoid  and  trapezius  and  the  right  splenius  capitis,  trachelomastoid,  superior 
and  inferior  oblique,  rectus  capitis,  posticus  major  complexus  and  trapezius. 

Robert  Kennedy  ("Brit.  Med.  Journ.,"  Oct.  3,  1908)  has  endeavored  to 
simplify  the  exposure  of  the  nerves,  no  easy  matter  at  the  best. 

Step  I. — Make  a  vertical  skin  incision  from  3^  inch  above  the  superior 
curved  line  downwards  for  3  to  3)-^  inches  midway  between  the  external  ear 
and  the  external  occipital  protuberance. 

Step  2. — Define  the  posterior  edge  of  the  sternomastoid  and  deepen  the 
incision  behind  the  sternomastoid  until  the  oblique  fibres  of  the  splenius  capitis 
are  exposed.  Do  not  injure  the  spinal  accessory  nerve  which  may  lie  near 
the  lower  angle  of  the  wound. 

Step  3. — Define  the  upper  border  of  the  splenius  capitis  and  divide  that 
muscle  in  the  line  of  the  original  incision.  Divide  the  subjacent  connective 
tissue  exposing,  above,  the  complexus  whose  fibres  run  longitudinally,  and 
below,  the  trachelomastoid  whose  fibres  run  obliquely. 

Define  the  outer  edge  of  the  complexus  and  the  upper  edge  of  the  trachelo- 
mastoid. 

The  upper  part  of  the  wound  is  crossed  by  the  occipital  vessels.  Deep 
down  in  a  triangle  formed  by  the  occipital  vessels  and  the  two  muscles  lies 
the  superior  oblique  muscle. 

Step  4. — Follow  the  outer  border  of  the  complexus  to  its  highest  slip  of 
origin  (third  cervical  articular  process).  Detach  this  slip  from  the  bone. 
Repeat  this  with  the  slip  originating  from  the  fourth  articular  process.  Re- 
tract the  trachelomastoid  outwards.  Fold  the  complexus  inwards  and  so 
expose  several  nerves  entering  its  deep  surface.  "The  largest  is  the  great 
occipital  or  internal  branch  of  the  posterior  primary  division  of  the  second 
cervical  and  this  pierces  the  complexus  about  the  level  of  the  lower  edge  of  the 
lobe  of  the  ear.  Above  the  point  at  which  the  great  occipital  enters  the  com- 
plexus a  slender  branch  can  be  seen  entering  the  muscle  and  it  can  be  traced 
back  to  the  posterior  primary  division  of  the  first  cervical  nerve.  The  latter, 
however,  is  best  found  by  tracing  out  the  slender  branch  of  communication 
with  the  second  posterior  primary  division  which  as  a  rule  is  present,  passing 
upwards  from  the  second  division  across  the  inferior  oblique.  It  is  very  diffi- 
cult to  deal  satisfactorily  with  the  suboccipital  nerve  unless  this  communi- 
cating branch  is  early  found  and  traced  upwards  at  once  to  the  first  division 
which  lies  between  the  vertebral  artery  and  the  arch  of  the  atlas,  and  of  course, 
the  operation  is  only  imperfectly  performed  unless  the  first  division  is  ade- 
quately dealt  with.  A  short  communicating  branch  leads  from  the  second  divi- 
sion down  to  the  third  division  and  is  a  safe  way  of  reaching  the  latter.  The 
fourth  and  fifth  divisions  can  be  easily  found  passing  downwards  and  back- 
wards close  to  the  vertebrae.  The  nerves,  from  the  second  downwards,  should 
be  isolated  to  the  point  of  separation  into  anterior  and  posterior  primary 
divisions,  but  not  further,  and  undue  traction  can  quite  easily  pull  the  anterior 
primary  division  backwards  and  expose  it  to  the  danger  of  being  damaged. 
The  first  nerve  is  sectioned  just  proximal  to  its  branches,  and  the  others  near 


MULTIPLE    MYOTOMY  207 

their  point  of  separation  from  the  anterior  primary  division.  In  the  great 
majority  of  cases  the  nerves  once  sectioned  are  excised  from  the  point  of  section 
as  far  distally  as  can  be  reached." 

Step  5. — The  nerves  having  been  exposed  excise  a  segment  of  each.  Do 
not  stretch  the  nerves  lest  rupture  of  the  roots  occur  and  paralyze  the  anterior 
primary  divisions.  Resection  of  the  nerves  means  total  and  permanent  pa- 
ralysis of  the  muscles  involved.  Kennedy  suggests  another  method  of  operation 
in  cases  where  the  spasm,  though  very  violent,  has  not  been  of  long  standing, 
and  which  refuses  to  yield  to  any  known  treatment  short  of  operation.  In 
such  acute  cases,  i.e.,  where  the  affection  has  lasted  only  a  few  months  and 
there  seems  hope  of  cure,  Kennedy  gives  the  muscles  rest  by  dividing  and 
immediately  suturing  the  spinal  accessory  of  one  side  and  the  posterior  primary 
divisions  of  the  opposite  side.  "The  result  is  that  the  violent  spasm  is  im- 
mediately abolished,  the  afifected  muscles  degenerate,  and  in  the  course  of 
some  weeks,  after  the  nerves  have  regenerated,  as  indicated  by  the  gradually 
returning  sensation,  the  muscles  begin  to  get  built  up  again  and  shortly  begin 
to  resume  their  functions." 

Multiple  Myotomy. — Kocher's  Operation. — Two  incisions  are  necessary. 

1.  Make  an  incision  i3<4  to  il^  inches  in  length  along  the  anterior  border 
of  the  sternomastoid,  commencing  opposite  the  angle  of  the  jaw  and  passing 
upwards.  Di\dde  the  platysma  and  if  possible  save  the  external  jugular  vein. 
Open  the  sheath  of  the  sternomastoid  along  its  anterior  border.  Introduce  a 
blunt  dissector  under  the  muscle  and  divide  it  layer  by  layer.  Attend  to 
hemostasis.  Close  the  wound  with  sutures.  If  desired,  the  spinal  accessory 
nerve  may  be  stretched  or  divided  during  this  procedure. 

2.  The  patient  is  turned  on  to  his  sound  side.  Beginning  at  the  mastoid, 
make  a  transverse  incision  backwards.  Through  this  divide  the  trapezius 
transversely  and  incise  the  splenius  capitis  and  complexus  muscles.  Avoid 
injuring  the  great  occipital  nerve,  which  here  traverses  the  complexus  and 
trapezius.  The  inferior  oblique  muscle  arises  from  the  spinous  process  of  the  axis 
and  is  inserted  in  the  transverse  process  of  the  atlas.  Look  for  this  muscle 
in  the  space  between  the  atlas  and  axis  and  divide  it.  Attend  to  hemostasis. 
Close  the  wound. 

Monod  and  Vanverts  vnite.  as  follows:  "Section  should  be  made  of  the  muscles  which 
participate  in  the  spasm.  It  is  necessary,  by  anatysis,  to  determine  prior  to  operation  the 
muscles  involved.  One  may  be  compelled  to  practise,  according  to  the  case,  the  following 
operations :  division  of  sternomastoid  and  of  the  muscles  of  the  nape  of  the  neck  on  the  opposite 
side  (tj-pical  rotary  tic);  division  of  the  sternomastoid  and  of  the  muscles  of  the  nape  of  the 
neck  on  the  same  side  (rotary  tic  with  predominance  of  lateral  deviation) ;  division  of  sterno- 
mastoid and  bilateral  division  of  the  muscles  of  the  nape  of  the  neck  (rotary  tic  with  much 
posterior  extension)." 

Remarks. — In  some  cases  of  torticollis  no  operation  seems  to  be  effectual; 
such  are  usually  due  to  affections  of  the  posterior  nerve  and  muscle  groups. 
Extirpation  of  the  nerves  involved  has  been  ad\ased,  but  this  is  a  very  compli- 
cated and,  for  most  surgeons,  inadvisable  operation,  and  is  not  a  glittering 
success. 


2o8  EXCISION    OF    CERVICAL    RIBS 

In  Other  cases  any  operation  involving  tenotomy  is  successful.  When 
the  muscle  is  greatly  degenerated  and  adherent,  Mikulicz's  procedure  is  the 
best.  In  spasmodic  varieties  of  torticollis  section  of  the  spinal  accessory  nerve 
is  the  operation  of  choice. 


CHAPTER   XX 
EXCISION   OF   CERVICAL  RIBS 

Excision  of  Cervical  Rib. — Cervical  ribs  vary  much  in  size  and  may  be 
unilateral  or  bilateral.  They  articulate  with  the  seventh  cervical  vertebra  and 
may  end  as  a  longer  or  shorter  process  lying  among  the  tissues  of  the  neck  or 
their  anterior  end  may  be  united  to  the  first  thoracic  rib  or  to  the  sternum. 
Commonly  no  sjinptoms  are  produced,  but  sometimes  the  rib  exercises  pressure 
on  the  vessels  or  on  the  nerve  trunks  passing  over  it  or  on  both.  When  these 
symptoms  are  severe  and  do  not  give  way  to  conservative  treatment,  operation 
becomes  necessary-.  Occasionally  the  rib  itself  is  short  but  is  continued  forwards 
as  a  strong  band  of  connective  tissue  and  this  band  exercises  pressure  and  gives 
rise  to  trouble.  In  such  a  case  excision  of  the  connective-tissue  band  is  of  course 
the  proper  treatment. 

A.  Operation  from  in  front.  Step  i. — Incision. — Numerous  incisions  have 
been  devised:  (a)  Transverse,  a  finger's  breadth  above  the  clavicle  reaching 
from  the  sternomastoid  to  the  trapezius,  ib)  Oblique,  along  the  anterior 
edge  of  the  trapezius  or  a  half  inch  in  front  of  it.  {c)  Vertical  over  the  most 
prominent  part  of  the  swelling  caused  by  the  rib.  One  incision  is  as  good  as 
another  provided  that  free  access  is  secured;  sometimes  it  is  necessary  to  com- 
bine two  incisions  so  as  to  obtain  room. 

Step  2. — Divide  the  platysma  and  superficial  fascia,  doubly  ligating  and 
dividing  the  external  jugular  vein.  Divide  the  deepT  fascia.  Penetrate  the 
underlying  loose,  vascular  fatty  tissue  so  as  to  expose  the  great  vessels  and 
the  brachial  plexus.  Cautiously  retract  the  vessels  and  nerves  from  over  the 
cervical  rib. 

Step  3. — By  blunt  and  sharp  dissection  separate  from  the  rib  the  soft  parts 
attached  to  it.  Great  care  is  necessan,-  to  avoid  injuring  the  pleura  which  may 
be  attached  to  the  rib.  The  danger  of  pleural  puncture  has  been  much  exag- 
gerated. Subperiosteal  resection  of  the  rib  is  easier  than  extra-periosteal  but 
one  or  more  cases  have  been  reported  in  which  a  secondary  operation  was  re- 
quired owing  to  reformation  of  the  rib.  At  first  expose  and  isolate  a  small 
median  portion  of  the  rib.  From  this  as  a  starting-point  follow  the  rib  towards 
the  spine  and  divide  it  with  bone  forceps,  being  careful  to  leave  no  sharp  spicules 
protruding  from  the  stump  left  attached  to  the  spine.  Follow  the  rib  to  its 
anterior  attachments  and  di\-ide  them.  Remove  the  rib.  If  complete. excision 
is  very  difficult  or  risky  it  may  occasionally  be  wise  to  resect  merely  that  portion 
of  the  bone  which  is  exercising  injurious  pressure  on  the  vessels  and  nerves. 

Step  4. — Attend  to  hemostasis.  Close  the  wound  with  deep  and  superficial 
sutures. 


CERVICAL   TUMORS  209 

B.  Operation  from  behind.  (Streissler's  method.)  From  a  point  ^:4  inch 
(2  cm.)  lateral  to  the  spinous  processes  of  the  vertebrae  and  one  hand-breadth 
above  the  vertebra  prominens  make  an  incision  downwards  parallel  to  the  spine 
to  a  point  one  hand-breadth  below  the  vertebra  prominens.  Divide  the  trape- 
zius, both  the  rhomboids,  serratus  posticus  and  splenius;  separate  the  fibres  of 
the  complexus  and  semispinaUs  colli.  Expose  the  transverse  processes  of  the 
two  lower  cervical  and  two  upper  thoracic  vertebrae.  The  articulation  between 
the  cervical  rib  and  the  transverse  process  of  the  seventh  cervical  vertebra  with 
its  strong  ligaments  is  now  in  view.  Remove  the  transverse  process  and  so 
expose  the  thin  neck  of  the  rib.  Pass  a  curved  elevator  around  the  neck  of  the 
rib  and  divide  it,  being  careful  not  to  injure  the  nerve  roots  immediately  in  front 
of  it.  Seize  the  rib  with  strong  forceps  and  with  sharp  and  blunt  dissection  free 
it  from  its  connection  as  far  forwards  as  possible.  If  the  rib  is  too  long  or 
its  anterior  connections  are  too  firm  to  permit  complete  and  easy  removal 
through  the  posterior  wound,  finish  the  removal  through  an  anterior  incision. 
The  results  obtained  from  excision  of  cervical  ribs  have  usually  been  good. 
Streissler  ("Ergebnisse  der  Chir.  und  Orthopedie,"  v,  280)  gives  an  exhaustive 
account  of  cervical  ribs. 


CHAPTER   XXI 
EXCISION   OF  CERVICAL  TUMORS 

The  various  operations  for  the  removal  of  cervical  tumors,  if  at  all  exten- 
sive, should  never  be  undertaken  by  a  tyro  in  surgery.  These  operations  are 
very  dangerous  in  the  hands  of  one  who  is  not  possessed  of  a  good  working 
knowledge  of  anatomy,  especially  of  the  anatomy  of  the  living,  and  of  wide 
surgical  experience. 

A  good  type  of  the  operations  under  discussion  is  the  removal  of  tubercu- 
lous glands.  Ideally,  when  the  disease  is  extensive,  one  should  endeavor  to 
remove  all  the  cervical  glands,  and  their  lymphatic  connections  in  one  piece. 
This  is,  of  course,  impossible;  but  it  is  a  good  plan  for  the  surgeon  to  try  to 
approximate  the  ideal,  even  although  he  knows  that  his  endeavors  to  do  so  will 
fall  far  short. 

Greenwood  SutcUffe  ("Practitioner,"  lxxx\dii,  641)  gives  the  following  indi- 
cations for  the  treatment  of  tuberculous  cervical  glands  in  children.  When  the 
disease  has  lasted  not  more  than  six  months  dietetic  treatment  with  rest  (in 
the  open  air)  gives  good  results.  Rest  here  means  lying  down  and  not  running 
about.  When  the  disease  has  lasted  longer,  there  is  usually  caseation  and  opera- 
tion is  demanded.  The  author  has  found  that  suction  hyperemia  is  often  of 
great  benefit  in  recent  disease  and  that  where  caseation  has  taken  place  or  even 
where  abscess  has  formed,  a  small  incision  followed  by  suction  hyperemia  after 
the  Klapp-Bier  method,  often  renders  excision  unnecessary.  When  a  reasonable 
trial  of  these  simpler  remedies  fails,  operation  is  proper. 

What  are  the  dangers  of  the  operation? 

I.  Hemorrhage. — If  care  is  taken,  bleeding  need  cause  little  anxiety.  The 
precautions  taken  to  avoid  air  embolism  will  certainly  have  the  eflfect  of  pre- 
venting much  hemorrhage. 


2IO  EXCISION   OF    CERVICAL   TUMORS 

2.  Air  Embolism. — During  inspiration  the  blood  in  the  cervical  veins 
is  under  negative  pressure.  If  under  these  circumstances  the  vein  is  wounded, 
air  is  liable  to  be  sucked  into  it  and  thus  into  the  heart — a  very  fatal  accident. 
Careful  attendance  to  the  principles  of  technic  for  cervical  operations  will 
obviate  most  of  the  danger. 

(a)  The  wound  through  the  skin  and  fascia  should  be  large  enough  to  give 
free  access  to  every  part  to  be  operated  upon. 

(b)  The  wound  should  be  kept  moist,  and  if  the  slightest  "hissing"  sound 
be  heard  in  the  wound,  the  finger  should  press  the  tissue  at  a  point  nearer  the 
heart  than  where  the  wounded  vein  is.  The  "hissing"  signifies  entrance  of 
air.  The  digital  pressure  is  meant  to  hinder  the  passage  of  the  air  towards 
the  heart.  At  the  same  time  as  the  finger  pressure  is  applied,  a  spongeful  of 
water  must  be  squeezed  into  the  wound.  This  effectually  prevents  more  air 
getting  in.  The  wound  in  the  vessel  must  be  caught  by  pressure  forceps.  J. 
B.  Murphy  places  a  small  pack  of  gauze,  with  a  thread  attached  to  it  to  keep 
it  from  being  lost,  under  the  sternal  attachment  of  the  sternomastoid  muscle. 
The  pressure  of  the  pack  keeps  the  cervical  veins  full,  prevents  the  danger  of 
negative  pressure,  and  makes  the  veins  very  visible.  This  expedient  is  of  great 
value;  the  trifling  increase  in  hemorrhage  is  of  no  importance.  When  "hiss- 
ing" in  the  wound  occurs  and  makes  one  suspect  air  embolism,  remember 
that  it  may  be  due  to  the  pleura  being  accidentally  opened.  The  pleura  ex- 
tends an  inch  or  more  above  the  first  rib. 

(c)  No  more  cutting  should  be  done  than  is  absolutely  necessary.  Blunt 
dissection  is  most  meritorious. 

(d)  Never  cut  in  the  dark  or  without  full  knowledge  of  the  safety  of  what 
is  being  divided. 

(e)  Bleeding  points  are  at  once  caught  by  pressure  forceps.  If  it  is  sus- 
pected that  forcipressure  kept  up  for  a  few  minutes  will  be  insufficient  to  stop 
the  bleeding,  the  vessel  should  be  secured  by  a  fine  ligature. 

(/)  In  removing  the  glands  no  forcible  tearing  should  be  perpetrated. 
Veins  are  often  very  friable. 

(g)  Structures  about  to  be  cut  ought  not  to  be  on  tension.  Tension  empties 
veins  and  makes  them  look  like  bands  of  fibrous  tissue. 

(h)  When  in  the  slightest  doubt  as  to  the  contents  of  a  strand  of  tissue 
which  must  be  severed,  apply  two  forceps  or  two  ligatures  and  cut  between. 

When,  in  spite  of  all  precautions,  air  has  been  sucked  into  a  vein,  fill  the 
cervical  wound  loosely  with  wet  gauze;  do  not  apply  forceps  to  the  vein;  during 
the  succeeding  expirations  forcibly  compress  the  chest;  do  not  lower  the  head 
and  shoulders  of  the  patient. 

3.  When  operating  down  low  in  the  neck  on  the  left  side,  avoid  injuring 
the  thoracic  duct.  Such  injury  is  not  uncommon.  If  noticed  at  the  time, 
one  sees  a  little  clear  fluid  escaping.  Compression  sutures  in  the  vicinity  of 
the  injured  duct  plus  gauze  packing  usually  leads  to  recovery,  but  fluid  escapes, 
in  spite  of  treatment,  for  about  two  weeks,  and  there  is  great  emaciation.  The 
injury  generally  heals  in  about  three  weeks  or  less.  P.  Lecene  thoroughly 
discusses  this  accident  ("Revue  de  Chir.,"  Dec,  1904). 


INJURIES    TO   THORACIC   DUCT 


211 


Edward  Harrison  (Brit.  J.  of  Surj!^.,  191 7,  IV,  304)  rcvicwinjr  the  treatment 
of  wounds  of  the  duct  comes  to  the  following  conclusions: 

1.  Suture  is  the  best  treatment.  Suitable  in  splits  and  tears.  (Five  cases 
all  successful.)  When  there  is  com[)letc  division  of  duct,  end-to-end  suture  is 
best. 

2.  Implantation  into  any  convenient  vein.  In  one  case  the  divided  duct 
was  put  into  the  central  segment  of  the  external  jugular  vein  which  was  divided 
for  the  purpose  and  fixed  by  sutures. 

3.  Occlusion  of  duct  by  ligature  or  forcipressure.  This  gave  many  good 
results,  possibly  because  in  18  out  of  40  cases  there  were  two  terminal  branches 
of  the  duct  and  perhaps  only  one  of  these  was  occluded.  Collateral  circulation 
may  aid  in  recovery  after  ligation. 

4.  Tamponade  is  a  dernier  ressort. 

4.  Injury  to  Important  Nerves. — The  danger  of  injuring  important  nerves 
in  the  neck  is  by  no  means  great.  The  vagus  is  well  protected,  lying  in  the 
carotid  sheath.  If  care  be  taken,  the  spinal  accessory  nerve  can  usually  be 
recognized  and  often  preserved;  its  preservation  is  of  much  greater  impor- 
tance in  the  young  than  in  the  mature.  Injury  to  the  phrenic  and  the  recurrent 
laryngeal  nerves  is  extremely  rare.  Injury  to  the  cervical  sympathetic  system 
seems  to  produce  no  ill  results. 

The  Operation. — In  slight  cases  where  the  glands  are  neither"  numerous  nor 
adherent  the  operation  is  extremely  simple.  An  incision  is  made  over  the 
swelling  and  through  this  the  tumors  are  easily  shelled  out.  The  method  of 
operating  about  to  be  described  is  for  extensive  and  complicated  disease. 


Fig.  346. 


Fig.  347. — Superficial  cervical  nerves. 


The  patient  lies  on  his  back  with  the  shoulders  supported  and  the  head 
turned  towards  the  side.  The  scalp  should  be  covered  by  a  weU-fitted  gauze 
or  rubber  cap,  to  keep  the  hair  out  of  the  way.  An  oblique  incision  is  made 
along  the  sternomastoid  muscle  from  the  mastoid  process  to  near  the  sterno- 
clavicular articulation.  The  external  jugular  vein  is  exposed  and  divided  be- 
tween two  ligatures.  The  skin  anterior  and  posterior  to  the  incision  is  dissected 
from  the  subjacent  tissues  and  retracted.  If  necessary,  a  second  cut  may  be 
made  parallel  to  and  near  the  clavicle,  from  the  lower  end  of  the  oblique  incision 
outwards.  Another  incision,  and  one  which  leaves  little  noticeable  scar,  follows 
the  margin  of  the  vertical  hair  line  of  the  back  of  the  neck;  to  this  cut  is  joined 
one  following  the  clavicle  forwards  (Fig.  346).  Expose  the  sternomastoid 
and  free  it  from  its  surroundings  throughout  its  whole  length.     Notice  the  point 


212  EXCISION    OF    CERVICAL   TUMORS 

of  emergence  of  the  superficial  cervical  nerves  at  the  posterior  edge  of  the 
muscle;  the  nerves  are  not  small,  and  here  the  muscle  is  more  firmly  attached 
to  its  surroundings  than  elsewhere,  hence  this  point  constitutes  an  anatomic 
landmark  (P'ig.  347).  One-half  inch  above  this  landmark  the  spinal  accessory 
nerve  emerges  from  the  sternomastoid  muscle  and  is  easily  found.  The  nerve 
enters  the  muscle  about  two  inches  below  the  tip  of  the  mastoid  process,  after 
passing  over  the  prominent  transverse  process  of  the  atlas.  In  cases  of  tuber- 
culosis it  is  commonly  easy  to  trace  the  nerve  in  its  course  to  the  trapezius  and 
to  separate  it  from  the  diseased  structures.  In  the  young  it  is  important  to 
preserve  the  nerve,  because  Fenger  has  shown  that  its  division  leads  to  droop- 
ing of  the  shoulder  and  to  scoliosis. 

The  packet  of  fascia  which  contains  the  carotid  artery,  internal  jugular 
vein,  and  the  vagus  must  now  be  exposed.  Once  exposed,  the  protection  of 
these  extremely  important  structures  becomes  more  or  less  easy.  Up  to  this 
time  no  attempt  has  been  made  to  remove  diseased  tissues.  The  disease  is 
now  attacked.  Beginning  near  the  lower  end  of  the  wound  and  by  the  side  of 
the  carotid  packet,  the  removal  of  the  diseased  glands  with  the  gland-bearing 
fascia  is  generally  a  comparatively  easy  matter  and  can  be  carried  out  sys- 
tematically. If  the  important  anatomical  structures  are  not  exposed  and  pro- 
tected at  an  early  stage  in  the  operation,  systematic,  thorough  removal  of  the 
glands  is  very  difficult  and  dangerous.  The  diseased  structures  having  been 
removed  and  all  hemorrhage  stopped,  carefully  suture  the  wound  in  the  cervical 
fascia,  preferably  with  catgut.  Suture  of  the  fascia  and  platysma  most  notably 
removes  tension  from  the  skin-wound.  If  the  fascia  is  not  well  united,  the  skin- 
wound  is  liable  to  stretch  and  give  rise  to  a  wide,  ugly  scar.  Provide  drainage 
at  the  lower  angle  of  the  wound.  Close  the  skin-wound  neatly,  using  in- 
tradermic  sutures  or  ordinary  sutures,  preferably  of  horse-hair.  Horse-hair 
SI  tures,  being  elastic,  leave  less  scar  than  sutures  of  any  other  material.  After 
operations  on  the  neck,  very  extensive  dressings  are  required  as  small  dressings 
are  difficult  to  keep  in  place. 

In  the  course  of  any  operation  for  the  removal  of  tuberculous  glands  some 
of  them  may  be  ruptured  and  from  them  there  escapes  caseous  material.  Such 
extravasated  matter  must  be  carefully  wiped  away,  and  it  is  good  practice 
to  scrape  the  remnants  of  the  caseated  material  from  the  ruptured  gland, 
subsequently  mopping  the  part  scraped  with  liquid  carbolic  acid,  followed 
by  the  application  of  alcohol  to  neutralize  the  carbolic.  When  glands  are  so 
firmly  united  to  the  great  vessels  of  the  neck  that  their  removal  is  very  risky, 
it  is  proper  to  remove  as  much  of  the  gland  as  possible  and  sterilize  the  re- 
mainder with  liquid  carbolic,  afterwards  neutralizing  with  alcohol. 

Subcutaneous  Removal  of  Tuberculous  Glands  in  the  Neck  and  Sub- 
maxillary Regions  (DoUinger's  Operation). — The  operator  sits  behind  the 
head  of  the  patient  and  wears  an  electric  headUght.  An  assistant  holds  the 
patient's  head  free  and  moves  it  to  suit  the  convenience  of  the  operator.  Be- 
ginning near  the  external  auditory  meatus,  make  an  incision,  2 3-^  to  3  inches 
in  length,  downwards  and  backwards,  parallel  to  and  about  }i  inch  from  the 
margin  of  the  hair.  Through  this  incision  packets  of  glands  in  almost  all  the 
cervical  region  may  be  reached  and  removed  by  blunt  dissection,  the  surgeon 


LYMPH    GLANDS    OF    NECK  213 

undermining  the  skin  to  a  point  below  the  packet  to  be  removed  and  removing 
the  glands  from  below  upwards.  Nerves  and  vessels  must  be  pushed  aside. 
When  the  glands  are  seized  with  forceps,  they  often  tear  or  collapse,  especially 
if  they  are  caseated.  This  accident,  according  to  Dollinger,  does  no  harm, 
provided  the  debris  is  promptly  washed  away.  Cases  in  which  peri-adenitis 
has  caused  the  formation  of  many  firm  adhesions  are  unsuitable  for  this  opera- 
tion. After  removal  of  the  glands  the  whole  wound  must  be  reviewed,  cleaned, 
drained,  and  sutured.     The  hemorrhage  is  remarkably  slight. 

The  location  of  particular  groups  or  packets  of  glands  is  as  follows:  I.  The 
retroauricular  and  subauricular  glands  lie  next  to  the  incision  and  are  easily 
removed. 

II.  The  preauricular  glands  lie  on  the  parotid  beneath  the  masseteric  fascia 
which  they  penetrate  and  so  reach  the  subcutaneous  tissues.  To  reach  them 
pass  under  the  external  auditory  meatus.     The  facial  nerve  is  not  in  danger. 

III.  The  glands  under  the  head  of  the  sternomastoid  lie  posterior  to  the 
accessory  nerve,  which  must  be  carefully  preserved. 

Glands  also  He  in  front  of  and  beneath  the  nerve  and  must  be  removed 
with  great  care.  One  reaches  these  glands  from  the  wound  by  dissecting  under 
the  posterior  edge  of  the  sternomastoid. 

IV.  Glands  in  the  vicinity  of  the  lower  end  of  the  parotid  gland  and  of  the 
posterior  facial  vein  are  reached  by  burrowing  between  the  skin  and  the  sterno- 
mastoid. When  the  disease  is  of  long  standing,  the  posterior  facial  vein  is 
often  obliterated.  Preserve  the  external  jugular  vein  and  the  great  auricular 
nerves. 

V.  Glands  about  the  submaxillary  salivary  glands.  These  are  usually 
three  in  number  and  lie  between  the  salivary  gland  and  the  lower  jaw.  One 
next  burrows  between  the  skin  and  the  sternomastoid  to  the  group  of  glands 
anterior  of  the  muscle,  and  illuminating  the  wound  with  the  headlight,  opens 
their  fascial  covering  and  removes  them  bluntly. 

VI.  The  submental  glands,  two  in  number,  lie  between  the  anterior  bellies 
of  the  digastric.  These  are  best  removed  through  a  small  incision  directly 
over  them. 

VII.  Glands  in  the  lateral  triangle  of  the  neck  number  about  50.  The 
upper  ones  can  be  easily  reached  through  the  primary  incision.  The  lower 
ones  lying  in  loose  connective  tissue  are  easily  pushed  upwards  and  extirpated. 
Look  out  for  and  preserve  the  branch  of  the  spinal  accessory  going  to  the  trape- 
zius, the  cervical  and  the  brachial  plexus.  These  structures  are  separated 
from  the  glands  by  a  layer  of  cervical  fascia.  The  external  jugular  vein  is 
often  obliterated. 

VIII.  The  deep  cervical  glands  lie  along  the  great  vessels  under  the  sterno- 
mastoid, and  can  be  reached  by  undermining  the  muscle.  If  the  glands  are 
firmly  united  to  the  vessels,  pull  them  to  the  surface  with  a  sharp  hook  and 
carefully  dissect  them  free.  Remember  that  the  traction  empties  the  internal 
jugular  vein  and  makes  it  look  like  an  innocent  band  of  tissue. 

This  proceeding  seems  to  the  author  very  hazardous.  Bollinger's  opera- 
tion seems  to  be  excessively  difficult,  and  may  easily  be  very  incomplete,  but 
that  surgeon  has  performed  it  in  very  many  cases,  and  with  excellent  results. 


214  EXCISION    OF   CERVICAL   TUMORS 

■[  Bollinger's  description  of  his  operation  appears  in  the  "Proceedings  of  the 
German  Surgical  Society,"  1903.] 

When  the  disease  for  which  operation  is  required  is  malignant,  almost 
everything  holds  good  which  has  been  said  regarding  the  excision  of  tuber- 
culous glands,  but  the  work  is  more  complicated  and  difficult.  That  malig- 
nant disease  should  be  excised  as  thoroughly  as  possible  is  as  true  in  the  neck 
as  elsewhere,  but  thoroughness  is  more  difficult  to  attain  in  this  region.  The 
incision  made  must  vary  according  to  circumstances.  It  may  be  obliquely 
vertical,  transverse,  or  a  horseshoe-shaped  flap  with  its  pedicle  upwards  or 
downwards  may  be  dissected  from  over  the  tumor.  When  the  growth  is  ex- 
posed, it  must  be  separated  from  its  surroundings.  In  doing  this  it  is  usually 
wise  to  attend  to  the  most  dangerous  part  first.  Thus,  when  feasible,  the 
surgeon  should  begin  the  enucleation  at  the  point  nearest  the  large  vessels, 
so  that  in  case  of  accident  or  difficulty  these  may  be  under  control.  If  the 
carotid  artery  or  the  internal  jugular  vein  passes  into  or  becomes  inseparably 
united  to  the  tumor,  it  is  well  to  know  the  trouble  early  in  the  operation  so  that 
one  may  inteUigently  make  up  his  mind  as  to  the  propriety  of  braving  the 
dangers  of  a  completed  operation  or  the  advisability  of  closing  the  wound 
before  it  is  too  late  to  recede. 


Fig.  348. — Crilc's  clamp. 

The  carotid  artery  lies  deeper  than  the  vein  and  is  rarely  involved  in  the 
disease.  The  vein  is  often  infiltrated  or  surrounded  by  the  tumor  and  requires 
ligation  or  removal,  which  is  not  particularly  dangerous.  Ligation  of  the 
common  carotid  has  a  mortality  of  about  26  per  cent,  (from  cerebral  softening 
principally).  See  p.  839.  In  operations  for  malignant  disease  Crile  applies 
his  clamp  (Fig.  348)  to  the  artery  and  thus  temporarily  controls  it.  Some 
surgeons  throw  a  soft  temporary  ligature  around  the  artery,  which  serves  the 
same  purpose  as  Crile's  clamp  but  does  not  do  so  in  quite  as  elegant  a 
fashion.  Temporary  control  of  the  carotid  is  of  great  value  in  operations  for 
malignant  neoplasms. 

If  it  seems  probable  that  the  tumor  may  be  dissected  free  from  the  vessels, 
it  is  often  proper  to  lay  a  ligature  loosely  in  position  around  the  internal  jugular 
vein  (to  the  cardiac  side  of  the  growth)  so  that,  should  air  embolism  be  seriously 
threatened  during  the  later  stages  of  the  operation,  an  assistant  can  quickly 
tighten  the  thread  and  avert  danger. 

Note. — In  connection  with  severe  surgical  operations  on  the  neck  it  should  be 
distinctly  understood  that  section  of  the  vagus  nerve  is  not  necessarily  fatal. 
Giordano  (quoted  in  "Annals  of  Surg.,"  June,  1894)  finds  that  after  mal- 
treatment of  the  nerve  in  surgical  cases  the  mortality  is  not  higher  than  45 
per  cent,  while  in  resection  it  is  75  per  cent.  Crile  ("Problems  Relative  to 
Surgical  Operations,"  1901)  has  made  numerous  experiments  on  the  vagus  and 
reports  a  number  of  cases  in  which  the  vagus  of  one  side  was  excised  without  ill 


CERVICAL   FISTUL.*:  21 5 

effect.  Before  operations  in  which  the  vagus  may  be  irritated  or  divided  he 
finds  it  wise  to  administer  J'loo  grain  of  atropin  in  order  to  prevent  any  cardiac 
or  respiratory  inhibition. 

Hydrocele  of  the  Neck ;  Cystic  Lymphangioma.—  A  hydrocele  of  the  neck 
consists  of  a  monolocular  or  multilocular  cyst  which  may  extend  into  the 
anterior  mediastinum  or  deep  down  among  the  large  vessels  of  the  neck.  The 
disease  is  congenital.  Of  course,  the  ideal  treatment  is  extirpation,  but  this 
is  rarely  proper  because  of  its  difficulty  and  danger.  If  extirpation  is  decided 
on,  the  operation  ought  to  be  delayed  until  the  end  of  the  first  year  of  life 
(Arrou).  The  most  common  operative  treatment  consists  in  evacuation  by 
trocar  and  cannula,  followed  by  irrigation  with  a  2  per  cent,  solution  of  carbolic 
acid,  or  by  injection  of  tincture  of  iodine  diluted  with  water.  This  simple 
treatment  often  gives  excellent  results;  it  is  liable  to  fail  when  there  are  many 
compartments  or  loculi  in  the  cyst.  When  evacuation  and  injection  fail  or  are 
inappropriate,  marsupialization  affords  a  means  of  treatment  which  is  thorough 
and  is  safer  than  extirpation.  Marsupialization  consists  in  incising  the  cyst; 
suturing  the  edges  of  the  wound  in  the  cyst  to  the  skin;  opening  the  subsidiary 
cyst  cavities;  evacuating  all  the  contents  and  providing  for  drainage  by  means 
of  a  gauze  tampon.  In  the  course  of  the  operation  part  of  the  cyst-wall  may 
be  removed  and  the  interior  of  the  cavity  may  be  swabbed  first  with  liquid 
carbolic  acid  and  then  with  alcohol  to  neutralize  the  carbolic. 

Congenital  cervical  fistulae  require  radical  treatment  when  they  give  rise 
to  much  inflammation  or  to  cystic  tumors;  esthetic  considerations  may  call 
for  their  removal.  Occasionally  the  fistulae  are  shallow  and  their  extirpa- 
tion is  then  easy.  Usually  they  are  complete,  reaching  from  the  neighbor- 
hood of  the  tonsil  (Rosenmiiller's  fossa  behind  the  tonsil),  passing  under 
the  digastric  muscles  to  penetrate  the  cervical  fascia  and  the  skin  in  almost 
any  location  between  the  sternomastoid  muscles.  Such  fistulas  must  be  com- 
pletely excised,  otherwise  recurrence  is  liable  to  take  place.  The  skin-incision 
must  be  extensive  and  the  cord-like  fistulous  track  followed  (preferably  with- 
out being  opened),  under  guidance  of  the  eye,  up  to  its  pharyngeal  termina- 
tion. The  dissection  is  not  one  for  the  tyro  in  surgery  to  attempt.  The  re- 
moval of  the  pharyngeal  end  and  closure  of  the  pharyngeal  wound  are  most 
difficult,  but  this  difficulty  has  been  evaded  in  a  most  ingenious  manner  by 
Fritz  Konig.  After  the  fistula  has  been  mobilized  to  a  point  above  the  digas- 
tric muscle,  Konig  separates  it  still  further  from  its  surroundings  by  blunt 
dissection  until  the  pharyngeal  mucous  membrane  is  nearly  reached;  then  he 
opens  the  mouth  with  a  Whitehead  speculum,  passes  a  stout  probe  with  an  eye 
on  the  proximal  end  through  the  wound,  and  makes  its  point  appear  elevating 
the  mucous  membrane  in  front  of  the  lower  margin  of  the  tonsil.  An  incision 
made  through  the  mouth  over  the  end  of  the  probe  permits  the  latter  to  be  pulled 
through,  and  with  it  a  thread  of  sUk.  The  end  of  the  fistula,  after  being  tied 
to  the  thread,  is  easily  pulled  into  the  mouth,  fastened  by  a  couple  of  stitches 
to  the  wound  in  the  mucosa,  and  its  free  end  cut  away.  The  external  wound 
is  now  closed.  Instead  of  a  long  fistula  leading  from  the  pharynx  to  the  skin, 
there  is  a  short,  harmless  fistula  leading  from  the  back  to  the  front  of  the 
tonsil.     This  simple  "dodge"  of  Konig's  is  one  of  great  value. 


2l6  EXCISIOX   OF   CERVICAL   TUMORS 

Median  cervical  fistulae  are  different  from  those  alluded  to  above;  they 
are  the  result  of  non-obliteration  of  the  thyroglossal  duct.  The  thyroglossal 
duct  leads  from  the  foramen  caecum  on  the  tongue  through  the  root  of  that 
organ  down  to  a  low  point  in  the  neck.  On  its  way  down  the  duct  either  passes 
through  or  is  closely  connected  with  the  body  of  the  hyoid  bone.  Excision 
of  a  patent  or  inflamed  duct  below  the  hyoid  is  easy;  above  that  bone,  it  may 
be  difficult  or  easy,  generally  the  former.  If  the  duct  passes  through  the 
hyoid,  the  portion  enclosed  in  the  bone  must  be  thoroughly  removed  even  if 
it  is  necessary  to  excise  a  portion  of  the  bone  itself.  Occasionally  that  part 
of  the  duct  which  traverses  the  tongue  gives  rise  to  a  tumor  consisting  of  tissue 
very  like  that  of  the  thyroid  gland.  Cysts  arising  from  distention  of  the 
duct  above  the  hyoid  may  give  rise  to  ranula-like  tumors.  In  treatment 
of  ranula  it  is  well  to  bear  this  fact  in  mind.  A  stubborn  and  obscure  recurrent 
phlegmonous  inflammation  in  the  submental  region  may  be  due  to  an  unsus- 
pected remnant  of  the  thyroglossal  duct. 

Lingual  thyroid  may  occasionally  be  easily  shelled  out  of  the  tongue  or 
extensive  operations  may  be  necessary. 

W.  G.  Spencer  (Royal  Soc.  Med.  Surg.  Sect.,  1914,  163)  draws  attention 
strongly  to  the  fact  that  a  lingual  thyroid  not  infrequently  is  the  only  active 
thyroid  present  in  the  individual  and  that  as  a  consequence  hj^jothyroidism 
must  result  should  that  tissue  be  removed.  He  writes  "from  the  standpoint 
of  a  clinical  examination,  then,  it  is  of  primary  importance  to  recognize  the 
presence  of  the  isthmus  of  the  thyroid  gland  or  the  reverse.  When  the  isthmus 
is  absent,  so  that  the  tracheal  rings  from  the  cricoid  cartilage  downwards  can 
be  felt,  it  should  be  assumed  that  the  patient's  actively  secreting  thyroid  may 
have  been  developed  in  the  course  of  the  thyreoglossal  tract,  and  although  there 
may  be  a  fullness  on  either  side  of  the  trachea  suggesting  the  existence  of 
lateral  lobes,  yet  these  may  be  parathyroids  destitute  of  any  true  thyroid 
function." 

Spencer  thinks  that  when  the  lingual  thyroid  has  caused  so  much  swelling 
at  the  base  of  the  tongue  as  to  impair  breathing  or  has  ulcerated  and  hemor- 
rhage has  followed,  then  the  removal  of  a  small  wedge  and  suture,  or  a  limited 
application  of  the  cautery  is  the  proper  treatment.  If  it  is  necessary  to  excise 
the  lingual  thyroid  probably  Matti's  operation  will  be  found  suitable  (Archiv 
f.  Klin.  Chir.,  ciii,  248). 

Matti's  Operation. — Preliminary  tracheotomy  is  advantageous. 

Step  I. — Make  a  curved  collar  incision  through  the  skin  and  platysma  at 
the  upper  margin  of  the  hyoid  bone.  The  length  of  the  incision  depends  on 
the  size  of  the  tumor  but  in  any  event  it  ought  to  be  long  enough  to  permit 
preliminary  ligation  of  one  or  both  lingual  arteries  beside  the  great  horn  of 
the  hyoid.     Reflect  the  flap  of  skin  and  platysma  upwards  as  far  as  possible. 

Step  2. — Isolate  and  divide  the  middle  of  the  body  of  the  hyoid  bone. 
Split  the  raphe  between  the  mylohyoid,  geniohyoid  and  genioglossus  muscles  and 
retract  these  muscles  laterally  along  with  the  two  segments  of  the  hyoid  bone. 

Step  3. — Remove  the  tumor  after  dividing  its  firm  attachments  to  the 
hyoid  bone.  This  may  sometimes  be  accomplished  without  penetrating 
the  lingual  mucosa.     The  operation  may  be  much  facilitated  if  an  assistant 


SYMPATHECTOMY  21 7 

presses  upon  the  lingual  surface  of  the  tumor  with  his  fingers  in  the  patient's 
mouth. 

Step  4. — If  the  mouth  has  been  penetrated,  the  wounded  mucosa  must  be 
sutured.  The  wound  must  be  packed  or  drained,  the  muscles  sutured  correctly 
and  the  skin  closed  except  where  the  drain  protrudes. 


CHAPTER  XXII 
EXCISION   OF  THE  CERVICAL   SYMPATHETIC 

Jonnesco  describes  the  total  excision  of  the  cervical  sympathetic  very 
nearly  as  follows: 

Step  I. — Cutaneous  incision:  Make  a  cut  from  behind  the  mastoid  process 
downwards  along  the  posterior  border  of  the  sternomastoid  to  a  point  a  little 
below  the  clavicle.     The  external  jugular  vein  is  divided  between  two  ligatures. 

Step  2. — Separation  oj  the  posterior  border  of  the  sternomastoid:  To  avoid 
section  of  the  external  branch  of  the  spinal  accessory  nerve  and  the  diffi- 
culties often  met  in  freeing  the  posterior  border  of  the  muscle  in  the  upper  part 
of  the  wound,  make  an  incision  along  the  muscle  parallel  and  close  to  the 
posterior  margin.  Separate  the  fibres  of  the  muscle  and  operate  through  this 
elongated  button-hole. 

Step  3. — Search  for  and  isolation  of  the  sympathetic  nerve:  Retract  the 
muscle  and  with  it  the  packet  of  cervical  vessels  and  nerves  (carotid  artery, 
internal  jugular  vein,  vagus  nerv^e)  inwards  and  upwards.  Two  blunt  hooks 
or  one  wide  blunt  retractor  are  useful  for  this  purpose.  Look  for  the  nerve 
in  the  middle  of  the  wound,  either  on  the  posterior  surface  of  the  sheath  of 
the  vascular  packet  with  which  the  nerve  may  have  been  retracted  inwards 
or  on  the  vertebral  column,  where  it  lies  in  a  special  aponeurotic  sheath.  The 
nerve  is  easily  found.  It  is  impossible  to  confound  it  with  the  vagus,  the 
descending  branch  of  the  hypoglossal  (descendens  noni),  or  the  phrenic.  To 
dispel  all  doubt  as  to  identity  follow  the  nerve  upwards  and  see  the  superior 
gangUon  (Fig.  349). 

Step  4. — Isolation  and  resection  of  the  superior  ganglion:  Follow  the  nerve- 
trunk  upwards  to  the  gangUon  and  isolate  the  latter  from  below  upwards 
by  blunt  dissection  with  a  director.  Divide  its  afferent  and  efferent  fibres  with 
blunt-pointed  curved  scissors.  When  the  upper  end  of  the  ganglion  is  isolated, 
divide  or  tear  away  the  trunk  which  leads  from  it  towards  the  skull  (Fig.  350). 

Step  5. — Liberation  of  the  inferior  thyroid  artery:  This  artery  is  surrounded 
by  a  dense  and  often  adherent  nervous  plexus  consisting  of  the  sympathetic 
trunk  and  its  branches.  The  nerve  often  is  swollen  at  this  point,  forming 
the  middle  cervical  gangUon.  Put  tension  on  the  nerve-trunk  already  isolated 
and  follow  it  downwards.  Elevate  the  nerve  and  the  inferior  thyroid  artery 
together  and  separate  them  by  careful  blunt  dissection  (Fig.  351). 

Step  6. — Isolation  and  resection  of  the  inferior  ganglion:  This  is  the  most 
difiicult  step  in  the  operation,  as  the  ganglion  lies  deeply  imbedded  in  a  special 
lodge  at  the  base  of  the  neck  or  even  in  the  thorax,  behind  the  clavicle,  against 
the  neck  and  head  of  the  first  rib,  between  the  scalenus  anticus  and  longus 


2l8 


EXCISION    OF   THE    CERVICAL    SYMPATHETIC 


colli  muscles  and  just  above  the  pleura.  Using  the  trunk  of  the  nerve  as  a 
guide,  penetrate  to  the  ganglion,  which  lies  sometimes  internal  to,  and  some- 
times  (though   rarely)    external   to,    the  vertebral  artery.     The  ganglion   is 


Sup.  ganglion 

Sp.  accessory  nerve  -j. 
Sternomastoid 

Carotid  packet  I  ..J'" 


Sympath.  n. 
Inf.  thyroid  artery 

Inf.  ganglion 
Vertebral  artery 


Phrenic  n. 


Fig.  349. — E.xcision  of  cervical  sympathetic.     (Jonnesco.) 

adherent  to  the  artery  and  enlaces  it  in  a  meshwork  of  its  efferent  and  afferent 
fibres  (Fig.  351).  With  appropriate  retractors  retract  the  scalenus  anticus, 
thyroid  axis,  and  the  vertebral  artery  and  vein,  downwards  and  outwards; 


Sympath.  n. 


Inf.  thyroid  artery- 


Middle  ganglion- 


Scalenus  ant. 
',    Thyroid  axis 

Vertebral  n. 
Fig.  350. — (Jonnesco.) 


retract  inwards  and  forwards  the  sternomastoid  muscle  and  the  carotid  sheath 
with  its  contents.  Divide,  with  a  grooved  director,  the  cellular  and  aponeurotic 
tissues  covering  the  vessels  and  the  ganglion.     Seize  the  ganglion  with  for- 


SYMPATHECTOMY 


219 


ceps  and  isolate  it  successively  from  the  vertebral  artery  externally  and  from 
the  rib  and  spine  internally.  Isolate  and  divide  the  afferent  and  efferent 
fibres,  and  remove  the  ganglion. 

The  dangers  which  may  be  encountered  are: 

1.  Injury  to  the  vertebral  artery  and  vein. 

2.  Injury  to  the  first  intercostal  artery  or  its  cervical  branch. 

3.  Injury  to  the  subclavian  artery,  especially  on  the  left  side. 

4.  Injury  to  the  pleura. 

5.  Friability  of  the  ganglion,  rendering  morcellement  necessary. 

6.  Intimate  union  of  the  inferior  cervical  and  first  thoracic  ganglia  into 
one  mass,  from  which  a  portion  must  be  removed. 

7.  Injury   to   the  retroclavicular    venous  plexus.     This  accident  will    be 
rare  if  the  trunk  of  the  nerve  is  followed  closely. 

Inf.  thvroid  art. 


Middle  ganglion 


Inferior  ganglion 


Vertebral  art.  and 
vein 


Vertebral  n. 

Fig.  351. — (Jonnesco.) 

Step  7. — Suture  of  the  Wound. — Close  the  wound  completely  with  buried  and 
superficial  catgut  sutures.  The  superficial  stitches  ought  to  be  introduced 
in  the  intradermic  fashion  so  as  to  leave  little  scar.  There  should  be  no  drainage. 
Apply  dressings. 

Immediately  after  operation  on  one  side  the  corresponding  pupil  dilates, 
the  face  flushes,  eye  waters,  and  nose  secretes  abundantly.  These  phenomena, 
except  the  pupillary  dilatation,  are  very  transitory.  The  pulse  falls  below 
normal  for  a  few  days;  after  partial  resection  of  the  sympathetic  it  is  accelerated. 
The  operation  seems  to  have  no  ill  effects. 

After  the  patient  has  recovered  from  the  operation  on  one  side  the  other 
side  should  be  attacked  in  the  same  manner. 

Jonnesco  ("German  Surg.  Congress,"  1906)  has  performed  cervical  sym- 
pathectomy in  159  cases,  in  141  of  these  the  three  gangha  were  removed  with 
or  without  the  first  thoracic  ganghon.  In  all  but  two  cases  the  operation  was 
bilateral.  There  were  no  deaths  and  no  secondary  trophic  troubles.  The 
therapeutic  results  were: 

I.  Twenty-five    cases  of    exophthalmic    goitre    (two    subtotal   resections; 


220  EXCISION    OF   THE    CERVICAL   SYMPATHETIC 

twelve  complete;  eleven  cervico-thoracic  resections).  In  every  case  the  disease 
was  primary  Basedow's  disease,  either  complete  or  incomplete,  often  of  serious 
degree.  All  the  patients  recovered,  every  symptom  disappearing.  He  recom- 
mends strongly  the  complete  operation  with  or  without  removal  of  the  first 
thoracic  ganglion. 

2.  Glaucoma. — Eighty-eight  cases  of  superior  sympathectomy  have  been 
collected  showing  sixty-one  cured  or  improved,  twenty-two  unimproved, 
five  aggravated. 

3.  Epilepsy. — One  hundred  and  seventeen  cases  with  but  twelve  definite 
cures. 

4.  Trigeminal  Neuralgia. — In  one  case  resection  of  the  superior  ganglion 
resulted  in  recovery  which  has  lasted  four  years,  in  another  case  for  six  months. 

De  Souza  has  had  similar  experiences  in  Basedow's  disease  and  in  facial 
neuralgia. 

Farquhar  Curtis  finds  that  the  mortality  after  sympathectomy  for  Basedow's 
disease  is  very  high  and  the  ultimate  results  in  the  survivors  fair.  (''Annals 
Surg.,"  March,  1906.)  Alexander  of  Liverpool  at  one  time  performed  sym- 
pathectomy frequently  for  epilepsy  but  gave  it  up.  The  operation  is  still  sub 
judice.  * 

Periarterial  Sympathectomy. — R.  Leriche  (La  Pr.  Med.,  Sept.  10,  191 7  and 
May  15,  1920)  recommends  periarterial  sympathectomy  in  causalgia  and  cer- 
tain trophic  troubles.  He  believes  that  most  if  not  all  rebellious  causalgias 
are  due  to  disturbances  of  the  sympathetic  system,  that  the  burning  pains 
following  certain  nerve  wounds  is  not  due  to  the  injury  to  the  nerve  itself,  but 
to  lesions  of  the  neighboring  perivascular  sympathetic  or  of  the  intra-nervous 
sympathetics,  e.g.,  of  the  sympathetic  fibres  brought  into  the  median  nerve 
by  its  special  artery.  This  explains  the  fact  noted  by  Marie,  Meige  and  Mme. 
Benisty,  that  the  pain  after  nerve  wounds  is  a  reaction  proper  to  nerves 
provided  with  a  special  artery  or  which  are  near  a  large  artery. 

The  sympathetic  plays  a  very  great  part  in  the  production  of  the  true 
Babinski — Froment  reflex  contractures  in  which  vaso-motor  and  thermic 
phenomena  are  associated  with  motor  disturbances  of  the  muscles.  In  cases 
of  this  kind  Leriche  has  seen  motor  troubles  disappear  almost  completely 
after  sympathectomy.  The  day  after  operation  mobiUty  has  returned  notably 
in  hands  up  till  then  so  contracted  that  the  fingers  were  flexed  into  the  palm  or 
stiflfly  extended  dorsally.  Sympathectomy  on  the  brachial  artery  has  ap- 
parently cured  ulnar  claw  hand  (griffe  cubital). 

The  results  of  Leriche's  observations  are: — (i)  In  causalgia  periarterial 
sympathectomy  sometimes  cures,  almost  always  improves  (2)  trophic  ulcer- 
ations. Five  patients  submitted  to  operation.  All  cured.  (3)  Blue  oedema 
of  the  extremities.  Three  submitted  to  operation.  Cured;  much  improved  i; 
some  improvement  i.  (4)  Reflex  disturbances  18  operations.  Practically 
cured  3,  (disappearance  of  vaso-motor  disturbances  and  of  contractures). 
More  or  less  improved  (some  almost  cured)  10;  improved  but  with  later  incom- 
plete recurrence  2 ;  failures  2. 

*Leriche  [Bui.  Soc.  Chir.  Paris  21,  Dec,  1920]  has  relieved  or  cured  (i)  progressive 
facial  hematroph}-,  (2)  post-herpetic  hemicrania,  and  (3)  permanent  lagophthalmos  in 
facial  palsy  bj-  means  of  excision  of  the  superior  cer\-ical  sympathetic  ganglion. 


PERIARTERIAL   SYMPATHECTOMY  221 

In  the  i6  cases  with  true  improvement  there  was  diminution  of  contracture 
with  more  or  less  reappearance  of  voluntary  motion.  After  some  weeks  as 
the  vaso-dilatation  caused  by  the  sympathectomy  lessens,  retrogression  takes 
place  but  the  operation  is  of  value,  according  to  Heitz,  as  a  step  in  treatment. 
The  treatment  by  sympathectomy  followed  by  hot  paraffin  baths,  massage  and 
reeducation  gave  the  best  results  in  Babinski's  service. 

(5)  In  one  case  of  diffuse  parenchymatous  goitre  Leriche  performed  unilateral 
periarterial  sympathectomy  of  the  superior  thyroid  and  noted  that  there  was  a 
''veritable  melting  away  of  the  corresponding  lobe."  If  this  observation  is 
verified  it  will  help  to  explain  the  good  results  from  ligation  of  the  thyroid 
vessels. 

The  Operation. — Expose  the  artery  as  usual  for  a  distance  of  8  to  10  cm. 
(3-4  ins.).  Incise  the  tunica  adventitia  and  separate  this  sheath  from  the 
artery  by  sharp  or  blunt  dissection.  If  the  integrity  of  the  vessel  is  accidentally 
injured  too  much,  doubly  ligate  it  and  excise  a  segment.  The  whole  procedure 
is  more  or  less  like  subserous  decortication  of  an  inflamed  appendix.  When  the 
decortication  of  the  artery  is  completed  close  the  wound. 

The  reactions  following  operation  are  primary  and  secondary.  Primarily 
the  artery  gradually  contracts  to  }/^  or  even  34  its  normal  size  throughout  the 
denuded  segment,  while  the  segments  above  and  below  remain  normal.  The 
pulse  usually  disappears,  but  the  circulation  is  not  abolished.  For  some 
hours  the  pulse  is  imperceptible  or  very  weak  and  the  limb  is  colder  than  it's 
fellow. 

Secondary  Reactions. — After  3-6  or  more  frequently  12  or  15  hours  the  local 
temperature  rises  2°  or  even  3°  (centigrad).  Arterial  pressure  sometimes 
becomes  4c.  higher  than  on  the  opposite  limb.  These  reactions  slowly  diminish 
after  two  weeks,  lasting  longer  when  the  artery  is  resected  than  when  its  outer 
tunic  alone  is  removed.  The  value  of  periarterial  sympathectomy  is  entirely 
sub  judice.     It's  preponents  are  apparently  fairly  conservative  in  their  claims. 

In  hyperthyroidism  with  extreme  exophthalmos  and  nervous  symptoms  out 
of  proportion  to  the  size  of  the  thyroid  C.  H.  Mayo  removes  the  superior 
sympathetic  ganglion  (sometimes  the  middle  one  also)  and  through  the  same 
incision  ligates  the  superior  thyroid  vessels.  It  is  best  to  operate  with  both 
general  and  local  anesthesia.  An  incision  is  made  opposite  the  bifurcation  of 
the  carotid,  the  sternomastoid  is  retracted  outwards,  the  carotid  packet  is 
drawn  inwards  and  opened  posteriorly  so  as  to  demonstrate  the  vagus  as  this 
nerve  may  be  mistaken  for  the  sympathetic.  Under  normal  conditions  the 
sympathetic  ganglion  is  3^  to  34  inch  wide  and  has  many  branches.  After 
division  of  the  connecting  branches  the  upper  part  of  the  ganglion  is  torn  off 
or  cut  and  the  lower  portions  of  the  nerve  cut  or  torn  off  at  the  middle  ganglion 
unless  that  also  is  removed.  The  superior  thyroid  vessels  are  secured  by 
ligating  the  upper  poles  of  the  thyroid.  Sympathectomy  causes  relaxation  of 
the  eyeballs,  slight  ptosis  of  the  upper  lid  with  general  improvement  of  symp- 
toms. In  Mayo's  cases  when  the  vessels  of  both  upper  poles  were  ligated  in 
addition  to  the  sympathectomy  the  primary  results  were  good  but  time  enough 
has  not  passed  to  permit  conclusions  being  drawn  regarding  permanency. 

Pleth  (see  p.  75)  recommends  this  method  of  sympathectomy  as  a  cure  for 
trifacial  neuralgia. 


222  RETROPHARYNGEAL   ABSCESS   AND   TUMORS 

CHAPTER   XXIII 

RETROPHARYNGEAL  ABSCESS  AND  TUMORS 

There  are  two  methods  of  opening  retropharyngeal  abscess,  viz.,  through 
the  mouth  and  through  the  neck. 

1.  Opening  the  Abscess  through  the  Mouth. — No  anesthetic,  not  even 
cocaine,  is  permissible.  If  the  pharyn.x  and  larynx  were  anesthetized,  there 
would  be  increased  danger  from  inspiration  of  discharges.  A  knife,  the  edge 
of  which  is  protected  with  cotton  or  adhesive  plaster  to  within  one  inch  of  the 
point,  is  guided  on  the  finger  of  the  left  hand  through  the  mouth  to  the  posterior 
wall  of  the  pharynx.  An  incision  is  made  into  the  abscess  at  its  most  promi- 
nent point.  The  knife  is  at  once  withdrawn.  If  the  patient  is  a  child,  the 
operation  should  be  performed  in  the  Rose's  position — i.e.,  with  hanging  head, 
and  in  any  case  as  soon  as  pus  begins  to  flow  the  head  should  be  lowered  and 
the  body  elevated.  The  after-treatment  consists  in  the  use  of  antiseptic  gar- 
gles and  sprays  and  in  keeping  the  wound  open  by  daily  probing,  if  this  is 
necessary. 

2.  Drainage  through  the  Neck, — Chienes  Operation. — Make  an  incision 
two  inches  in  length  along  the  posterior  margin  of  the  sternomastoid,  beginning 
at  the  apex  of  the  mastoid  process  and  running  downwards.  After  division 
of  the  deep  fascia  one  can  by  blunt  dissection  reach  the  anterior  surface  of 
the  bodies  of  the  cervical  vertebrae  where  the  abscess  is  situated.  The  skin 
and  fascia  having  been  incised  as  above,  the  pus  may  be  reached  and  evacuated 
by  Hilton's  method.     This  is  a  very  safe  and  easy  procedure. 

Remarks. — Retropharyngeal  abscess  may  be  acute  or  chronic.  It  is  only 
for  the  former  that  operation  through  the  mouth  is  suitable.  On  purely 
theoretical  grounds  the  operation  through  the  mouth  must  be  condemned  for 
the  following  reasons:  (a)  When  the  pus  begins  to  flow  there  is  danger  of  asphyxi- 
ation, {h)  No  dressings  can  be  applied  to  soak  up  discharges  and  keep  out 
dirt,  (c)  There  is  grave  danger  of  septic  pneumonia  and  of  infection  to  the 
gastrointestinal  canal,  {d)  If  the  case  is  one  of  tuberculous  abscess,  secondary 
infection  is  certain.  Practically  it  has  been  found  that  by  using  Rose's  position 
or  by  inverting  the  patient  during  the  first  flow  of  pus  the  danger  of  asphyxia- 
tion is  averted,  and  that  in  acute  cases  rapid  recover^'  does  ensue.  An  advan- 
tage is  claimed  for  this  operation,  viz.,  that  an  anesthetic  is  not  necessary,  but 
certainly  in  case  of  need  the  external  operation  can  be  done  under  a  local 
anesthetic. 

The  advantages  of  the  external  route  are:  (c)  The  possibility  of  careful 
removal  of  diseased  foci,  e.g.,  diseased  bone,  etc.;  {b)  the  possibility  of  treat- 
ing the  abscess  antiseptically  and  providing  for  permanent  draining;  (c)  the 
possibility  of  avoiding  secondary  infection;  {d)  the  avoidance  of  the  danger 
of  drowning  the  patient  in  his  own  pus. 

The  principal  disadvantage  is  the  scar  which  must  be  left,  but  as  a  rule  it 
is  not  very  noticeable. 


RETROPHARYNGEAL   TUMORS  223 

Retropharyngeal  Tumors. — I.  The  tumor  is  not  adherent  to  the  spinal 
column,  but  is  movable.  Perform  tracheotomy.  Tampon  the  larynx  or  tra- 
chea. Place  the  patient  in  Rose's  position.  Introduce  a  mouth-gag  and  open 
the  mouth.  Pierce  the  tongue  with  a  needle  and  pull  through  a  stout  thread 
which  serves  as  a  handle  to  manipulate  the  tongue.  Make  an  incision  through 
the  mucous  membrane  of  the  posterior  pharyngeal  wall  and  expose  the  tumor 
freely.  Busch  has  shown  that  the  tumor  lies  loosely  imbedded  in  the  retro- 
pharyngeal tissues  and  can  be  shelled  out.  Generally  blunt  dissection  with 
closed  curved  scissors  will  result  in  easy  removal  of  the  growth.  Clean  the 
pharyngeal  cavity  and  the  wound  with  a  non-poisonous  antiseptic. 

If  necessary  to  obtain  more  room,  the  soft  palate  may  be  divided  longitu- 
dinally.    This  wound  must  be  closed  by  suture  as  soon  as  the  tumor  is  removed. 

II.  The  tumor  is  so  extensive  that  removal  through 
the  mouth  is  impossible.     The  pharynx  must  be  opened    ^^  ,    r ^$^ 

from  the  neck. 

Step  I. — Make  a  U-shaped  incision  beginning  in 
front  of  the  masseter  and  ending  at  the  tip  of  the  mas- 
toid process.     The  lowest  part  of  the  U  reaches  below 

the  level  of  the  hyoid  bone.     Doubly  ligate  and  divide    ,  ^^'?-    352  —Exposure 
1  •         1  •  -r.    n  1      1        1  •      n        '^^     pharynx     from     the 

the  external  jugular  vem.     Reflect  upwards  the  skm-nap  neck. 

outlined  by  the  incision  (Fig.  352). 

Step  2. — Divide  the  cervical  fascia  along  the  anterior  margin  of  the  sterno- 
mastoid.  Expose  the  external  carotid  artery.  This  artery,  partly  covered 
by  the  internal  jugular  vein,  should  be  sought  on  the  line  of  the  anterior  margin 
of  the  sternomastoid  between  a  point  on  a  level  with  the  hyoid  and  one  on  a 
level  with  the  upper  edge  of  the  thyroid  cartilage.  Before  tying  the  vessel 
expose  at  least  one  of  its  branches.  This  precaution  is  recommended  because 
the  internal  has  occasionally  been  mistaken  for  the  external  carotid. 

Step  3. — Doubly  ligate  the  artery  and  divide  it  between  the  ligatures. 
Expose  as  thoroughly  as  possible  such  part  of  the  tumor  as  may  present  between 
the  inferior  maxilla  and  the  mastoid.  If  it  is  feasible  to  remove  the  tumor 
through  this  space,  do  so;  otherwise  proceed  to  the  next  step. 

Step  4. — Cut  through  the  soft  structures  covering  the  inferior  edge  of  the 
horizontal  ramus  of  the  lower  jaw  at  a  point  just  in  front  of  the  masseter  muscle. 
Through  this  incision  with  an  elevator  separate  the  periosteum  from  the  bone 
sufficiently  to  allow  of  subperiosteal  section  of  the  bone.  With  finger-saw, 
forceps,  Gigli's  wire  or  the  chain  saw  divide  the  bone.  Dislocate  the  temporo- 
maxillary  joint  and  turn  the  ascending  ramus  of  the  jaw  upwards  together 
with  the  soft  parts  covering  it.  This  gives  very  free  access  to  the  pharyngeal 
wall. 

Step  5. — Isolate  the  tumor  by  blunt  dissection  if  possible.  Do  not  open 
the  pharyngeal  cavity  before  it  is  absolutely  necessary  to  do  so.  Remove  the 
growth. 

Step  6. — Pack  the  cavity  with  iodoform  gauze.  Replace  the  dislocated 
portion  of  the  lower  jaw  and  wire  it  in  position.  Close  most  of  the  wound 
in  the  soft  parts  by  interrupted  silkworm-gut  sutures,  leaving  an  opening 
through  which  the  gauze  pack  protrudes.     Dress. 


224  CESOPHAGUS 

In  one  case  the  writer  was  surprised  to  find  that  he  was  able  to  shell  out 
in  the  above  manner  a  large  tumor  affecting  the  right  side  and  roof  of  the 
pharynx,  without  tearing  or  dividing  the  pharyngeal  mucous  membrane. 

As  a  preUminary  to  the  operation  tracheotomy  may  or  may  not  be  per- 
formed. If  the  growth,  either  from  size  or  location,  does  not  interfere  with 
respiration;  if  the  surgeon  ligates  the  external  carotid  artery  near  its  origin 
and  does  not  open  the  pharynx  until  the  tumor  is  almost  entirely  separated 
and  hemostasis  has  been  secured,  then  a  preliminary  tracheotomy  appears 
superfluous. 


CHAPTER   XXIV 
CESOPHAGUS 


(Esophagotomy. — The  oesophagus  may  be  opened  either  in  the  neck  or  in 
the  posterior  mediastinum.     The  latter  operation  is  discussed  elsewhere. 

Cervical  oesophagotomy  is  performed  for  the  removal  of  foreign  bodies, 
the  treatment  of  stricture,  the  excision  of  small,  sharply  defined  tumors,  or  as  a 
step  in  the  operation  of  oesophagostomy.  Place  the  patient  on  the  table  with 
shoulders  slightly  elevated  and  the  face  turned  towards  the  right.  Beginning 
at  the  level  of  the  thyroid  cartilage,  make  an  incision  downwards  for  about 
three  inches  along  the  anterior  margin  of  the  left  sternomastoid  muscle.  Divide 
the  platysma,  superficial  and  deep  fasciae.  The  omohyoid  may  be  divided 
or  retracted  according  to  convenience.  Retract  the  thyroid  gland  and  trachea 
towards  the  right.  Notice,  in  the  wound,  the  common  sheath  containing  the 
carotid,  internal  jugular,  and  vagus.  Retract  these  structures  to  the  left. 
The  oesophagus  will  now  be  exposed.  If  a  foreign  body  is  present,  fix  the 
oesophagus  with  small  volsellum  forceps  and  make  a  longitudinal  cut  into  it 
over  the  foreign  body.  If  necessary,  enlarge  the  wound  with  a  probe-pointed 
bistoury  or  with  scissors.  Gently  extract  the  foreign  body.  This  frequently 
requires  much  patience.  The  incision  through  the  oesophagus  should  be  made 
on  the  side,  as  the  recurrent  laryngeal  lies  in  the  groove  between  it  and  the 
trachea. 

When  no  foreign  body  is  present  distending  the  oesophagus,  pass  an  oesoph- 
ageal bougie  through  the  mouth  and  cut  down  upon  it  when  incising  the  gullet 
wall. 

V.  Haecker  (Muenchener  med.  Woch.,  Oct.  15,  1907)  reports  the  case  of  a 
pregnant  woman  who  swallowed  her  plate  with  artificial  teeth.  This  irregular 
body  became  impacted  where  the  oesophagus  crosses  the  left  bronchus.  At- 
tempts at  removal  by  the  oesophagoscope  having  failed,  Friedrich  opened  the 
oesophagus  just  above  the  upper  thoracic  aperture  and  removed  the  plate  after 
dividing  it  with  cutting  forceps.  The  wound  was  packed  around  an  oesophageal 
catheter  through  which  food  was  administered.  Soon  an  cesophageal-bronchial 
fistula  formed  and  gangrene  developed.  Gastrostomy  was  now  performed 
and  for  three  months  the  patient  was  nourished  through  the  gastric  fistula. 
After  this  time  the  broncho- oesophageal  fistula  closed  and  the  patient  recovered 
perfectly. 


(ESOPHAGEAL   DIVERTICULA  225 

Bodies  impacted  low  down  in  the  oesophagus  have  been  extracted  through 
a  gastrotomy  wound  in  twenty  out  of  twenty-four  cases  (v.  Haecker).  A 
bougie  passed  through  the  mouth  gives  great  assistance  in  the  work. 

Foreign  bodies  may  be  removed  from  the  lower  oesophagus  through  the 
stomach.  M.  H.  Richardson  successfully  performed  gastrotomy,  explored  the 
lower  oesophagus  and  removed  a  plate  containing  four  teeth  which  had  been 
lodged  there  for  eleven  months.  A  peach  stone  was  arrested  6  or  7  inches  above 
the  cardiac  orifice;  the  usual  measures  failed  to  dislodge  it;  W.  T.  Bull  per- 
formed gastrotomy,  passed  a  small  bougie,  with  a  loop  at  its  point,  from  the 
stomach  to  the  mouth,  pulled  a  stout  thread  through  the  oesophagus  with  the 
bougie;  tied  a  sponge  to  the  lower  end  of  the  thread  and  pulled  the  sponge 
through  the  oesophagus  and  out  of  the  mouth.  The  sponge  swept  away  the 
foreign  body. 

Through  the  oesophageal  wound  one  may  divide  or  forcibly  dilate  a  stricture 
or  even  remove  a  small  tumor.  For  such  purposes,  however,  the  operation  will 
be  but  little  used,  as  strictures  are  generally  more  suitably  treated  by  other 
means,  and  tumors  eradicable  by  the  above  operation  must  be  of  great  rarity. 

Closure  of  the  Wound. — Close  the  oesophageal  wound  by  a  row  of  sutures  of 
fine  catgut  not  involving  the  mucosa.  Lessen  the  size  of  the  external  wound 
by  a  few  stitches  at  its  upper  and  lower  extremities.  Loosely  pack  the  remainder 
of  the  wound  with  iodoform  gauze.  Apply  plentiful  dressings.  Treves  advises 
the  use  of  some  orthopaedic  apparatus  to  secure  rest  for  the  parts. 

For  the  first  day  or  two  after  the  operation  the  patient  should  be  nourished 
by  means  of  enemata;  subsequently  food  should  be  administered  through  a 
small  soft-rubber  stomach-tube  passed  through  the  mouth.  This  method  of 
feeding  must  be  kept  up  until  it  is  evident  that  the  oesophageal  wound  has 
healed.  The  cervical  wound  requires  frequent  dressing  and  the  mouth  must 
be  washed  at  short  intervals  with  some  antiseptic  lotion.  The  great  danger 
to  be  apprehended  is  sepsis,  especially  septic  mediastinitis. 

(Esophageal  Diverticula. — Diverticula  occasionally  are  present  in  the  neck 
and  communicate  with  the  oesophagus  or  pharynx.  When  these  are  large, 
food  passes  into  them  and  serious  symptoms,  even  death,  may  result.  The 
condition  is  often  unrecognized  by  the  physician.  In  serious  cases  operation 
is  demanded.  Sometimes  good  results  are  obtained  by  having  the  patient 
swallow  a  whip  cord  and  using  this  as  a  guide,  passing  bougies  in  a  manner 
analogous  to  the  passage  of  Gouley's  tunnelled  sounds  over  a  whalebone  fili- 
form in  urethral  stricture  (Mixter). 

The  Operation. — Proceed  as  in  oesophagotomy.  Retract  the  trachea  to- 
wards the  right,  the  sternomastoid  and  the  sheath  containing  the  carotid, 
internal  jugular,  and  vagus  to  the  left.  Pass  an  oesophageal  bougie  through 
the  mouth  into  the  diverticulum,  if  this  is  possible.  Recognize  the  divertic- 
ulum and  its  relations  to  surrounding  structures.  Remove  the  bougie.  Sepa- 
rate the  diverticulum  from  its  surroundings.  This  can  generally  be  accom- 
plished by  blunt  dissection.  Where  the  diverticulum  joins  the  oesophagus  its 
neck  may  be  as  thick  as  a  man's  thumb.  Divide  the  neck  of  the  diverticulum 
layer  by  layer  close  to  the  oesophagus.  With  catgut,  suture  the  wound  of  the 
mucous  membrane.     The  wound  of  the  outer  tunics  of  the  neck  of  the  diver  tic- 

15 


2  26  OESOPHAGUS 

ulum  is  closed  by  an  invaginating  suture  like  Lembert's  intestinal  stitch. 
Partially  close  the  external  wound.  Provide  very  free  drainage  by  means  of 
iodoform  gauze.  The  after-treatment  is  the  same  as  that  for  cesophagotomy. 
When  the  diverticulum  is  comparatively  small  the  skin-incision  need  not  be 
longer  than  that  for  cesophagotomy;  but  when  it  is  large,  then  the  incision  must 
be  longer.  It  is  better  to  make  an  incision  longer  than  is  absolutely  necessary 
than  be  cramped,  while  operating,  through  lack  of  room. 

Girard  and  A.  E.  Halstead  in  cases  of  small  diverticula  avoided  opening  the 
sac.  .After  exposing  and  isolating  the  sac,  they  surround  it  near  its  base  by 
a  catgut  purse-string  suture,  invaginate  the  diverticulum  into  the  oesophagus, 
pull  the  purse  string  tight  and  tie  it.  This  method  avoids  the  necessity  of 
drainage.     The  pouch  is  said  to  become  atrophied. 

Gehles  Method. — To  avoid  dangers  of  mediastinitis,  etc.,  especially  in  de- 
bilitated individuals,  Gehle  ("Muenchener  med.  Woch.")  operates  as  follows: 

Expose  and  isolate  the  diverticulum.  Make  a  small  opening  into  the 
distal  end  of  the  sac.  Remove  the  mucous  membrane  as  well  as  possible  with 
a  sharp  spoon.  Through  the  sac  pass  a  small  oesophageal  tube  into  the  stomach. 
Rotate  the  sac  (and  tube)  on  its  long  axis,  to  the  extent  of  i8o°.  FLx  the 
sac  in  its  position  of  torsion  by  means  of  three  catgut  purse-string  sutures  after 
freshening  the  surfaces  to  be  brought  in  contact.  These  sutures  tie  the  sac 
firmly  to  the  tube.  Suture  the  opening  in  the  sac,  where  the  tube  protrudes, 
to  the  superficial  fascia.  Close  the  wound  around  the  sac.  Gehle  was  able  to 
feed  his  patient  through  the  tube  on  the  day  of  operation.  The  tube  was 
removed  on  the  sixth  day.  On  the  sixteenth  day  both  solid  and  fluid  food  could 
be  swallowed. 

To  the  author  it  appears  that  Gehle  is  wrong  in  calling  the  operation  "radi- 
cal," but  in  suitable  cases  it  seems  to  be  the  least  dangerous  method  and  at 
the  same  time  the  alteration  in  position  and  shape  of  the  diverticulum  promises 
good  practical  results.  It  is  difficult  to  believe  that  curettement  will  suflS- 
ciently  remove  the  mucosa  to  permit  of  obliteration  of  the  lumen. 

CESOPHAGE.AL   STRICTURE 

Non-malignant  strictures  of  the  oesophagus  should  be  treated  by  the  passage 
of  bougies  through  the  mouth.  It  is  said  that  dilatation  may  sometimes  be 
aided  by  the  hypodermic  administration  of  suitable  doses  of  thiosinamin  (thio- 
sinamin,  15;  antipyrin,  7.50;  water,  100.  Dose,  0.5  c.c.  Ten  injections  usually 
suffice)  or  some  of  its  equivalents.  This  drug  acts  by  softening  scar  tissue 
to  such  an  extent  that  mechanical  treatment  is  greatly  facilitated.  The  oesoph- 
agus commonly  becomes  greatly  distended  above  the  site  of  a  stricture  hence 
it  is  often  difficult  to  pass  a  sound  into  the  stricture.  Under  these  circum- 
stances retrograde  catheterization  becomes  proper. 

Abbe's  Operation. — The  oesophageal  pouch  which  forms  above  a  stricture 
is  a  great  hindrance  to  the  passage  of  bougies.  Abbe  overcomes  this  difficulty 
by  retrograde  dilatation  which  he  carries  out  in  characteristically  ingenious 
fashion.  Perform  gastrotomy.  Pass  a  fine  whale-bone  bougie  from  below 
upwards  until  it  protrudes  from  the  mouth.     To  the  end  of  the  bougie  tie 


CESOPHAGECTOMY  227 

two  long  and  stout  threads  of  braided  silk  (whip  cord  will  do).  Pull  the  bougie 
out  through  the  stomach  wound  and  leave  the  two  threads  protruding  from 
the  mouth  and  the  stomach  wound.  Tie  the  lower  end  of  one  thread  to  an 
eye  at  the  point  of  a  conical  oesophageal  bougie  (Billroth).  By  pulling  on  the 
upper  end  of  this  thread  it  is  easy  to  bring  the  conical  tip  of  the  bougie  into 
the  stricture  and  render  that  stricture  tense.  Keep  up  gentle  traction  to 
dilate  the  stricture  with  the  bougie  and  at  the  same  time  pull  the  second  cord  up- 
wards and  downwards  vigorously  with  a  see-saw  motion.  The  friction  of  the 
cord  divides  the  stricture  without  damaging  other  strictures.  The  conical  bougie 
rapidly  passes  upwards  as  the  friction  wears  away  the  strictures,  and  the 
largest  bougie  suitable  to  the  oesophagus  is  rapidly  forced  upwards  to  the  mouth 
by  a  few  moments'  stretching  and  "string-sawing."  The  gastrotomy  wound 
may  now  be  closed  by  inversion  and  double  suturing.  Subsequent  passage 
of  a  full-size  bougie  once  a  week  will  complete  the  cure,  but  must  be  continued 
at  longer  intervals  for  one  year  or  more.  Instead  of  dividing  the  stricture 
by  friction  and  bougies,  Ochsner  draws  a  rubber  tube,  under  tension,  through 
the  stricture.  When  the  tension  is  taken  off  the  tubing  it  expands  and  so 
dilates  the  stricture.  In  the  course  of  some  days,  during  which  larger  or  double 
tubes  are  introduced,  Ochsner  obtains  good  results. 

The  author  was  much  prejudiced  against  the  Abbe  operation,  thinking  it 
harsh  and  dangerous,  but  since  seeing  it  performed  by  Abbe  he  has  changed 
his  views. 

In  any  method  of  treatment  where  a  gastrostomy  is  performed,  do  not 
administer  thiosinamine.  If  this  drug  has  any  marked  softening  effect  on  the 
scar  tissue  forming  the  stricture  it  ought  to  have  a  similar  and  disastrous  effect 
on  the  union  between  the  stomach  and  the  belly  wall. 

In  one  case  operated  on  by  Maurice  Richardson  a  friable  stricture  existed 
in  the  oesophagus  immediately  below  the  opening  of  a  diverticulum.  Richard- 
son split  or  ruptured  the  stricture  longitudinally  and  repaired  the  defect  by 
means  of  a  flap  provided  by  the  diverticulum.  The  excess  of  tissue  in  the 
diverticulum  was  excised 

CEsophagostomy  may  be  performed  below  a  stricture  or  neoplasm  as  a  means 
of  feeding,  but  gastrostomy  is  infinitely  easier  and  safer  to  perform  and  is 
much  less  disagreeable  to  the  patient  subsequently.  It  may  be  performed 
above  the  stricture  to  permit  the  passage  of  a  funnel-shaped  tube  from  the 
pharynx  over  the  chest  wall  to  a  gastric  fistula  (Gliick),  The  operation  is 
practically  the  same  as  oesophagotomy  but  the  oesophageal  wound  is  kept  patent 
either  by  suturing  or  by  the  introduction  of  a  rubber  tube. 

Cervical  (Esophagectomy  for  malignant  neoplasms  is  not  very  promising, 
according  to  deQuervain's  statistics,  but  if  performed  early  and  thoroughly, 
results  ought  to  be  improved. 

1.  Expose  the  oesophagus  as  in  oesophagotomy,  the  incision  must  be  more 
extensive  as  a  rule.  If  the  thyroid  adheres  to  the  neoplasm,  remove  that  portion 
of  the  thyroid.  Carefully  separate  the  oesophagus  from  the  back  of  the  trachea 
and  larynx,  paying  special  attention  to  the  preservation  of  the  recurrent 
laryngeal  nerve.     Completely  isolate  the  affected  segment  of  the  gullet. 

2.  Choose  the  line  of  section  at  least  }/2  i^ich  above  and  below  the  neoplasm. 


2  28  CESOPHAGUS 

Introduce  an  anchor  suture  of  silk  or  hemp  into  the  wall  of  the  gullet  above  and 
below  the  part  to  be  removed.  Divide  the  oesophagus  at  the  selected  points. 
Attend  to  hemostasis. 

3.  A.  A  very  limited  portion  of  gullet  has  been  removed  (4  cm.,  1^  inches, 
Czerny),  restore  the  continuity  by  sutures.  B.  If  a  longer  portion  has  been 
excised  and  approximation  is  impossible,  anchor  the  upper  and  lower  oesopha- 
geal stumps  to  the  skin  by  means  of  sutures.  Pack  the  wound  carefully,  paying 
special  attention  to  protecting  the  mediastinum.  When  the  wound  has  become 
sufficiently  covered  with  granulation  tissue  a  secondary  oesophagoplasty  may  be 
attempted  or  a  tube  may  be  passed  from  the  pharynx  to  the  stomach  as  men- 
tioned  in   oesophagostomy. 

C.  Primary  oesophagoplasty  (Arbuthnot  Lane,  "Brit.  Med.  Journ.,"  Jan. 
7,  1911).  Cut  a  flap  of  skin  about  5  inches  long  and  2  or  more  inches  wide  (ac- 
cording to  the  amount  of  disease  to  be  removed)  extending  horizontally  from  a 
vertical  line  to  the  left  of  the  larynx  over  the  anterior  and  right  sides  of  the  neck. 
Reflect  the  flap  up  to  its  base.  Expose  and  excise  the  affected  segment  of 
gullet.  Fold  the  skin  flap  in  the  form  of  a  tube  of  appropriate  diameter  and 
suture  it  carefully  to  the  oesophageal  stumps.  Pass  a  tube  through  the  pharynx 
and  oesophagus  and  leave  it  in  situ  for  feeding  purposes.  (Gastrostomy  is  com- 
monly performed  as  a  preliminary  operation  so  that  nourishment  can  be 
given.)     Pack  the  wound  with  gauze  and  partially  close  it  with  sutures. 

D.  Secondary  oesophagoplasty  has  been  performed  byHascker  and  others  but 
it  is  so  similar  to  the  primary  operation  that  a  special  description  is  unnecessary. 

Antethoracic  CEsophagoplasty. — Roux  ("Semaine  medicale,"  Jan.,  1907) 
reported  an  operation  for  impermeable  oesophageal  stricture.  The  operation 
consists  in  performing  an  oesophago-jejuno-gastrostomy. 

1.  Open  the  abdomen.  Choose  a  very  mobile  loop  of  jejunum.  Doubly 
ligate  and  divide  four  or  five  of  the  vessels  passing  to  the  loop  of  jejunum  pre- 
serving the  peripheral  vascular  arcades  intact.  Be  sure  that  sufficient  blood 
passes  through  the  vascular  arcades  of  the  selected  portion  of  gut  from  unligated 
vessels  near  its  anal  end.  Apply  intestinal  clamps  to  and  divide  the  gut  at  both 
ends  of  the  selected  segment. 

2.  Anastomose  the  open  anal  end  of  the  segregated  segment  to  the  stomach 
near  its  lesser  curvature. 

3.  With  forceps  make  a  subcutaneous  tunnel  from  the  abdominal  wound  to 
the  notch  of  the  sternum.  Protect  with  gauze  the  oral  end  of  the  segregated 
segment  of  jejunum  and  pull  it  up  through  the  tunnel.  With  sutures  fix  the 
upper  end  of  the  gut  to  the  upper  end  of  the  tunnel.  Pass  a  stomach  tube 
through  the  segment  of  gut  buried  in  the  chest  wall,  into  the  stomach  and  fix 
it  to  the  opening  at  the  sternal  notch. 

4.  With  suture  or  Murphy's  button  restore  the  continuity  of  the  intestine. 
If  the  patient  survives  the  above  rather  strenuous  procedure  the  cervical 

oesophagus  may  be  exposed,  incised  and  anastomosed  to  the  upper  end  of  the 
subcutaneous  tube  by  means  of  flaps  of  skin. 

Th.  Gliick  in  cases  of  malignant  oesophageal  stricture  exposes  the  cervical 
oesophagus,  makes  an  opening  in  it,  and  unites  the  opening  to  the  skin.  A 
gastrostomy  has  also  been  performed.     When  the  wounds  are  healed  Gliick 


CESOrHAGOPLASTY  229 

introduces  a  rubber  tube  through  the  mouth  to  emerge  from  the  oesophageal 
fistula  and  pass  over  the  chest  to  enter  the  stomach  via  the  gastrostomy  opening. 
The  upper  end  of  the  tube  is  funnel  shaped  so  as  to  remain  in  the  oesophagus. 
Prof.  Gluck  informed  the  author  that  his  patients  could  swallow  their  food 
satisfactorily,  the  bolus  passing  through  the  rubber  gullet  as  well  as  if  there 
was  peristalsis. 

In  one  case  of  oesophageal  cancer  Kelling  ("Zent.  fiir  Chir.,"  No.  36,  191 1) 
found  the  mesentery  of  the  small  intestine  too  short  to  permit  of  Roux's  opera- 
tion being  performed  so  he  operated  as  follows :  Laparotomy.  The  transverse 
colon  was  found  long  and  mobile.  At  each  end  of  the  most  mobile  and  con- 
venient segment  of  colon  two  intestinal  clamps  were  applied  and  the  gut  divided. 
After  restoring  the  continuity  of  the  remainder  of  the  colon,  the  right  end  of  the 
segregated  segment  was  closed  with  sutures  and  the  left  end  was  anastomosed  to 
the  stomach.  The  meso-colon  was  divided  below  the  vascular  arcade,  only  the 
left  portion  being  retained  intact.  A  Stamm-Kader  gastrostomy  was  performed. 
An  incision  was  made  through  the  skin  from  the  level  of  the  mamma  on  the  left 
of  the  sternum  down  to  the  abdominal  wound  and  a  subcutaneous  gutter  formed 
in  which  the  mobilized  colon  was  planted,  the  skin  wound  being  sutured  over 
the  gut.  The  abdominal  wound  was  closed.  After  seven  days  the  buried  blind 
end  of  the  colon  was  opened  and  its  mucosa  sutured  to  the  skin.  After  25  days 
cervical  oesophagostomy  was  performed.  To  unite  the  upper  end  of  the  trans- 
planted colon  to  the  cervical  stoma  by  means  of  a  tube  of  skin,  two  parallel 
incisions  about  four  finger-breadths  apart  were  made  through  the  skin  just 
above  the  cervical  opening  to  below  the  fistula  on  the  chest.  By  undermining 
it  was  easy  to  form  a  tube  of  the  skin  between  the  incisions  and  so  to  complete 
the  new  oesophagus.  The  raw  surfaces  occasioned  by  the  formation  of  the 
epidermal  tube  were  covered  by  pedunculated  flaps  of  skin  taken  from  else- 
where on  the  chest. 

Instead  of  using  intestine  in  antethoracic  cesophagoplasty,  Bircher  and  Wull- 
stein  have  constructed  a  tube  entirely  composed  of  skin  just  as  Kelling  did  for 
part  of  the  oesophagus  in  his  case. 

Frangenheim  (German  Surg.  Congr.,  191 2)  reported  one  case  of  antethoracic 
cesophagoplasty  in  which  both  skin  and  jejunum  were  used;  the  patient  after 
the  lapse  of  a  year  was  still  swallowing  all  sorts  of  food  without  trouble. 

Jianu's  CEsophagoplasty. — Open  the  abdomen.  Pull  the  stomach  forwards. 
Divide  the  great  omentum  transversely  below  the  gastro-epiploic  vessels.  Li- 
gate  and  divide  the  right  gastro-epiploic  vessels.  The  greater  curvature  of  the 
stomach  is  now  free  from  the  omentum  and  well  nourished  by  the  left  gastro- 
epiploic vessels. 

Put  a  row  of  mattress  sutures  through  both  the  anterior  and  posterior 
walls  of  the  stomach  along  the  line  A  B,  Fig.  353.  (With  a  complex  machine 
devised  by  Hiiltl,  Willy  Meyer  in  one  movement  inserts  a  double  line  of  wire 
stitches  along  A  B  and  cuts  between,  thus  saving  time  and  soiling.) 

Incise  the  stomach  (both  walls)  along  the  line  CD.  Close  the  flap  of 
stomach  between  the  cut  CD  and  the  greater  curvature  by  a  double  line  of 
sutures  (CD')  so  as  to  form  it  into  a  tube  open  at  its  distal  end  (C)  and  con- 
tinuous with  the  cardia  at  D.D'.     This  tube  is  well  nourished  by  the  left 


230 


PHARYNGOTOMY  AND  LAKYXGOTOMY 


gastro-epiploic  vessels.  Bury  the  line  of  mattress  sutures  by  a  row  of  Lembert 
sutures.  The  result  is  seen  in  Fig.  354.  Make  a  subcutaneous  tunnel  from 
the  abdominal  wound  upwards  on  the  chest  to  about  the  level  of  the  third 
costal  cartilage.  Incise  the  skin  here.  Pull  the  tube  of  stomach  up  through 
this  tunnel  and  suture  the  mucous  membrane  at  its  distal  extremity  to  the 
skin.  The  rest  of  the  operation  is  the  same  as  in  some  of  the  procedures 
alreadv  described. 


"'mm^^'^'^ 


Fig.  353. 


Fig.  354. 


Willy  Meyer  (Trans.  Surg.  Section  A.  ]M.  A.,  1913)  thinks  it  feasible  to 
complete  the  Jianu  operation  by  opening  the  chest  in  the  seventh  left  inter- 
space, e.xcising  the  diseased  oesophagus,  closing  the  distal  oesophageal  stump 
and  making  an  end  to  end  anastomosis  between  the  proximal  stump  of  the 
oesophagus  and  the  open  end  of  the  "Jianu  tube."  This  would  of  course  be 
much  preferable  to  the  antethoracic  cesophagoplasty,  is  entirely  possible 
technicallv  but  must  ever  remain  extremelv  dangerous. 


CHAPTER  XXV 


PHARYNGOTOMY,  LARYNGOTOMY,   PARTIAL 
LARYNGECTOMY,  AND  LARYNGECTOMY 

SUBHYOID   PHARYNGOTOMY 

Place  the  patient  on  his  back,  the  shoulders  supported  on  a  cushion  and 
the  head  extended.     Palpate  the  hyoid  bone  and  thyroid  cartilage. 

Step  I. — Make  a  transverse  cutaneous  incision  immediately  below  and 
parallel  to  the  hyoid  bone.  If  the  operation  is  for  the  purpose  of  exposing 
the  entrance  to  the  larynx,  an  incision  two  inches  in  length  is  sufficient;  if  for 
the  removal  of  a  tumor  of  the  pharynx  or  upper  larynx,  the  incision  must  be 
much  longer. 

Step  2. — Divide  the  platysma  myoides,  and  omohyoid,  sternohyoid,  and 
thyrohyoid  muscles  close  to  the  hyoid  bone,  but  leaving  sufficient  of  their 
substance  attached  to  the  bone  to  permit  of  their  union  by  suture. 


PHARYNGOTOMY  231 

Step  3.— Divide  the  thyrohyoid  membrane  along  the  posterior  surface  of  the 
hyoid,  the  knife  being  directed  backwards  and  upwards.  Leave  enough 
membrane  attached  to  the  bone  to  permit  the  use  of  sutures  when  closing  the 
wound.     Attend  to  hemostasis. 

Step  4. — The  mucosa  now  pouts  into  the  wound  during  expiration;  seize  it 
with  forceps  and  divide  it.  Be  careful  not  to  injure  the  epiglottis.  Insert 
two  catgut  sutures  into  the  upper  edge  of  the  wound  in  the  mucosa  to  act  as 
guides  or  tractors  when  closure  is  begun.  Pull  the  epiglottis  out  of  the  wound 
and  insert  into  it  a  suture  to  be  used  as  a  tractor.  The  upper  part  of  the 
larynx  and  the  lower  pharynx  now  lie  exposed,  and  one  may  proceed  to  re- 
move any  foreign  body  or  accessible  tumor.  If  the  operation  is  done  for 
malignant  disease  of  the  upper  zone  of  the  larynx  (extrinsic  disease — Semon), 
or  if  any  hemorrhage  is  anticipated,  it  is  wxU  to  perform  a  preliminary 
tracheotomy. 

Step  5. — Close  the  wound  in  the  mucosa  with  fine  catgut  sutures.  Unite 
the  thyrohyoid  membrane,  the  divided  muscles,  and  the  skin  each  by  a  separate 
layer  of  sutures.  Insert  a  small  drain  of  gauze  or  oiled  silk  down  to  the  line 
of  suture,  closing  the  wound  in  the  mucosa.  If  a  large  part  of  the  pharynx 
has  been  excised,  it  is  wase  to  pack  the  cavity  with  gauze  and  only  partially 
close  the  wound  with  sutures;  under  these  circumstances  a  tracheotomy  will 
have  been  performed. 

TRANSHYOID   PHARYNGOTOMY 

Vallas  obtains  access  to  the  pharynx  by  a  median  incision. 

Step  I. — Make  a  median  cutaneous  incision  from  a  point  one  finger-breadth 
above  the  hyoid  to  the  thyroid  notch.  Divide  the  skin,  subcutaneous  tissue, 
etc.,  and  separate  the  mylohyoid  muscles. 

Step  2. — Denude  a  small  portion  of  the  hyoid  bone  in  the  middle  line  and 
divide  the  bone  with  scissors  or  forceps.  Retract  the  two  halves  of  the  hyoid 
and  the  attached  soft  structures.  This  gives  a  space  about  i^-^  inches  in 
width,  and  exposes  the  mucous  membrane  of  the  pharynx  above  and  the 
thyrohyoid  membrane  below  the  bone. 

Step  3. — Guided  by  a  finger  passed  into  the  pharynx  through  the  mouth 
open  the  pharynx,  cutting  from  above  downwards. 

Step  4. — Having  attended  to  the  disease  which  necessitated  operation, 
close  the  w'ound  with  several  layers  of  sutures,  after  providing  for  drainage. 
It  is  unnecessary  to  suture  the  hyoid  bone. 

SUPRAHYOID   PHARYNGOTOMY 

Eremitsch,  Griinwald,  Fedoroff  and  others  recommend  suprahyoid  pharyn- 
gotomy  as  a  means  of  access  to  tumors,  especially  to  those  at  the  base  of  the 
tongue  or  on  the  epiglottis.  Preliminary  tracheotomy  is  unnecessary.  Place 
the  patient  on  his  back.     Support  the  shoulders,  letting  the  head  fall  backwards. 

Step  I. — Make  a  tranverse  incision,  concave  upwards  about  3^^  inch  above 
the  hyoid.     Divide  the  skin  and  platysma. 


232  PHARYNGOTOMY  AND  LARYNGOTOMY 

Step  2. — Retract  the  submaxillary  gland  which  presents.  Find  the  inser- 
tions of  the  digastric  muscles  and  preserve  them.  Divide  transversely  the 
mylohyoids,  geniohyoids  and  hyoglossi.  Open  the  pharynx,  being  careful 
not  to  injure  the  epiglottis.  The  pharynx,  soft  palate,  tonsils,  epiglottis  and 
the  base  of  the  tongue  are  well  exposed.  In  order  to  operate  on  the  base  of 
the  tongue  the  posterior  half  of  the  tongue  must  be  pulled  into  the  wound 
by  means  of  a  sharp  retractor. 

INTERCRICOTHYROTOMY.    LARYNGOTOMY 

This  operation  is  commonly  employed  as  a  safe  substitute  for  tracheotomy 
as'  a  preliminary  to  operations  upon  the  tongue.  Butlin  is  an  enthusiastic 
advocate  of  the  operation  which  he  uses  in  all  such  procedures  as  excision 
of  the  tongue,  of  the  upper  jaw,  etc.  It  only  consumes  about  one  minute  of 
time  and  renders  easy  work  which  would  otherwise  be  troublesome. 

Place  the  patient  on  his  back  with  head  thrown  back  and  the  neck  sup- 
ported on  a  firm  pillow.     Identify  the  thyroid  and  cricoid  cartilages  by  touch. 

Step  I.— With  finger  and  thumb  hold  the  larynx  steady.  Make  an  inci- 
sion 1 3^  inches  long  in  the  middle  line  over  the  lower  part  of  the  thyroid, 
the  cricothyroid  interval,  and  the  cricoid.  Retract  the  edges  of  the  wound. 
Expose  the  cricothyroid  membrane.     Attend  to  hemostasis. 


Fig.  355. — Butlin's  laryngotomy  cannula. 
X.  Silver  tube  inserted  into  cannula.     On  this  it  is  easy  to  fix  a  rubber  tube  through  which  the  anesthetic 

can  be  administered. 

Step  2. — Divide  the  cricothyroid  membrane  transversely  just  above  the 
cricoid  cartilage  and  so  avoid  injury  to  the  vocal  cords  and  the  cricothyroid 
vessels.  Penetrate  the  mucous  membrane.  Pass  a  closed  forceps  through 
the  wound  in  the  mucosa  and  open  the  blades  so  as  to  dilate  the  wound. 

Step  3. — Pass  a  Butlin's  laryngotomy  cannula  into  the  cavity  of  the  larynx. 
The  error  has  been  made  of  passing  the  cannula  (Fig.  355)  into  the  cellular 
tissue  with  nasty  results.  Fix  the  cannula  in  place  by  tapes  passed  around 
the  neck. 

It  is  easy  to  administer  an  anesthetic  through  the  cannula.  After  the 
operation  on  the  tongue  or  mouth  is  completed  the  cannula  may  be  removed 


LARYNGOTOMY  233 

as  soon  as  the  patient  is  put  to  bed.     No  stitches  are  required  to  close  the 
wound. 

LARYNGOTOMY  AND   PARTIAL  LARYNGECTOMY 

Laryngotomy  is  an  operation  in  which  the  larynx  is  split  open,  its  interior 
exposed,  and  any  foreign  body  or  disease  removed.  The  operation  is  frequently 
accompanied  by  partial  laryngectomy. 

The  Operation. — Step  i.— Perform  a  low  tracheotomy.  Insert  a  Tren- 
delenburg or  a  Hahn  cannula. 

Step  2. — Make  a  median  incision  from  a  point  immediately  below  the 
hyoid  bone  to  one  just  below  the  cricoid  cartilage.  Divide  the  cervical  fascia 
to  the  full  extent  of  the  wound.  Separate  the  sternohyoid  muscles  by  blunt 
dissection. 

Step  3. — Incise  the  cricothyroid  membrane  after  fixing  the  cricoid  carti- 
lage with  a  sharp  hook  or  small  volsella  forceps.  With  a  probe-pointed 
strong  knife,  with  strong  scissors,  or  with  thin-bladed  bone  forceps  divide 
the  thyroid  cartilage  accurately  in  the  middle  line.  When  the  cartilage  is 
very  hard,  Treves  advises  the  use  of  a  fine  saw  instead  of  the  bone  forceps.  In 
such  cases  probably  it  might  be  easier  and  less  damaging  to  pass  a  Gigli  wire 
saw  through  the  wound  in  the  cricothyroid  membrane,  behind  the  thyroid 
cartilage  and  out  through  a  cut  in  the  thyrohyoid  membrane,  and  saw  through 
the  cartilage  in  the  middle  line  from  within  outwards. 

Step  4. — Retract  the  lateral  halves  of  the  thyroid  cartilage  with  sharp  hooks. 

Step  5. — Remove  the  foreign  body  or  tumor  or  excise  the  laryngeal  contents 
completely. 

Step  6. — Either  completely  or  partially  close  the  larynx  with  sutures. 
Partial  closure,  a  gauze  wick  being  left  for  twenty-four  hours  to  drain  the  lower 
angle  of  the  wound  in  the  larynx,  is  preferable  to  complete  closure. 

Step  7. — Replace  the  Trendelenburg  by  an  ordinary  tracheotomy  cannula. 

In  Step  5  various  degrees  of  interference  may  be  requisite.  Even  in  cases 
of  rather  extensive  malignant  disease  below  the  vocal  cords  (intrinsic  disease) 
thorough  removal  of  the  growth  and  surrounding  soft  parts  plus  energetic 
scraping  of  the  cartilage  often  gives  good  results.  If  the  growth  invades  the 
cartilage,  then  portions  of  that  structure  must  be  removed.  Sir  F.  Semon 
("Brit.  Med.  Journ.,"  Oct.  31,  1903)  limits  the  term  partial  laryngectomy  to 
cases  where  not  less  than  one  wing  of  the  thyroid  cartilage,  with,  possibly,  a 
part  of  the  cricoid  and  one  arytenoid,  is  removed.  Removal  of  small  fragments 
of  these  cartilages  he  includes  under  the  name  "thyrotomy." 

The  lymphatics  of  the  larynx  may  be  considered  as  being  in  two  groups, 
one  above  the  other,  below  the  true  vocal  cords.  The  cords  have  very  scanty 
and  thin  lymphatics  which  drain  into  the  supraglottic  zone  for  the  most  part. 
The  network  of  lymphatics  above  the  vocal  cords  (supraglottic  zone)  is  very 
dense,  easily  injected,  covers  the  epiglottis,  the  aryteno-epiglottic  folds,  the 
superior  or  false  vocal  cords,  and  the  ventricles  of  the  larynx.  The  subglottic 
zone  of  lymphatics  is  not  so  dense  as  that  above.  "Though  the  two  lymphatic 
territories  of  the  larynx  largely  communicate  with  each  other  in  the  posterior 
walls  of  the  larynx,  it  is  rare  to  obtain  a  complete  injection  of  the  endolaryngeal 


234  PHARVNGOTOMY  AND  LARYNGOTOMY 

network  by  puncturing  only  one  of  these  territories.  It  may  be  added  that 
injections  easily  cross  the  middle  line;  but  though  the  mass  injected  into  one-half 
of  the  larynx  easily  passes  into  the  mucous  membrane  of  the  other  side,  it 
is,  on  the  other  hand,  exceptional  for  it  to  pass  as  far  as  the  corresponding 
glands  of  that  side."  ("The  Lymphatics,"  Poirier,  Cuneo,  Delamere.  Leaf's 
translation.) 

The  great  importance  of  the  above  anatomical  facts  is  very  evident  and 
they  show  very  clearly  the  reasonableness  of  Semon's  dicta  regarding  the 
conditions  required  for  successful  thyrotomy  for  malignant  disease.  Semen 
gives  the  name  "extrinsic  malignant  disease"  to  that  situated  in  the  supra- 
glottic  lymphatic  zone,  and  "intrinsic"  to  that  in  the  subglottic  zone. 

Conditions  Essential  to  the  Success  of  Th3nrotomy  for  Malignant  Disease. — 

1.  Operation  must  be  restricted  to  early  stages  of  intrinsic  malignant  disease. 

2.  Early  diagnosis  is  indispensable. 

3.  Operation  must  be  thorough.  No  sentimental  considerations  as  to 
the  amount  of  vocal  power  to  be  retained  must  interfere  with  the  removal  of 
sufficient  healthy  tissue  from  around  the  neoplasm  in  all  directions. 

4.  Laryngoscopic  examination  rarely  gives  correct  information  as  to  the 
extent  of  the  disease.  If,  on  opening  the  larynx,  the  disease  is  found  to  invade 
the  cartilages,  partial  laryngectomy  must  be  performed,  "or  indeed  any  other 
operation,  the  necessity  of  which  may  become  apparent  when  the  extent  and 
depth  of  infiltration  of  the  new  growth  have  been  definitely  ascertained." 

Intralaryngeal  operations  are  useless  in  the  face  of  malignancy:  they 
merely  take  away  portions  of  the  growth  and  may  stimulate  it  to  more  rapid 
development.  Even  in  cases  where  there  is  doubt,  but  malignancy  is  strongly 
suspected,  th}Totomy  is  the  proper  operation.  When  the  disease  is  situated 
on  the  posterior  laryngeal  wall  or  when  it  is  too  advanced  for  thjTOtomy  or 
partial  laryngectomy  to  be  successful,  then  total  laryngectomy  becomes  a 
necessity.  In  cases  of  extrinsic  malignant  disease  of  the  larynx  subhyoid 
pharyngotomy  gives  the  best  access  for  its  removal. 

LARYNGECTOMY 

Complete  Laryngectomy. — The  operation  of  laryngectomy  is  called  for 
in  cases  of  malignant  disease  of  the  larynx.  Usually  cases  in  which  the  disease 
has  broken  through  the  bounds  of  the  larynx  and  invaded  neighboring  tissues 
are  considered  inoperable,  but,  as  will  be  seen  in  succeeding  pages,  such  cases 
have  been  successfully  attacked.  The  greatest  danger  of  laryngectomy  is 
not  the  immediate  risk  of  operation,  but  the  subsequent  aspiration  of  wound 
secretions  into  the  lungs,  causing  pneumonia.  This  danger  is  combated  by 
careful  asepsis,  or,  better,  antisepsis,  and  by  using  the  resources  of  plastic  surgery. 
After  operation  it  is  wise  to  encourage  the  patient  to  leave  his  bed  as  early  as 
possible. 

The  Operation. — Step  i. — Perform  a  low  tracheotomy  and  insert  a  Tren- 
delenburg cannula  to  prevent  the  entrance  of  blood  into  the  lungs. 

Step  2. — Make  an  incision  in  the  middle  line  from  the  hyoid  bone  to  below 
the  cricoid  cartilage.     This  divides  all  the  soft  parts  down  to,  but  not  through, 


AFTER-TREATMENT  235 

the  cartilages  and  their  connecting  membranes.  If  necessary,  convert  the 
vertical  into  a  T-shaped  incision  by  means  of  a  transverse  cut  near  the  hyoid 
bone. 

Step  3. — (A)  Separate  the  soft  parts  which  are  connected  with  the  laryngeal 
cartilages,  on  each  side,  from  the  larynx.  Do  this  as  much  as  possible  by 
blunt  dissection;  an  occasional  cut  with  knife  or  scissors  will  be  necessary. 
In  making  this  separation  keep  close  to  the  cartilaginous  walls  of  the  larynx. 
The  larynx  is  now  exposed  anteriorly  and  laterally;  it  is  still  united  to  the 
hyoid  bone  above,  to  the  trachea  below,  and  to  the  oesophagus  behind. 

(B)  If  the  disease  has  infiltrated  surrounding  structures,  then,  of  course, 
this  step  of  the  operation  must  be  carried  out  by  means  of  dissection  beyond 
the  disease.  The  operation  becomes,  in  fact,  one  for  the  excision  of  a  tumor  in 
which  the  larynx  happens  to  be  located. 

Step  4. — Stop  all  bleeding.  Divide  the  thyrohyoid  membrane  transversely 
close  to  the  upper  edge  of  the  thyroid  cartilage.  Injure  the  oesophagus  as 
little  as  possible.  Examine  the  epiglottis  carefully.  If  it  is  diseased  or  if  its 
appearance  is  doubtful,  remove  it.  Carefully  separate  the  posterior  wall 
of  the  larynx  from  the  oesophagus,  but  always  bear  in  mind  the  necessity  of 
getting  beyond  the  disease.  The  larynx  is  now  attached  to  the  body  by  the 
trachea  alone.  If  possible,  cut  through  the  cricoid  cartilage  transversely 
and  remove  the  larynx.  If  the  cricoid  is  diseased  or  in  a  suspicious  condition, 
make  the  section  through  the  trachea  at  as  low  a  point  as  may  be  necessary. 

Step  5. — Suture  the  divided  trachea  to  the  skin.  The  trachea  is  liable  to  be 
retracted  downwards.  Stop  all  bleeding.  Introduce  an  oesophageal  tube  into 
the  gullet  to  permit  feeding.  Pack  the  wound  with  iodoform  gauze.  Apply 
dressings.  Replace  the  Trendelenburg  cannula  by  an  ordinary  tracheotomy 
tube. 

After-treatment. — Give  the  patient  fluid  food  through  the  oesophageal 
tube,  which  is  left  in  situ.  It  is  probably  better  to  omit  the  introduction 
of  the  oesophageal  tube  at  the  time  of  operation,  but  to  pass  the  tube  each 
time  the  patient  requires  nourishment.  The  wound  should  be  frequently 
dressed  and  the  mouth  should  be  kept  clean. 

In  order  to  avoid  confusion  the  author  has  described  the  operation  of 
laryngectomy  as  if  the  removal  of  the  diseased  larynx  constituted  the  whole  of 
the  procedure.  It  would  be  almost  as  logical  to  amputate  the  cancerous  breast 
without  removing  the  fatty  and  lymphatic  contents  of  the  axilla  as  to  remove 
the  larynx  without  attacking  the  cervical  lymphatics  at  the  same  time.  When 
the  larynx  has  been  removed  and  provision  has  been  made  to  retain  control 
of  the  divided  trachea  (Step  5),  it  is  easy  to  gain  access  to  the  cervical  lymphatics 
and  to  remove  them  in  the  manner  described  for  excision  of  cervical  tumors 
or  by  some  slight  modification  of  that  method. 

Perier's  Operation. — In  extirpating  the  larynx  Perier  discards  the  aid  of  a 
preliminary  tracheotomy. 

Step  I. — Make  a  vertical  m.edian  incision  from  the  hyoid  bone  down  to  a 
point  well  below  the  cricoid  cartilage.  Make  two  horizontal  incisions,  one  at 
each  end  of  the  vertical  cut.     The  wound  is  now  I-shaped. 

Step  2. — Separate  the  soft  parts  from  the  larynx  and  upper  part  of  the 


236 


PHARYNGOTOMY  AND  LARYNGOTOMY 


trachea,  as  has  been  already  described.  With  a  curved  blunt  instrument 
introduced  laterally  separate  the  larynx  and  upper  portion  of  the  trachea 
from  the  oesophagus  (Fig.  356). 

Step  3. — Stop  all  bleeding.     Introduce  a  stout  thread  on  each  side  of  the 
trachea  below  the  line  where  it  is  to  be  divided.     These  threads  are  for  pur- 


FiGS.  356  AND  357. — Excision  of  larynx.     {Monod  and  Vanverts.) 


poses  of  traction.  Rapidly  divide  the  trachea  immediately  below  the  cricoid 
cartilage  and  pull  the  stump  upwards  and  forwards  by  means  of  the  traction 
threads  (Fig.  357).  Introduce  into  the  trachea  a  large  curved  cannula  provided 
with  lugs  through  which  the  traction  threads  may  be  passed  and  fastened.  The 
ends  of  the  threads  are  left  long.  The  threads  prevent  the  cannula  changing 
its  position  and  can  still  be  used  for  traction  purposes. 
The  anesthesia  is  continued  through  the  cannula. 

Step  4. — Complete  the  extirpation  of  the  larynx. 
Close  the  wound  with  sutures  after  providing  for 
drainage. 

Step  5. — Suture  the  tracheal  opening  to  the  lowest 
angle  of  the  wound  (Fig.  358). 

Th.  Gliick  brings  the  tracheal  stump  out  through 

a  special  buttonhole   in   the   skin   near  the  sternal 

notch,  thus  isolating  it  from  the  laryngectomy  wound. 

Keen's    Method. — In     1898     Keen     described    a 

method    of   operating,    the   details    of    which    lead 

towards  safety.  ■  For  several  days  prior  to  operation 

brush  the  teeth  thoroughly  and  spray  the  nose  and 

fauces  with  a  mild  antiseptic  every  two  hours,  when 

the  patient  is  awake. 

Step  I. — Give  chloroform.     Median  incision  from  above  the  hyoid  bone 

nearly  to  the  sternum.     Expose  the  thyrohyoid  membrane,  larynx,  and  two 

or  more  tracheal  rings.     Divide  the  isthmus  of  the  thyroid. 

Step  2. — Separate  the  structures    to  be  removed  from   their  lateral  con- 
nections.    Attend  to  hemostasis. 

Step  3. — Put    patient    in   Trendelenburg's    position.     Divide  the  trachea 
transversely  well  below  the  disease  and  below  the  area  of  the  beard  in  men 


FtG.  358. — Excision  of 
larynx.  {Monod  and 
Vanverts.) 


LARYNGECTOMY  237 

(lest  hair  grow  into  the  trachea).  With  three  sutures  fix  the  upper  end  of 
the  trachea  to  the  skin.  Introduce  an  ordinary  tracheotomy  tube  Yi  inch 
in  diameter.  Secure  the  tube  with  sterile  tapes  passed  around  the  neck. 
Continue  the  anesthetic  through  a  sterile  rubber  tube  passed  into  the  cannula 
and  provided  with  a  funnel. 

Step  4. — Pull  the  upper  end  of  the  trachea  forwards,  and  by  blunt  or 
sharp  dissection  separate  it  from  the  oesophagus.  Close  any  accidental 
wounds  of  the  oesophagus  at  once  with  Lembert  sutures.  Remove  the 
disease  and  the  larynx. 

Step  5. — Pull  the  epiglottis  into  the  wound  and  remove  it. 

Step  6. — Suture  the  anterior  wall  of  the  oesophagus  to  the  tissues  just  below 
the  hyoid  bone.  This  must  be  done  thoroughly  to  prevent  leakage  from  the 
mouth  into  the  wound. 

Step  7. — Remove  the  tracheotomy  cannula  and  close  the  external  wound. 
Provide  drainage  for  twenty-four  hours.  Apply  dressings  above  and  below 
the  tracheal  opening,  which  is  protected  by  any  framework — e.g.,  a  pill-box 
without  top  or  bottom — covered  with  gauze  to  filter  the  air. 

After -treatment. — Put  to  bed  without  bolster  or  pillow.  Raise  the  foot  of  the 
bed  on  a  chair.  Get  the  patient  up  as  soon  as  possible  (about  the  third  day). 
For  one  or  two  days  feed  by  enemata.    By  the  third  day  the  patient  can  swallow. 

F5derl  has  paid  great  attention  to  means  of  avoiding  postoperative  pneu- 
monia due  to  the  aspiration  into  the  lungs  of  secretions  from  the  open  wound 
generally  left  after  laryngectomy.  The  method  of  operating  adopted  by  him  is 
based  on  experience  gained  in  a  case  of  tracheal  stenosis.  In  this  case  he  re- 
sected the  affected  portion  of  the  trachea  and  restored  continuity  by  means 
of  a  circular  suture  of  the  windpipe.  The  result  was  perfect.  After  the  trachea 
has  been  divided,  and  provided  it  is  not  abnormally  adherent  to  its  surround- 
ings, it  is  very  easily  pulled  up.  On  the  cadaver  it  has  been  shown  that  the 
larynx  may  be  completely  excised,  the  hyoid  bone  united  by  sutures  to  the 
first  ring  of  the  trachea  the  head  thrown  into  a  position  of  overextension,  and 
that  the  sutures  will  still  hold. 

FoderVs  Operation. — A  preliminary  tracheotomy  is  performed.  The  larynx 
is  removed,  but  the  epiglottis  and  the  ary-epiglottidean  folds  are  preserved  if 
possible.  Hemostasis  is  carefully  secured  by  means  of  ligatures,  pressure,  or 
torsion.  Unite  the  ends  of  the  ary-epiglottidean  folds  to  the  posterior  mem- 
branous portion  of  the  trachea,  and  complete  the  continuity  of  the  posterior 
part  of  the  tube.  The  lateral  and  anterior  portions  of  the  windpipe  are  united 
by  catgut  sutures.  The  sutures  are  not  tied  until  all  of  them  are  in  place.  Two 
or  more  of  the  anterior  sutures  surround  the  hyoid  bone  (submucously),  catch 
the  base  of  the  epiglottis,  and  surround  the  first  tracheal  ring.  After  these  deep 
sutures  are  tied,  silk  sutures  are  inserted  through  the  soft  parts,  and  help  to 
relieve  tension  on  the  buried  stitches.     The  external  wound  is  closed. 

Foderl  remarks  ("Archiv  f.  klin.  Chir.,"  Iviii,  803)  that  after  his  operation 
scarcely  any  more  wound  secretion  enters  the  respiratory  tract  than  does  so 
subsequent  to  any  of  the  endolaryngeal  operations.  A  nearly  linear  circular 
wound  is  left,  the  windpipe  is  cut  off  from  the  rest  of  the  wound,  and  there 
is  little  danger  of  the  aspiration  of  wound  secretions. 


238  PHARYNGOTOMY  AND  LARYNGOTOMY 

Foderl  has  operated  on  one  case  in  the  above  manner.  The  patient  was 
out  of  bed  on  the  second  day,  able  to  feed  himself  with  the  oesophageal  tube 
on  the  third  day,  and  went  home  after  two  weeks.  Eight  months  after  opera- 
tion there  was  no  recurrence.  Deglutition  was  good.  Speech  could  be  heard 
at  thirty  feet.  The  patient  still  wore  a  fenestrated  tracheotomy  tube,  but 
he  was  expected  to  give  up  that  before  long. 

The  operation  of  laryngectomy  is  not  absolutely  limited  to  cases  in  which 
the  disease  is  confined  to  the  larynx  itself.  Portions  of  the  oesophagus,  etc., 
may  be  removed  along  with  the  larynx.  Narath  ("Archiv  f.  klin.  Chir.,"  Iv, 
840)  has  published  some  instructive  experiences  on  this  subject.  The  follow- 
ing description  is  based  on  Narath's  work : 

Combined  Laryngectomy  and  (Esophagectomy. ^^/f/?  i. — Perform  a  low 
tracheotomy. 

Step  2. — Extend  the  tracheotomy  wound  upwards  in  the  middle  line  to  near 
the  chin.  Reflect  the  skin  on  either  side  of  the  neck  so  as  to  expose  the  larynx 
and  surrounding  structures.     Isolate  the  diseased  organs. 

Step  3. — Divide  the  trachea  below  the  disease.  The  inferior  portion  of 
trachea  (i.e.,  the  portion  leading  to  the  lungs)  is  separated  from  its  surroundings 
for  a  short  distance  and  its  open  end  brought  into  the  tracheotomy  wound  in 
the  soft  parts;  and  is  there  sutured  after  the  tracheotomy  tube  is  removed. 
In  the  manoeuvre  the  open  end  of  the  trachea  is  so  bent  that  its  opening  faces 
directly  forwards.  There  is  little  danger  of  blood  being  aspirated  into  the 
tracheal  opening  in  its  new  position. 

Step  4. — Remove  the  larynx  and  such  portions  of  the  oesophagus  as  may 
be  diseased,  remembering  to  cut  away  too  much  rather  than  too  little. 

Step  5. — If  comparatively  little  of  the  oesophagus  has  been  removed,  it  may 
be  possible  to  secure  closure  of  its  lumen  by  means  of  suture.  If  a  large  portion 
of  the  anterior  oesophageal  wall  has  been  removed  and  a  small  portion  to  the 
posterior,  it  has  been  possible  to  loosen  the  remnants  of  the  posterior  wall 
from  their  surroundings  sufl5ciently  to  permit  of  the  upper  and  lower  fragments 
being  brought  together  and  so  to  obtain  a  continuous  posterior  oesophageal 
wall. 

Step  6. — Pack  the  whole  wound  with  iodoform  gauze.  Change  the  dressings 
whenever  it  is  desired  to  nourish  the  patient.  Nutriment  is  given  through  a 
stomach-tube. 

As  the  wound  heals  the  cutaneous  edges  become  inverted  and  the  granu- 
lations covered  with  epithelium  until  at  last  the  whole  space  between  the  pos- 
terior oesophageal  wall  and  skin  is  covered  by  epithelium.  Thus  a  gutter 
is  formed  leading  from  the  pharynx  to  the  intact  oesophagus  below.  At  the 
lower  end  of  the  gutter  the  tracheal  opening  is  seen  facing  forwards.  The 
gutter  must  now  be  converted  into  a  tube  by  a  plastic  operation  very  similar 
to  the  operation  for  hypospadias. 

On  each  side  of  the  gutter  A,  B  (Fig.  359)  make  the  skin-flaps  abed  and 
a'  b'  c'  d'.  The  hinge  of  the  flap  a  b  c  d  is  along  the  line  a  b;  that  of  flap 
a'  b'  c'  d'  is  along  the  line  a'  b'.  Having  separated  the  above  flaps  from  the  sub- 
jacent tissues,  turn  them  inwards  so  that  the  edge  d  c  of  the  one  flap  meets  and 
is  sutured  to  the  edge  d'  c'  of  the  other  flap.     The  oesophageal  gutter  has  now 


TRACHEOTOMY 


239 


been  converted  into  a  tube  the  anterior  half  of  which  is  lined  by  epidermis. 
The  external  or  raw  surfaces  of  the  two  flaps  (abed  and  a'  b'  c'  d')  now  call 
for  treatment.  Continue  the  horizontal  incision  a,  d  outwards  to  the  point  e; 
the  incision  b  c  to  f;  a'  d'  to  e';  b'  c'  to  f.  Separate  the  flap  e  d  c  f  from  the 
subjacent  tissues,  the  base  of  the  flap  being  the  line  e  f.  Do  the  same  with 
the  flap  e'  d'  c'  f.  Slide  the  two  flaps  towards  each  other  so  that  the  edge  d  c 
meets  the  edge  d'  c'  in  the  middle  line.     Suture.     The  sliding  of  these  flaps 


Figs.    359    and    360. — (Esophagoplasty. 

is  rendered  possible  because  the  skin  of  the  neck  is  so  loosely  attached  to  sub- 
jacent structures.  After  healing  has  taken  place,  if  it  is  desired  to  make  use 
of  an  artificial  larynx,  it  will  be  necessary  to  make  an  opening  into  the  pharynx 
at  the  point  A  (Fig.  .360).  A  cannula  is  placed  in  the  trachea.  By  means  of 
a  T-joint  on  the  exposed  part  of  the  cannula  a  tube  is  led  upwards  over  the 
skin  through  the  opening  at  A  into  the  pharynx.  In  the  cannula  is  placed  a 
reed.  As  the  patient  expires  air  the  reed  gives  a  musical  note;  the  vibrating 
air  is  carried  into  the  pharynx  through  the  system  of  tubing  described  and  is 
modified  by  the  tongue,  lips,  etc.,  into  speech.  The  speech  is,  of  course,  in 
one  tone,  viz.,  that  of  the  reed. 


CHAPTER  XXVI 


TRACHEOTOMY 

Tracheotomy  is  an  exceedingly  simple  operation  under  some  circumstances, 
but  when,  as  is  often  the  case,  one  has  to  dispense  with  the  use  of  an  anesthetic 
and  operate  on  a  struggling,  choking  child,  on  an  inconvenient  table,  in  a 
badly  lighted  room,  without  proper  assistance,  the  task  of  the  surgeon  is  no 
light  one. 

There  are  two  classical  sites  at  which  the  trachea  may  be  opened — one 
above,  the  other  below,  the  isthmus  of  the  thyroid  gland.  At  the  former  site 
the  trachea  is  much  more  superficial  than  the  latter. 

The  High  Operation. — Place  the  patient  on  his  back  with  the  shoulders 
raised  on  a  pillow,  the  head  extended,  and  in  a  good  light.  If  possible,  ad- 
minister a  general  or  local  anesthetic.  With  the  finger  locate  the  thyroid  and 
cricoid  cartilages. 

Step  I. — From  a  point  a  little  below  the  middle  of  the  thyroid  cartilage 
make  an  incision,  exactly  in  the  middle  line,  downwards  for  a  distance  of  about 
i3>-^  inches.     Expose  the  deep  fascia,  which  is  attached  to  the  thyroid  car- 


240  TRACHEOTOMY 

tilage  above  and  the  isthmus  below.  Divide  the  fascia  in  the  middle  line. 
By  blunt  dissection  expose  the  trachea,  the  rings  of  which  are  easily  felt  with 
the  finger.  If  there  is  not  enough  space  between  the  cricoid  cartilage  and  the 
isthmus  of  the  thyroid  (which  lies  across  the  third  and  fourth  tracheal  rings), 
make  short  transverse  incisions,  through  the  deep  fascia  where  it  is  attached 
to  the  thyroid  cartilage;  this  permits  one  to  drag  the  isthmus  downwards.  In 
children  preservation  of  the  isthmus  is  of  little  value.  Thomas  Bryant  stated 
long  ago  that  its  division  did  no  harm,  and  the  author,  following  his  advice, 
has,  when  operating  on  children,  paid  no  attention  to  preserving  the  thyroid 
isthmus,  but  has  divided  it  whenever  it  seemed  convenient  to  do  so.  St.  Clair 
Thomson  (Brit.  Med.  J.,  Oct.  ii  and  25,  1919)  recommends  that  about  20  drops 
of  2^^  per  cent,  cocaine  solution  (in  children  5  drops  of  i  per  cent,  solution)  ibe 
injected  by  means  of  a  hv'podermic  syringe  directly  into  the  trachea  as  early  in 
the  operation  as  possible  before  completion  of  tracheal  exposure.  If  the  trachea 
is  not  opened  until  10  minutes  have  elapsed  after  the  injection,  there  will  be 
none  of  that  spasmodic  coughing  which  is  a  real  danger.  Crosby  Green  advised 
this  procedure  in  Thyrotomy  for  cancer  of  the  lar>'nx  when  the  injection  should 
be  made  through  the  crico-thyroid  membrane. 

An  evident  objection  to  injection  of  cocaine  is  that  the  prevention  of  cough- 
ing may  mean  serious  pulmonary  trouble  due  to  retention  of  mucus,  blood,  etc., 
in  the  trachea.  Therefore  its  use  should  be  avoided  in  bronchitic  or  emphy- 
sematous conditions  or  if  there  is  any  "water-logging." 

Step  2. — The  trachea  is  now  bare  to  the  extent  of  three  or  four  rings.  Fasten 
the  trachea  with  a  sharp  hook  a  Uttle  to  one  side  of  the  middle  line.  Let  an 
assistant  hold  the  hook.  Guided  by  the  finger,  introduce  a  knife  slowly  but 
steadily  into  the  trachea  at  the  lower  end  of  the  exposed  area.  Be  careful 
not  to  push  the  knife  in  so  far  as  to  injure  the  posterior  wall  of  the  trachea. 
Cut  upwards  in  the  middle  line  until  three  tracheal  rings  are  divided.  Hold  the 
knife  in  position  in  the  trachea  until,  guided  by  the  knife,  one  can  insert  into 
the  trachea  a  closed  hemostat  or  blunt-pointed  narrow-bladed  scissors.  With- 
draw the  knife.  Open  the  blades  of  the  hemostat  or  scissors  so  as  to  distend 
the  tracheal  wound,  and  slip  a  tracheotomy  tube  into  position.  There  are 
many  manoeuvres  or  dodges  to  facilitate  the  introduction  of  the  cannula; 
the  one  described  has  suited  the  author.  A  few  surgeons  discard  the  cannula 
but  suture  the  edges  of  the  tracheal  wound  to  the  corresponding  edges  of  the 
skin.     One  suture  on  each  side  suffices  to  keep  the  tracheal  opening  patent. 

Transverse  Tracheotomy. — Otto  Franck  ("Munch,  med.  Woch.,"  1910, 
No.  6)  recommends  the  following  method: 

1.  Transverse  incision  over  the  cricoid.  The  wound  gapes  spontaneously, 
giving  excellent  exposure. 

2.  Division  of  the  linea  mediana  albicans  and  retraction  of  the  muscles 
down  to  the  isthmus. 

3.  Transverse  incision  into  the  trachea  immediately  below  the  cricoid. 
When  the  head  is  extended  the  tracheal  wound  remains  wide  open. 

4.  Introduction  of  tracheotomy  tube  and  suture  of  the  excess  of  skin  wound. 
When  the  cannula  is  removed  the  tracheal  wound  closes  of  itself. 


TRACHEOTOMY  24I 

The  Low  Operation. — The  steps  in  the  operation  are  very  similar  to  those 
of  the  high  operation.  The  incision  begins  near  the  cricoid  cartilage  and  runs 
downwards  for  two  inches.  After  the  cervical  fascia  is  divided  blunt  dissec- 
tion will  serve  to  expose  the  trachea.  All  veins  which  appear  during  the  dis- 
section must  be  drawn  aside  or  divided  between  ligatures  or  forceps.  The 
index  finger  of  the  left  hand  should  be  frequently  put  into  the  wound  to  feel 
the  position  of  the  trachea  and  to  discover  if  any  abnormal  artery  is  in  the  way. 
The  author  well  remembers  the  glee  with  which  the  late  Sir  John  Struthers 
used  to  exhibit  a  specimen  showing  an  enormous  abnormal  artery  crossing  the 
territory  involved  in  a  low  tracheotomy.  If  the  isthmus  of  the  thyroid  appears, 
it  should  be  pulled  upwards.  The  trachea  is  opened  in  exactly  the  same  man- 
ner as  is  done  in  the  high  operation. 

The  low  operation  is  not  suitable  in  children,  as  in  them  the  trachea  is 
very  deeply  situated,  their  necks  are  short,  and  the  thymus  gland  gets  in  the 
way.     For  adults  and  adolescents  the  low  operation  is  suitable. 


Fig.  361. — Konig's  cannula.  Fig.  362. — Trendelenburg's  cannula. 

Figs.  361  and  362. — (Esmarck  and  Kowalzig.) 


When  the  operation  is  performed  in  cases  of  obstruction  from  external 
pressure,  e.g.,  in  cases  of  goitre,  and  some  obstruction  exists  below  the  trache- 
otomy opening,  a  tube  should  be  passed  down  the  trachea  beyond  the  obstruc- 
tion. In  emergency,  one  may  use  a  gum-elastic  catheter  for  this  purpose, 
passing  it  through  the  tracheotomy  cannula.  Konig  has  devised  a  special 
metal  cannula  with  a  long  pliable  tube  which  is  occasionally  of  service  (Fig. 
361).  When  a  tracheotomy  tube  has  to  be  worn  for  a  long  time,  one  made  of 
hard  rubber  is  less  irritating  and  more  durable  than  the  usual  metal  instru- 
ment. Fenestrated  tubes  permit  the  patient  to  breathe  through  the  natural 
passages,  and  are  useful  to  test  whether  it  is  safe  to  discard  the  cannula  or  not. 

Trendelenburg's  cannula  (Figs.  362  and  363)  has  rubber  so  arranged  round 
the  intratracheal  part  of  the  tube  that  it  can  be  inflated  and  fill  up  the  space 
between  the  trachea  and  the  tube,  thus  preventing  the  entrance  of  blood, 
etc.,  into  the  limgs.  This  cannula  is  of  great  service  during  certain  operations 
on  the  upper  air  passages,  as  through  it  anesthetics  may  be  administered. 

16 


242  TRACHEOTOMY 

Instead  of  surrounding  the  tube  with  an  inflatable  rubber  bag,  some  sur- 
geons prefer  to  cover  the  tube  with  compressed  sponge,  which  when  moistened 
swells  in  situ  and  serves  the  same  purpose.  (Hahn's  cannula,  Fig.  364.) 
When  a  tracheotomy  cannula  is  in  position,  it  must  be  retained  by  means  of  a 
tape  passed  round  the  neck  and  secured  to  the  eye-holes  provided  in  the  instru- 
ment. The  inner  tube  should  be  frequently  removed  and  cleaned.  During 
the  first  few  days  after  operation  the  outer  tube  should  never  be  removed 
except  by  the  surgeon.  Patient  or  nurse  should  never  be  permitted  to  remove 
the  outer  tube  until  the  surgeon  has  satisfied  himself  by  observation  that  they 
are  capable  of  replacing  it. 


Fig.  363. — Trendelenburg's  cannula  in  situ.         Fig.  364.— Hahn's  cannula. 
Figs.  363  and  364. — {Esmarch  and  Kowahig.) 

Tracheotomy  is  occasionally  performed  as  a  preliminary  to  such  opera- 
tions as  excision  of  the  larynx,  Kocher's  excision  of  the  tongue,  etc.  Pre- 
liminary tracheotomy  is  either  mediate  or  immediate.  When  the  "mediate" 
operation  is  chosen,  it  should  be  performed  two  or  three  weeks  before  the  major 
operation  to  which  it  is  preliminary. 

The  advantages  claimed  for  mediate  tracheotomy  are:  (i)  The  patient 
has  free  respiration  for  a  period  of  weeks  and  so  may  gain  strength.  (2)  The 
patient  becomes  accustomed  to  respiring  air  which  has  not  passed  through 
the  nose  and  mouth.  (3)  The  tracheal  wound  becomes  fixed  to  the  soft  parts, 
thus  anchoring  the  windpipe  and  preventing  retraction  after  the  larynx,  for 
example,  has  been  excised.  (4)  The  tracheotomy  having  been  done  before- 
hand, the  duration  of  the  major  operation  is  shortened  thereby. 

Advocates  of  the  immediate  operation  claim:  (i)  That  the  time  con- 
sumed in  performing  tracheotomy  is  not  sufficient  seriously  to  influence  the 
success  of  the  major  operation;  (2)  that  it  is  unnecessary  to  accustom  the 
patient  beforehand  to  breathing  through  a  cannula:  (3)  that  while  the  patient 
is  breathing  through  the  cannula  discharges  from  the  cancerous  tongue  or 
larynx  are  liable  to  gravitate  down  the  trachea,  past  the  cannula  into  the  lungs, 
and  cause  pneumonia,  while  the  resisting  power  of  the  lungs  is  lowered  from 
receiving  air  directly  through  the  tracheotomy  tube;  (4)  that  if  any  attempt  is 
to  be  made  to  restore  the  continuity  of  the  windpipe  after  laryngectomy,  the 
adhesions  formed  around  the  tracheotomy  wound  will  prevent  the  necessary 
elevation  or  pulling  up  of  the  lower  trachea. 

In  the  opinion  of  the  author  the  disadvantages  of  mediate  tracheotomy  are 
greater  than  the  advantages,  and  the  immediate  operation  is  preferable,  except 
when  it  is  preliminary  to  excision  of  the  tongue. 


CHAPTER   XXVII 
FOREIGN   BODIES   IN   TRACHEA   OR  BRONCHUS 

Sometimes  foreign  bodies  may  be  expelled  from  the  trachea  by  inverting 
the  patient,  but,  as  a  rule,  the  body  impinging  against  the  larynx  will  set  up 
such  spasm  as  to  render  its  expulsion  impossible.  Lejars  is  most  vigorous  in 
his  denunciation  of  the  method.  Tracheoscopy  or  tracheo-bronchoscopy 
(Killian),  whether  the  tube  be  introduced  through  the  mouth  or  through  a 
tracheotomy  wound,  has  frequently  permitted  the  extraction  of  foreign  bodies. 
This  is  a  most  valuable  procedure  and  in  most  cities  there  are  men  who  possess 
the  necessary  apparatus  and  skill  to  ^carry  it  out.  [See  Chevalier  Jackson's 
article  in  Binnie's  Regional  Surgury,  Vol  I.]  If  tracheoscopy  is  not  available 
recourse  must  be  had  to  high  tracheotomy.  A  general  anesthetic  is  desirable. 
Do  not  place  the  patient  in  the  dependent  position  until  the  trachea  is  opened. 
After  opening  the  trachea  and  retracting  the  edges  of  the  tracheal  wound  with 
retractors  or  stitches,  the  foreign  body  will  often  pop  out,  or  may  be  lifted  out 
with  forceps  or  a  scoop.  If  the  foreign  body  does  not  promptly  appear  opposite 
the  wound,  investigate  the  lower  surface  of  the  glottis;  if  the  body  happens  to  be 
there,  remove  it.  Lowering  the  patient's  head  and  shoulders,  after  opening  the 
trachea,  is  often  helpful.  Touching  the  mucosa  of  the  trachea  excites  coughing 
and  so  may  force  the  foreign  body  into  view  Coughing  and  inversion  of  the 
patient  may  bring  a  non-impacted  body  from  the  bronchus  into  the  wound. 

If  the  above  measures  are  successful  the  author  inserts  a  linen  or  silk  suture 
in  the  trachea  on  each  side  of  the  wound  and  leaves  these  long  to  serve  as 
tractors  by  means  of  which  the  nurse  may  easily  open  the  trachea  should 
oedema  glottidis  or  such  like  accident  develop.  These  threads  may  be  re- 
moved after  twenty-four  or  forty-eight  hours.  Cover  the  wound  loosely  with 
warm,  moist,  non-fluffy  gauze.  Instead  of  the  thread  tractors  a  tracheotomy 
cannula  may  be  used.     It  is  not  a  safe  practice  to  close  the  wound  entirely. 

If  the  above  means  fail  to  give  relief  it  is  best  either  to  suture  the  edges  of 
the  tracheal  wound  to  the  skin  or  to  insert  a  large  cannula  and  let  the  patient 
rest.  After  some  hours,  or  next  day,  reopen  the  wound;  if  the  body  is  not 
now  coughed  out,  introduce  a  small  laryngeal  mirror  and  by  the  aid  of  a  strong 
light  investigate  the  trachea.  If  the  body  is  seen  caught  in  the  mucosa,  spray 
with  cocaine  and  endeavor  to  extract  it  with  laryngeal  forceps  or  a  wire  loop. 
This  may  require  several  sittings  before  success  is  attained. 

When  a  foreign  body  is  impacted  in  a  bronchus  and  the  above  measures 
fail  to  give  relief,  one  may  either  attempt  its  extraction  by  means  of  posterior 
bronchotomy  or  await  the  formation  of  a  pulmonary  abscess  which  may  be 
opened  and  drained.  Unfortunately,  posterior  bronchotomy  is  a  formidable 
operation  and  if  the  Fabian  policy  is  adopted  the  patient  may  die  before  or  after 
solidification  of  the  lung,  and  pneumotomy  under  the  most  favorable  circum- 
stances is  no  triviality. 

The  bronchoscope  has  made  a  great  difference  in  the  treatment  of  foreign 
bodies  in  the  trachea  and  ought  to  be  employed  but  only  by  an  expert. 

243 


2  44 


FOREIGN  BODIES  IN  TRACHEA  OR  BRONCHUS 


POSTERIOR   BRONCHOTOMY   (SCHWARTZ'S   OPERATION) 

Anatomy. — The  bronchi  may  be  reached  through  the  posterior  medias- 
tinum, and  as  this  region  is  full  of  vitally  important  structures  it  is  necessary 
to  review  its  anatomy  in  a  practical  manner.  If  one  excises  the  third  to  the 
ninth  dorsal  vertebrae  inclusive,  the  posterior  mediastinum  will  be  sufficiently 
exposed  for  study.  The  most  superficial  (posterior)  structures  which  pre- 
sent are  vascular,  viz.,  to  the  left  the  aorta,  to  the  right  the  azygos  vein.  At 
the  lower  part  of  the  exposed  area  these  vessels  lie  alongside  each  other  and 
hide  all  subjacent  structures.     As  these  vessels  ascend   they  separate,   the 


Thyroid 


Com.  car  A 


Sup.  lar.  n. 


Vagus 

Int.  jug.  V. 
Trachea 

Inf.  thyroid  a. 
Recurrent  lar.  n. 
Subclav.  art. 


■-ubclav.  V. 


Fig.  365. — (Poirier  and  C harpy.) 

aorta  going  to  the  left  where  at  the  level  of  the  fourth  dorsal  vertebra  it  passes 
forwards  (as  the  aortic  arch)  into  the  anterior  mediastinum;  the  azygos  vein 
ascends  towards  the  right  until  it  bends  forwards  at  the  level  of  the  fourth  dorsal 
vertebra  to  enter  the  anterior  mediastinum.  The  aorta  and  azygos  thus  form  a 
triangle  with  base  above,  and  the  floor  of  which  is  formed  by  the  oesophagus. 
The  apex  (lower  end)  of  the  triangle  is  about  two  inches  below  the  bifurcation 
of  the  trachea.  The  thoracic  duct  follows  the  inner  side  of  the  aorta  and  later 
the  subclavian  artery.  The  right  and  left  pleurae  approach  each  other  between 
the  aorta  and  azygos  behind,  and  the  oesophagus  in  front.  The  right  pleura 
passes  behind  the  oesophagus  in  front  of  the  azygos  so  as  to  form  a  sort  of 
cul-de-sac  (Quenu).  The  two  pleurae  are  loosely  connected  by  areolar  tissue. 
The  position  of  the  pneumogastric  nerves  is  well  seen  in  Fig.  365.     To  expose 


BRONCHOTOMY 


245 


the  oesophagus  it  is  necessary  to  retract  the  pleurae  and  with  them  the  pneu- 
mogastric  nerves.  Retraction  of  the  pleurae  and  of  the  oesophagus  exposes 
the  trachea  and  primary  bronchi. 

I.   RIGHT   BRONCHOTOMY 

The  Operation. — Place  the  patient  in  the  latero-ventral  position  on  the 
edge  of  the  table  with  the  right  arm  hanging  over  the  table  (Fig.  366). 

Step  I. — From  a  point  (A)  at  the  junction  of  the  spine  and  median  border 
of  the  scapula  make  an  incision  to  a  point  (B)  about  i^^  inches  to  the  right 
of  the  spines  of  the  vertebrae.  From  the  point  B,  cut  downwards  parallel  to 
the  spinous  processes  for  a  distance  of  about  five  inches  (C).  Make  the  in- 
cision C,  D  which  passes  just  below  the  angle  of  the  scapula.     The  result 


Figs.  366  and  367. — Bronchotomy.     (Schwartz.) 


is  the  flap  A,  B,  C,  D.  Reflect  the  flap  A,  B,  C,  D  outwards  so  as  to  expose 
the  fifth,  sixth,  seventh  and  eight  ribs;  the  flap  consists  of  all  the  soft  parts 
down  to  the  ribs.  J.  D.  Bryant^  makes  the  flap  with  its  pedicle  towards  the 
spine. 

Step  2. — Subperiosteally  divide  the  spinal  ends  of  the  exposed  ribs  just 
external  to  the  transverse  process  (about  ij^  inches  from  the  mid-line  of 
the  back).  In  the  same  way  divide  the  ribs  as  far  outwards  as  possible.  Care- 
fully raise  the  lower  and  inner  angle  of  the  flap,  consisting  of  ribs  and  inter- 
costal muscles,  and  separate  it  from  the  subjacent  structures.  Divide  the 
intercostal  muscles  along  the  posterior  or  spinal  line  on  which  the  ribs  were 
divided,  carefully  exposing  and  tying  the  intercostal  vessels.  Divide  the  inter- 
costal muscles  parallel  to  and  below  the  lowest  rib  to  be  mobilized.  Care- 
fully separate  the  parietal  pleura  from  the  flap  of  ribs  and  intercostal  muscles; 
in  doing  this,  gauze  dissection,  i.e.,  brushing  away  the  pleura  with  gauze,  will 
be  useful.  Turn  the  flap  outwards;  this  is  possible  because  the  ribs  have  been 
divided  far  out  and  the  periosteum  and  intercostal  structures  act  as  a  hinge 
(Fig.  367). 

Step  3. — Carefully  separate  the  pleura  from  the  remnants  of  the  ribs  at- 
tached to  the  spine  and  from  the  side  of  the  vertebrae.     Push  the  pleura  and  the 


246 


FOREIGN  BODIES  IX  TRACHEA  OR  BRONCHUS 


lung  outwards,  away  from  the  mediastinum  (Fig.  368).  As  soon  as  the  side 
of  the  vertebra  is  passed,  the  azygos  vein  may  be  seen  running  vertically  through 
the  wound  and  at  the  upper  end,  arching  forwards  to  reach  the  anterior  medias- 
tinum (Fig.  369^.  Continue  the  separation  of  the  pleura  under  the  arch  of 
the  azygos  until  the  oesophagus,  lying  on  the  bodies  of  the  vertebrae,  is  reached. 
External  to  the  oesophagus  lies  the  pneumogastric  nerve.  Retract  the  pleura 
outwards. 


Figs.    368    and    369. — Bronchotomy.     (Scli'dartz.) 


Step  4. — Introduce  the  finger  deeply  into  the  wound  directly  in  the  concavity 
of  the  arch  of  the  azygos  and  feel  the  hard,  prominent,  posterior  border  of  the 
cartilaginous  rings  of  the  bronchus.  Pick  up  the  membranous  posterior  wall 
of  the  bronchus  with  sharp  hooks  or  forceps,  and  incise  it.  Remove  the  foreign 
body.  The  exposed  bronchus  is  situated  about  2^<4  inches  from  the  surface 
of  the  ribs  (Gliick). 

Step  5. — Introduce  a  soft  dressed  drain  to  the  wounded  bronchus,  possibly 
fixing  it  to  the  bronchial  wound  by  means  of  a  fine  stitch  of  catgut.  •  Be  sure 
there  is  no  loose  "fluff"  about  the  gauze  at  the  end  of  the  tube.  The  drain 
must  be  soft  to  prevent  dangerous  pressure  necrosis.  Replace  the  flap  and 
sutures,  leaving  or  making  space  for  the  exit  for  the  drain.  If  the  foreign  body 
has  given  rise  to  a  peribronchial  phlegmon,  a  more  liberal  drainage  by  means 
of  loose  packing  of  gauze  may  be  advisable. 


II.  LEFT   BRONCHOTOMY 

Place  the  patient  in  the  left  latero- ventral  position  with  the  left  arm  hanging 
over  the  edge  of  the  table. 

Steps  I  and  2.- — Same  as  in  right  bronchotomy  except  that  the  work  is  done 
on  the  left  side. 

Step  3. — Separate  the  parietal  pleura  from  the  remnants  of  ribs  attached  to 
the  spine.  When  the  side  of  the  vertebrae  is  reached,  the  huge  aorta  is  found 
lying  against  the  side  of  the  spine.  At  the  upper  end  of  the  wound  the  aorta 
passes  towards  (arch  of  aorta)  the  anterior  mediastinum.  Continue  the 
separation  of  the  pleura  under  the  arch  of  the  aorta  to  a  height  of  about  2 
inches.     The    left    pneumogastric    soon    presents.     Stop    the  dissection  and 


THE    THYROID  247 

pull  the  lung  (covered  by  the  intact  pleura)  outwards  with  a  good  retractor. 
With  the  linger  in  the  depth  of  the  wound  feel  the  posterior  prominent  edges 
of  the  bronchial  cartilages.  The  rest  of  the  operation  is  the  same  as  in  right 
bronchotomy. 

In  cases  of  tracheal  stenosis  threatening  life  and  comfort,  whether  the 
stenosis  is  from  contraction  or  compression,  the  ideal  treatment  is  to  remove  the 
cause.  [Thyroidectomy,  tracheal  plastic,  etc.].  Where  this  is  impossible 
one  may  perform  tracheotomy  and  introduce  through  the  aflfected  area  a  long 
cannula  (Konig's  cannula;  lobster  tail  cannula)  but  the  cannula  irritates  the 
air  passages  and  gives  rise  to  so  much  trouble  that  the  cannula  may  require 
to  be  removed.  Under  these  grave  circumstances,  the  patient  being  "between 
the  devil  and  the  deep  sea,"  Th.  Gliick  suggests  posterior  bronchotomy.  In 
one  of  Gllick's  cases  of  pneumectomy  the  patient,  while  convalescent  from  the 
operation  and  original  disease,  was  able  to  breathe  easily  and  comfortably 
through  the  thoracic  wound  while  the  nose  and  mouth  were  completely  closed. 
This  suggestion  seems  entirely  reasonable  and  should  be  borne  in  mind.  Pos- 
terior bronchotomy  is,  of  course,  no  operation  for  the  tyro,  but  in  a  few  cases 
the  e.xperienced  surgeon  may  find  it  of  value. 


CHAPTER   XXVHI 
GOITRE;  BRONCHO CELE  ;  STRUMA 

It  may  not  be  out  of  place  to  remind  the  reader  that  there  are  several 
varieties  of  goitre;  viz.,  parenchymatous,  where  there  is  uniform  enlargement 
of  the  thyroid  tissues;  adenomatous,  where  the  glandular  tissue  is  in  excess  and 
forms  single  or  multiple  tumors;  cystic,  where  from  degeneration  a  cavity  is 
formed  filled  with  colloid  or  other  fluid  and  often  containing  adenomatous 
masses.  There  is  also  that  form  known  as  "exophthalmic  goitre,"  where  the 
tumor  is  associated  with  notable  general  symptoms.  In  any  of  the  above 
varieties  operation  may  be  required. 

THYROID 

Experiments  and  clinical  observations  have  so  enriched  our  knowledge, 
still  woefully  scant,  of  the  function  of  the  thyroid  and  the  parathyroid  glands 
that  it  is  imperative  to  preface  any  description  of  the  operations  performed 
for  goitre  by  a  very  few  practical  remarks  on  the  thyroid  and  parathyroids,  on 
hj-perthyroidism,  hypothyroidism  and  hypoparathyroidism.  The  thyroid  is 
surrounded  by  a  thin,  firm  membrane  of  fibro-elastic  tissue  which  sends 
processes  between  the  glandular  units  for  their  support  and  which  act  as 
pathways  for  the  blood-vessels  and  lymphatics  of  the  gland.  This  covering 
must  not  be  considered  as  a  capsule  in  a  surgical  sense;  it  is,  surgically,  part 
and  parcel  of  the  gland  itself.  Bands  of  dense  connective  tissue  unite  the 
covering  of  the  thyroid  with  the  trachea  (ligaments  of  the  thyroid).     Fig.  370 


248 


goitre;  bronchocele;  struma 


shows  how  the  pretracheal  portion  of  the  deep  cervical  fascia  forms  a  fibrous 
or  surgical  capsule  to  the  thyroid;  it  is  the  structure  referred  to  as  the  fibrous 
capsule  when  the  operation  of  thyroidectomy  is  described.  Any  space  which 
may  exist  between  the  fibrous  capsule  and  the  thyroid  gland  is  filled  with 
loose  connective  tissue.  The  loose  connective  tissue  is  apt  to  be  most  abundant 
behind  the  lateral  lobes  of  the  gland.  This  connective  tissue  under  the  pres- 
sure of  a  goitrous  enlargement  becomes  condensed  and  is  what  Mayo  speaks 
of  in  his  subcapsular  operation. 

The  parathyroids  are  two  or  more  glandular  bodies  which  exist  on  each  side  of 
the  neck  behind  the  lateral  lobes  of  the  thyroid.     The  bodies  are  elliptical, 


"are  6  or  7  mm.  long,  3  or  4  mm.  broad  and  i- 
may  be  as  much  as  15  mm."     (Piersoll.) 


or  2  mm.  thick.     The  length 


S.h.S.t. 


MC 


370. 


C.  Fibrous  or  surgical  capsule.  P.  Parathyroids.  MC.  Connective  tissue  packing,  or  Mayo's  capsule. 
X.  Carotid  packet  of  vessels  and  nerves.  Tr.  Trachea.  Oes.  CEsophagus.  S.  h.  Stemo-liyoid.  S.  t. 
Stemo-thyroid.     S.  m.  Sterno-mastoid. 


The  parathyroids  lie  between  the  fibrous  capsule  and  the  thyroid,  in  the 
loose  areolar  tissue  there  present;  they  may  be  in  contact  with  the  thyroid  or 
with  the  capsule  or  with  both.  Halsted  writes,  "One  is  likely,  therefore,  to 
encounter  these  little  bodies,  usually  two  on  each  side,  at  any  level  from  the 
superior  to  the  inferior  pole  on  the  postero-internal  surface  of  the  gland,  but 
most  commonly  just  internal  to  the  rounded  postero-external  border  and  quite 
regularly  near  the  site  of  the  distribution  of  the  terminal  branches  of  the  inferior 
thyroid  artery.  If  the  thyroid  is  lobulated  in  this  situation,  as  is  quite  com- 
monly the  case,  a  parathyroid  may  be  concealed  in  the  cleft  between  the 
lobules."  The  parathyroids  "are  little  ovoid,  spheroid,  lenticular  or  very  flat 
bodies,  exhibiting  much  variety  in  form  and  size  and  even  in  color.  Externally 
they  often  resemble  fat  very  closely  in  consistence  as  well  as  in  color"  (Halsted). 
The  blood-supply  of  the  parathyroids  has  been  carefully  studied  by  Evans 
(Halsted  and  Evans,  "Annals  of  Surg.,"  xlvi.  No.  4)  Fig.  371.  The  glands 
are  always  supplied  by  definite  parathyroid  arteries  which  usually  arise  from 
the  inferior  thyroid,  but  frequently  come  from  an  anastomosing  channel  ex- 
isting between  the  inferior  and  superior  thyroid  arteries. 

Few,  if  any,  direct  vascular  connections  exist  between  the  parathyroids  and 
the  connective-tissue  envelope  of  the  thyroid. 


THE    THYROID 


249 


Complete  excision  of  the  thyroid  glands  has  been  followed  by  myxoedema 
and  by  tetany.  These  operations  were  performed  before  the  importance  of 
the  parathyroids  was  known.  Later,  when  the  thyroid  has  been  completely 
removed,  experimentally,  but  the  parathyroids  preserved,  myxoedema  has 
developed,  but  not  tetany.  Hypothyroidism  due  to  degeneration  of  the  thyroid 
leads  to  cretinism  or  to  myxoedema.     Overactivity  of  the  thyroid  (hyper- 


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Fig.   371. — Thyroids   and   parathyroids   seen  from   behind.     {Halsted   and  Evans.) 


thyroidism)  gives  rise  to  a  complex  of  symptoms  described  by  Graves  in  1835 
and  by  Basedow  in  1840,  and  known  by  the  names  exophthalmic  goitre,  Graves' 
disease,  Basedow's  disease.  Usually  the  thyroid  is  evidently  enlarged  in  hyper- 
thyroidism, but  sometimes  it  is  apparently  normal  in  size.  The  normal  ap- 
pearance is,  however,  only  apparent;  closer  examination  shows  that  the  secret- 
ing epithelium,  instead  of  merely  lining  the  acini,  pushes  in  folds  into  the 
acini,  thus  greatly  increasing  the  secreting  surfaces  without  notably  increasing 


250  goitre;  bronchocele;  struma 

the  size  of  the  gland.  This  is  important  to  remember.  When  the  parathyroid 
glands  are  excised  tetany  results  (hypoparathyroidism).  Halsted  observed  the 
early  symptoms  of  tetany  in  one  patient  and  was  able  to  keep  the  disease  in 
check  by  the  administration  of  the  parathyroids  of  beeves  and  later  by  Beebe's 
parathyroid-nucleoproteid.  In  the  published  statistics  of  partial  strumectomy 
the  death  rate  from  tetany  is  3.5%;  in  Kocher's  clinic  only  }-2%  (.\rnd).  Of 
course  there  are  many  cases  of  non-fatal  tetany  following  partial  strumectomy. 
The  reason  why  many  cases  of  tetany  recover  is  probably  due  to  the  fact  that 
the  parathyroids  have  not  teen  removed,  but  that  their  circulation  has  been 
interfered  with  and  has,  in  time,  become  reestablished.  One  must  remember 
that  a  lingual  thyroid  may  constitute  the  whole  active  thyroid;  that  its  re- 
moval may  lead  to  disaster  (see  p.  216). 

Indications  for  Strumectomy. — Very  many  goitres  are  removed  for  cosmetic 
reasons.  The  position,  size,  and  character  of  the  goitre  may  each  constitute 
a  positive  indication  for  operation.  Position  and  size  may  give  rise  to  re- 
spiratory and  circulatory  troubles,  as  well  as  to  interference  with  nerves.  The 
character  of  the  disease  indicates  whether  ot  not  internal  treatment  may  be  of 
value.  Soft  colloid  nodules  usually  decrease  and  occasionally  disappear  during 
internal  treatment.  Diffuse  strumata  are  those  most  suitable  to  medication 
with  iodine  administered  externally  and  internally.  Medical  treatment  must 
be  stopped  as  soon  as  it  is  shown  to  be  ineffective,  or  the  slightest  evidence  of 
iodism  or  of  Basedow's  disease  appears  (De  Quervain). 

The  local  use  of  iodine  is  liable  to  cause  adhesions  around  the  goitre  and 
thus  render  operation  more  difficult.  Injections  of  iodine  or  such  like  drugs 
are  always  improper. 

Almost  all  forms  of  goitre  are  suitable  for  operation  if  causing  symptoms  or 
deformity  or  increasing  in  size  rapidly.  In  exophthalmic  goitre  (Basedow's, 
Graves'  disease)  the  use  of  iodine  is  more  dangerous  than  in  other  forms. 
Remember  that  Graves'  disease  often  remains  stationary  or  improves  under 
any  or  no  treatment,  hence  operation  is  by  no  means  always  called  for,  but 
remember  also  that,  as  the  disease  progresses,  the  powers  of  resistance  decrease, 
hence  operation  must  not  be  too  long  delayed. 

The  chief  local  characteristic  of  exophthalmic  goitre  is  the  great  vascularity 
of  the  gland.  The  principle  of  treatment  is  to  remove  degenerated  segments 
and  decrease  the  blood-supply.  Kocher,  since  1890,  has  done  this  by  multiple 
ligation  of  the  thyroid  arteries  and  partial  excision.  This  work  he  accomplishes 
in  several  sittings.  Most  surgeons  operate  in  these  cases  exactly  as  in  ordinary 
goitre. 

Kummel  operates  either  by  enucleation  or  resection  of  a  portion  of  the  goitre 
or  partial  ligation  of  the  afferent  vessels.  His  statistics  show  70  per  cent, 
recoveries  with  5  per  cent,  mortality. 

Kocher  (''Brit.  Med.  Journ.,"  June  2,  1906),  out  of  one  hundred  and  forty- 
nine  cases,  had  nine  deaths;  one  hundred  and  forty  cases  were  kept  under 
observation  long  enough  after  operation  to  permit  of  a  definite  statement  as 
to  results:  of  these  one  hundred  and  thirty-one  were  cured  and  nine  notably 
ameliorated.     He  writes: 

"If  we  ligature  one  artery  we  get  some,  but  only  a  slight, amelioration  of  the 


HYPERTHYROIDISM  2$! 

symptoms.  If  we  ligature  two  arteries  the  effect  will  be  exactly  so  much  greater 
as  more  of  the  function  is  inhibited.  If  we  take  away  one  lobe  of  the  gland  the 
efifect  is  still  greater.  If  we  put  a  ligature  on  three  of  the  four  arteries,  we  may 
have  a  very  good  result,  and  still  better  if  we  excise  one  lobe  and  put  a  ligature 
on  the  superior  thyroid  artery  of  the  other  side:  it  will  be  even  more  complete 
when  we  combine  unilateral  excision  with  the  resection  of  the  upper  and  lower 
half  of  the  other  lateral  lobe.  If  we  have  begun  with  one  or  two  ligations, 
and  have  had  an  unsatisfactory  result,  we  are  sure  to  complete  it  by  adding  a 
third  ligature  or  by  excision  of  one-half  of  the  gland.  In  short,  we  may  say  that 
by  operation  it  is  in  our  hands  to  guarantee  a  more  or  less  complete  result." 
These  are  Kocher's  words,  and  the  surgeon  of  Berne  was  not  given  to 
exaggeration. 

In  July,  1910,  Kocher  reported  that  he  had  operated  four  hundred  and 
sixty-nine  times  for  Basedow's  disease  with  a  mortality  of  3.4  per  cent.  In  the 
last  seventy-two  cases  there  was  no  death.  Glycosuria  and  hypertrophy  of  the 
thymus  positively  contraindicate  operation.  To  refuse  operation  during  the 
initial  period  of  the  disease  is  to  lose  the  best  chance  of  success. 

Mayo's  statistics  in  cases  of  exophthalmic  goitre  are  as  follows:  Prior 
to  January  i,  1906,  there  were  fifty  primary  thyroidectomies  with  five  deaths 
(10  per  cent,  operative  mortality). 

From  January  i,  1906,  to  July  i,  1910,  there  were  459  primary  thy- 
roidectomies with  sixteen  deaths  (3.4  per  cent,  operative  mortality). 

During  this  latter  period  there  were  267  primary  ligations  with  eleven  deaths 
(4.1  per  cent,  operative  mortality). 

The  reason  for  the  death  rate  being  higher  after  ligation  than  after  thyroid- 
ectomy is  of  course  that  the  lesser  operation  was  chosen  in  the  more  dangerous 
cases,  in  fact  in  patients  for  whom  any  severe  operation  was  entirely  unjustifiable. 

C.  H.  Mayo  suggests  that  some  of  the  good  results  following  ligation  of  the 
thyroid  arteries  or  after  sympathectomy  may  be  due  to  destruction  of  many 
of  the  lymphatics  coming  from  the  thyroid;  this  destruction  of  lymphatics  is 
well  calculated  to  diminish  absorption  of  the  thyroidal  secretions  and  thus  to 
prevent  hyperthyroidism. 

The  fact  that  alarming  symptoms  of  hyperthyroidism  very  commonly  fol- 
low operations  for  Graves'  disease  have  led  to  many  endeavors  to  obviate  these 
symptoms  and  dangers.  None  of  the  endeavors  have  been  proven  effectual 
though  some  of  them  may  be  so.  A  good  rule  to  adopt  is  one  based  on  common 
sense,  viz.,  handle  the  goitre  gently  as  so  to  avoid  expressing  thyroid  juices 
which  may  be  absorbed  and  cause  trouble.  Observance  of  this  rule  may  do  good 
and  cannot  do  harm.  It  probably  does  no  good,  as  Crile  has  gently  massaged 
goitres  in  Graves'  disease  and  has  seen  no  evil  follow.  C.  H.  Mayo  after  re- 
moval of  goitres  swabbed  the  wound  with  Harrington's  solution  so  as  to  close  the 
lymphatics  and  prevent  absorption.  He  has  come  to  the  conclusion,  and  other 
surgeons  agree  with  him,  that  this  procedure  while  it  may  be  harmless,  is  of  no 
particular  value.  Crile  came  to  the  conclusion  that  fear  or  psychic  shock  was  a 
great  factor  of  danger  in  the  highly  strung  subjects  of  exophthalmic  goitre,  and 
to  avoid  this  he  adopted  the  plan  of  "stealing"  the  goitres  according  to  his  wells 
known  principles  of  anoci-association.     He  carries  out  the  following  measure- 


252  goitre;  bronchocele;  struma 

two  to  four  days  before  the  operation:  (i)  Operating  room  clothes  are  worn  by 
the  patient  continually.  (2)  Hypodermic  injection  of  sterile  water  daily  at  8 
A.  M.  (3)  Inhalations  of  Nitrous  Oxide  and  Oxygen  at  9  a.  m.  daily,  the  pa- 
tient being  informed  that  this  is  'for  the  heart.'  (4)  On  the  day  of  operation 
morphine  gr.  ^^  with  atropine  gr.  K50  is  administered  at  8  a.  m.  in  place  of 
sterile  water.  (5)  At  q  a.  m.  Nitrous  Oxide  and  Oxygen  having  been  admin- 
istered the  operation  is  performed.  If  the  symptoms  are  severe  and  the  opera- 
tive risk  great,  operation  is  performed  with  the  patient  in  bed.  Complete  local 
anesthesia  is  obtained  by  novacaine.  After  the  goiter  has  been  removed  and 
hemostatis  effected  the  wound  is  dressed  with  gauze  wrung  out  of  a  i  to  5000 
watery  solution  of  Flavine.  After  24  hours  the  divided  muscles  are  sutured 
with  catgut  and  the  wound  closed. 

The  following  are  Crile's  rules  for  after  treatment:  Place  the  patient  in  a 
comfortable  position  and  keep  him  quiet  with  morphine  in  gr.  ^q  doses  repeated 
as  may  be  necessary.  Give  plenty  water  by  the  mouth.  Enemata  of  water 
with  bicarbonate  of  soda  and  5  per  cent,  glucose  if  required.  Hypodermoclysis 
(under  complete  local  anesthesia)  if  indicated.  Ice  bag  to  heart  continuously. 
House  inhalations  (Tr.  Benzoini  Co.5j  to  a  pint  of  hot  water)  twice  daily.  If 
the  temperature  reaches  ioi°F.  apply  4  ice  bags  to  the  body;  if  102°,  8  to  12 
ice  bags.  If  the  temperature  is  104°  apply  a  complete  ice  pack  as  follows: 
Put  large  rubber  sheets  both  over  and  under  the  patient  to  keep  him  dry. 
Entirely  cover  the  patient  (except  head  and  neck)  with  about  150-200  lbs.  of 
cracked  ice.  By  means  of  an  electric  fan  direct  a  current  of  air  over  the  patient 
from  the  foot  of  the  bed.  As  a  rule  under  the  ice  pack  treatment  the  tempera- 
ture falls  about  2°  each  hour.  Discontinue  the  pack  as  soon  as  the  temperature 
falls  to  ioo°F.  If  there  is  decompensating  myocarditis  give  Digitalin  gr.  3^5 
hypodermatically  (into  muscle)  every  two  hours  until  the  patient  is  able  to  take 
digitalis  by  mouth,  when  MM.  xxx  of  tincture  of  digitalis  is  given  every  three 
hours  until  the  maximum  effect  is  secured  or  nausea  presents  itself.  If  there  is 
acute  dilatation  of  the  heart  slowly  inject  intramuscularly  strophanthin  m.g.  ^-^ 
in  10  cc.  salt  solution.  Klose  and  others  think  that  failure  to  cure  exophthalmic 
goitre  by  operations  on  the  thyroid  as  well  as  the  severe  symptoms  following 
thyroidectomy  are  due  to  toxic  material  coming  from  the  thymus  (see  p.  268). 
Riedel  performs  thyroidectomy  under  local  anesthesia  using  an  extremely  weak 
solution  of  cocaine  or  eucaine  plus  some  adrenalin.  The  injections  are  massive — 
first  under  the  skin  and  then  under  the  deep  fascia  and  fibrous  capsule  of  the  gland. 
A  pint  or  more  of  the  solution  is  used.  This  of  course  obscures  to  some  extent 
anatomic  relationships  but  it  so  distends  the  spaces  in  the  areolar  tissue  between 
the  fibrous  capsule  and  the  true  capsule  of  the  gland  that  it  practically  separates 
the  gland  from  its  surroundings  so  that  it  is  easy  to  find  and  ligate  the  vessels 
and  remove  the  gland.  If  Crile's  ideas  are  correct  regarding  reflex  nerve  im- 
pulses causing  ejaculation  of  thyroid  juice,  then  Riedcl's  massive  injections  are 
well  calculated  to  cut  off  these  impulses  and  at  the  same  time  facilitate  the  opera- 
tion. Mayo's  rules  for  operation  in  Graves'  disease  are: If  the  condition  is  fair, 
operate;  if  the  pulse  is  130  to  160,  or  if  it  suddenly  fluctuates  in  tension  and 
rapidity,  if  there  is  anaemia  with  swelling  of  the  feet,  the  patients  are  placed  upon 
belladonna  treatment  for  some  days.     The  more  severe  types  are  also  given 


ANATOMY 


253 


X-ray  exposures  in  addition,  a  treatment  which  is  continued  from  two  to  six 
weeks. 

Whenever  the  symptoms  are  severe  Mayo  contents  himself  with  ligating  the 
superior  pole  of  the  thyroid  on  one  or  both  sides:  later,  if  necessary,  he  removes 


Fig.  372. — Posterior  view  of 
trachea,  etc.,  showing  course  of  re- 
current laryngeal  nerve.  (Esmarch 
and  Kowalzig.) 


Fig.    373. — Superficial    veins    over    a 
goitre.     {Esmarch  and  Kowalzig.) 


part  of  the  gland  when  the  patient  is  in  better  condition.     In  very  grave  cases 
he  treats  the  goitre  by  injections  of  boiling  water  after  the  manner  of  Porter. 

Besides  the  two  lateral  lobes  and  isthmus  which  compose  the  thyroid  gland, 
the  remnant  of  the  thyroglossal  duct  running  up  from  the  isthmus  often  forms 
an  extra  lobe,  the  pyramidal  lobe,  and  along  its 
course  there  may  be  developed  irregular  masses 
of  glandular  tissue — accessory  thyroids.  The 
frequent  presence  of  these  extra  masses  of 
thyroid  is  not  surprising,  the  thyroid  itself  being 
developed  from  the  thyroglossal  duct;  surgically 
they  are  of  importance,  as  their  presence  is  cal- 
culated to  confuse  the  operator,  ignorant  of  their 
existence. 

The  thyroid  is  surrounded  by  a  strong 
covering  of  fascia — fibrous  capsule.  When  a 
goitre  is  present  in  the  gland  (adenoma  or  cyst), 

it  is,  of  course,  surrounded  by  more  or  less  altered  Fig.  2,1  a— De  Quervain,  Deutsche 
glandular   tissue — glandular  capsule.     The  word 
capsule,  being  applied  both  to  the  outer  fibrous 

covering  and  to  the  glandular  tissue  inside  which  (chTef  liTd 'acces^soo^'^°'^^*  '™*  ^""^^ 
the  tumor  lies,  leads  to  confusion  when  methods 

of  operating  are  described.     In  the  succeeding  pages  the  outer  or  surgical 
capsule  will  be  called  the  fibrous;  the  inner,  the  glandular  capsule. 

The  arteries  of  the  thyroid  are :  (a)  The  superior  thyroid,  entering  the  upper 
pole  of  the  lateral  lobe;  (b)  the  inferior  thyroid,  entering  the  posterior  surface  of 


Leitschf.  chir.,  cxvi,  574. 
I.  Superior  thyroid  artery  and  vein. 
2.    Superior   thyroid   vein.     3.    Acces- 
sory inferior  thyroid  vein.     4.  Inferior 


254 


goitre;  bronchocele;  struma 


the  lower  pole  and  in  close  and,  surgically,  dangerous  relation  to  the  recurrent 
laryngeal  nerve  (Fig.  372);  (c)  the  thyroidea  ima,  entering  the  isthmus  from 
below. 

The  veins  of  the  thyroid  are  of  very  great  importance;  a  study  of  Kocher's 
schemata  (Figs.  373  and  374)  will  give  a  fair  idea  of  their  location  and  im- 
portance. 

Operations  for  the  cure  of  goitre  may  be  divided  into  three  groups:  I. 
Excision;  II.  Intraglandular  enucleation;  III.  Incision  and  evacuation. 

I.   EXCISION 

Complete  excision  of  the  thyroid  gland  is  an  unjustifiable  operation,  as  it 
is  followed  by  fatal  consequences.  As  in  the  case  of  other  organs,  nature  has 
been  lavish  in  her  provision  of  functional  material  in  the  thyroid,  and  it  is  safe 
to  say  that  one-fourth  of  the  gland  is  sufficient  for  the  maintenance  of  health. 

De  Quervahi's  methods  of  operating  upon  the  thyroid  are  worthy  of  serious 
study. 

I.  Ligation  of  the  Inferior  Thyroid  Artery  External  to  the  Fibrous  Capsule  of  the 
Gland. — Through  Kocher's  collar  incision  divide  the  platysma  and  expose  the 


Stenfotkj/md 

Mrous  carjusa/e  -^^v^-s.'^ 

True  capsule 


Route  toJnf.Thyr.Att. 

Stfrno  ^/mstoid 


>^  Omo  //^oi'd 


/Vatf/swa 


Trachea 

Recvrre//t  /ar.?/ 
Oesopha^u^s  ^.^^^^ 
Parat/ii^roid 


Carofu/parht 


Inf.//ij//vida^^^m 

Fig.  375- 


inner  margin  of  the  sternomastoid  muscle.  Retract  the  muscle  gently  out- 
wards (Fig.  375).  IMake  a  vertical  incision  about  i  inch  in  length  through 
the  external  fascia  of  the  sternohyoid;  separate  this  fascia  from  the  muscle  and 
retract  it  outwards  with  the  sternomastoid.  It  is  now  easy  to  penetrate  the 
loose  connective  tissue  until  the  carotid  packet  of  vessels  and  nerve  is  reached. 
Note  the  carotid  tubercle  of  the  transverse  process  of  the  6th  cervical  vertebra; 
about  %  inch  (i  cm.)  below  this  the  convex  curve  of  the  inferior  thyroid  artery 
can  be  felt  immediately  to  the  inner -side  of  the  carotid  packet.  The  artery 
may  be  found  slightly  higher  or  lower  in  individual  cases.  The  advantage  of 
this  route  is  that  when  the  sternohyoid  and  sternothyroid  muscles  are  to  the  in- 


DE   QUERVAIN  S    METHODS 


255 


ner  side  of  the  line  of  dissection  one  is  in  little  danger  of  opening  the  fibrous 
capsule  of  the  thyroid  and  thus  one  avoids  interfering  with  the  numerous  veins 
which  lie  between  the  gland  and  its  fibrous  capsule. 

With  suitable  retractors  gently  retract  the  sternohyoid  and  thyroid  muscles 
and  the  thyroid  gland  towards  the  median  line,  the  sternomastoid  and  the 


(fe?l 


hu..  370. — dc  Quervain.     Deutsche  Zeilsch.  f.      Fig.  377. — dc  {Jucrvaui.     Deutsche  Zeitsch.  f. 
Chir.,  cxvi,  574.  Chir.,  cxvi,  574. 

outer  portion  of  the  sheath  of  the  sternohyoid  being  at  the  same  time  retracted 
outwards. 

With  dissecting  forceps  clear  the  inferior  thyroid  artery  from  the  loose 
connective  tissue  around  it  and  ligate  it.  The  only  vein  which  interferes  in  the 
dissection  is  the  median  thyroid  and  it,  as  a  rule,  is  at  a  higher  level. 


Fig.  378. — dc  Quervain.     Deutsche  Zeitsch.  J. 
Chir.,  cxvi,  574. 


Fig.  379.- 


-de  Quervain.     Deutsche  Zeitsch.  f. 
Chir.,  cxvi,  574. 


2.  The  inferior  thyroid  artery  has  been  ligated,  the  skin  and  platysma  have 
been  reflected  from  the  whole  thyroid  region.  Make  a  longitudinal  median 
incision  between  the  two  sternohyoid  and  sternothyroid  muscles  and  penetrate 
the  fibrous  capsule  of  the  gland.     In  the  usual  manner  dislocate  the  affected 


Fig.  380. — de  Quervain.     Deutsche  Zeitsch.  f. 
Chir.,  cxvi,  574. 


Fig.  381. — de  Quervain.     Deutsche  Zeitsch.  f. 
Chir.,  cxvi,  574. 


lobe  of  the  thyroid  inwards.  There  will  be  much  less  venous  bleeding  than  in 
the  usual  operation  because  of  the  Hgation  of  the  inferior  artery.  From  this 
point  onwards  De  Quervain  follows  no  "hard  and  fast"  method  of  operating. 
According  to  the  needs  of  the  individual  case  he  performs  resection,  enucleation 


256 


goitre;  bronchocele;  struma 


or  a  combination  of  these  methods,  and  like  most  surgeons  he  always  leaves  a 
substantial  portion  of  the  posterior  surface  of  the  gland  in  order  to  avoid  in- 
juring the  recurrent  laryngeal  nerve  and  the  parathyroids. 

In  performing  resection  the  following  may  be  taken  as  a  type:  Ligate 
the  upper  pole  of  the  lobe  of  the  gland  to  be  removed.  Note  and  clamp  the 
vessels  running  over  the  gland  at  the  chosen  site  for  section  (Fig.  384), 


a 

Fig.  382. — de  Queniain.     Deutsche  Zeilsch.  f.       Fig.  383. — de  Queroain.     Deutsche  Zeilsch.  f. 
Chir.,  c.xvi,  574.  Chir.,  cxvi,  574. 

Incise  the  true  capsule  along  the  anterior  part  of  the  outer  surface  of  the 
gland.  Make  a  similar  incision  through  the  true  capsule  to  the  inner  side  of 
the  lobe.  Excise  all  the  gland  lying  between  these  two  incisions,  leaving  the 
posterior  portion  of  the  true  capsule  with  a  moderate  amount  of  glandular 
tissue  attached  to  it. 


Fig.  384. — de  Quervain.    Deutsche  Zeitsch.  f.  Chir.,  cxvi,  574. 

Attend  to  hemostasis.  Suture  the  remnant  of  the  gland  close  to  the  wound 
after  providing  for  drainage.  Figures  376  to  381  show  types  of  resection. 
When  enucleation  is  preferable  to  resection  one  or  several  of  the  thyroid  arteries 
may  require  preliminary  ligation.  Figures  382  and  383  show  various  types  of 
enucleation. 


Partial  Excision — ^Excision  of  One  Lobe 

Method  A. — Kocher's  Transverse  Incision. — Step  i. — Over  the  most  promi- 
nent part  of  the  tumor  make  a  slightly  curved  transverse  incision  (concavity 
upwards)  from  the  outer  surface  of  one  sternomastoid  muscle  to  the  corre- 
sponding point  on  the  other.  Make  the  incision  too  long  rather  than  too  short, 
as  thorough  exposure  is  the  key  to  safety.  Divide  the  skin  and  platysma. 
Reflect  the  divided  tissues  upwards  and  downwards;  the  sternohyoid,  stemo- 


kocher's  operation 


257 


thyroid,  omohyoid,  and  inner  margin  of  the  sternomastoid  muscles  lie  more  or 
less  exposed.  Find  the  anatomic  middle  line  of  the  neck.  Remember  that 
a  unilateral  goitre  pushes  this  line  towards  the  opposite  side  (Figs.  385 
In  the  median  line  divide  the  fascia  uniting  the  right  and  left  muscle 
groups.  Do  this  extensively  both  upwards  and  downwards  under  guidance 
of  the  finger  passed  under  the  fascia.     Pass  the  finger  under  the  muscles  of 


Fig.  385. — {Kocher.) 

the  diseased  side  immediately  below  the  larynx  and,  if  necessary,  divide  them 
transversely  to  the  extent  necessary  for  thorough  exposure  of  the  tumor.  It 
is  well  to  divide  the  muscles  between  clamps  so  as  to  prevent  staining  of  the 
wound  with  blood.  Demonstrate  the  fibrous  capsule  of  the  thyroid  and  split 
it  without  injuring  the  gland  beneath.  Division  of  the  fibrous  capsule  is 
absolutely  essential. 


{Kocher.) 


Step  2. — With  the  finger  separate  the  fibrous  capsule  from  the  anterior  sur- 
face of  the  gland,  at  the  same  time  pulling  the  muscles  and  fibrous  capsule 
outwards  with  blunt  retractors.  The  goitrous  thyroid  now  presents,  covered 
by  a  peritoneal-like  membrane  (Fig.  394).  Any  veins  (accessory  veins)  passing 
from  the  fibrous  capsule  to  the  gland  must  be  doubly  ligated  and  divided.  Do 
the  same  for  the  outer  and  posterior  surfaces  (Figs.  386,  387,  and  388).  Now 
dislocate  the  goitre  and  pull  it  out  of  the  wound.     This  removes  pressure  from 

17 


^5^ 


goitre;  bronchocele;  struma 


trachea.  If  a  general  anesthetic  is  being  used,  warn  the  anesthetist  before 
dislocating  the  gland. 

Step  3. — Systematic  ligation  of  vessels. 

(a)  With  Kocher's  director  push  the  fibrous  capsule  inwards  and  outwards 
from  the  upper  pole  of  the  thyroid  until  the  superior  thyroid  artery  and  vein 
are  isolated  like  a  pedicle.  Divide  these  between  ligatures  applied  tightly 
(Fig.  389). 


Fig.  387. — (Kocher.) 

(b)  Vigorously  retract  the  muscles  (sternomastoid,  etc.)  of  the  afifected  side. 
Firmly  pull  the  goitre  over  towards  the  sound  side  (Fig.  388).  The  inferior 
thyroid  artery  lies  on  the  deep  muscles  of  the  neck  and  may  be  felt  as  a  trans- 
verse or  oblique  pulsating  cord  running  from  the  outer  side,  under  the  carotid 
to  the  thyroid  gland,  where  that  structure  is  attached  to  the  trachea.  Isolate 
the  artery  with  great  care  and  precision,  because  close  to  it  is  the  recurrent 
laryngeal  nerve.  Only  apply  one  ligature  to  the  vessel.  Many  surgeons  ligate 
each  branch  of  the  inferior  thyroid  close  to  the  gland  and  so  avoid  the  nerve. 


-^x 


388.— (Kocher.) 


Fig.  389. — {Kocher.) 


(c)  At  the  lower  pole  of  the  tumor  on  its  median  side  look  for,  doubly 
ligate,  and  divide  the  thyroidea  ima  artery  and  the  accompanying  veins  (Fig. 

391)- 

Step  4. — Isolate  the  thyroid  isthmus.  Doubly  ligate  and  divide  all  vessels 
visible  on  it.  Catch  the  isthmus  in  strong  forceps  (Fig.  392)  and  crush  it 
forcibly.  Remove  the  crushing  forceps.  Doubly  ligate  the  gutter  crushed  in 
the  isthmus  with  single  or  chain  ligatures  and  divide  it. 

Step  5. — The  gland  now  remains  attached  to  the  trachea  and  cricoid  by  its 
inner  margin.     If  this  portion  of  the  gland  is  healthy,  cut  away  the  gland  in 


MAYO  S    OPERATION 


259 


such  a  manner  as  to  leave  a  thin  layer  in  situ,  protecting  the  recurrent  laryngeal 
nerve.    Ligate  any  bleeding  vessels. 

Step  6. — Wash  the  wound  with  hot  solution.  Examine  for  any  bleeding 
points.  Return  any  divided  muscles  to  their  normal  place  and  unite  them 
by  sutures.     Provide  for  drainage^  especially  in  exophthalmic  cases.     Close 


Fig.  390. — {Kocher.) 


Fig.  391. — {Kocher.) 


the  wound.  Apply  dressings.  The  drainage  must  be  removed  in  twenty- 
four  hours  if  no  fluid  blood  is  escaping. 

Method  B. — Mayors  Operation. — Step  i. — As  in  method  A. 

Step  2. — With  the  fingers  separate  the  fibrous  capsule  from  the  anterior 
surface  of  the  gland,  at  the  same  time  pulling  the  muscles  and  fibrous  capsule 
outwards  with  blunt  retractors  or  forceps.     Doubly  ligate  and  divide  any 


Fig.  392. — {Kocher.) 


accessory  veins.     Expose  and  elevate  the  upper  pole  of  the  th3'roid;  doubly 
ligate  and  divide  the  superior  thyroid  vessels. 

Step  3. — Elevate  the  lower  pole  of  the  th}T:oid  and  bring  it  into  the  wound. 
If  necessary  make  an  incision  along  the  outer  posterior  border  of  the  thyroid 
so  as  to  divide  any  condensed  areolar  tissue  which  may  be  adherent  to  the 
peritoneal-like  investment  of  the  gland.     This  incision  is  not  always  necessary. 


26o 


goitre;  bronchocele;  struma 


With  a  piece  of  gauze  wipe  or  brush  all  areolar  tissue  adherent  to  the  posterior 
surface  of  the  gland  from  the  gland  so  that  that  surface  of  the  gland  has  no 
moss  of  areolar  tissue  left  adherent  to  it,  but  presents  a  smooth  peritoneal- 
like  appearance.  If  this  is  done  carefully  and  every  bit  of  areolar  tissue,  which 
may  have  penetrated  into  sulci  on  the  gland  surface,  has  been  brushed  off  and 
left  adherent  to  the  fibrous  capsule,  then  the  parathyroids  must  also  have  been 
brushed  off  and  preserved.     Continue  this  gauze  dissection  or  brushing  to  the 


i''i*-  sgo'—O^^y^-) 


middle  line.  Ligate  the  inferior  thyroid  artery  close  to  the  tumor  as  the  gauze 
dissection  is  being  carried  out.  This  leaves  the  recurrent  laryngeal  nerve 
behind  and  usually  out  of  sight. 

Steps  4,  5  and  6. — As  in  method  A. 

Method  C. — Halsted's  operation  is  the  same  as  Kocher's  or  Mayo's  up  to 
a  certain  point.  The  following  quotation  from  Halsted  gives  the  main  points 
of  his  method.  "  Contrary  to  the  universal  custom,  I  do  not,  as  a  rule,  complete 
at  this  moment  the  full  delivery  of  the  entire  gland,  for  fear  of  soiling,  but 
grasp  very  firmly  between  the  thumb  and  finger  the  superior  pole  and  pull  it 
forwards  and  towards  the  mid-line  far  enough  to  make  the  ultraligation  of  the 
superior  thyroid  vessels  perfectly  easy.     Attempts  to  completely  dislocate  the 


HALSTED  S    OPERATION 


261 


entire  gland  of  the  inferior  pole  in  this  manner  at  this  stage  of  the  operation 
may  cause  the  rupture  of  some  delicate  blood-vessels  and  consequent  staining 
of  the  field  containing  the  parathyroid  glandules.  But,  if  judiciously  done 
in  the  manner  described,  the  superior  pole  may  be  fearlessly  grasped,  because 
at  this  horizontal  level  there  are  no  vessels  behind  the  superior  pole  to  be  torn. 
When  the  superior  thyroid  vessels  have  been  safely  passed  by  the  thumb  or 
finger,  one  may  proceed  with  considerable  roughness  and  without  fear  of  hemor- 
rhage to  dislocate  even  the  highest  and  deepest  superior  pole.     This  grasp  of 


Fig.  394. — {Mayo.) 

the  upper  portion  of  the  lobe,  putting  on  stretch  the  superior  thyroid  vessels, 
must  not  be  relinquished  until  released  by  the  ultradivision  of  the  finest  branches 
distributed  to  the  thyroid  gland  in  the  vicinity  of  the  superior  pole.  The  upper 
end  being  thus  liberated  the  delivery  of  the  entire  lobe  is  continued,  and  without 
the  tearing  of  the  blood-vessels.  From  this  step  on,  throughout  the  operation, 
until  the  last  vessel  has  been  divided,  the  thyroid  lobe  must  be  firmly  drawn 
towards  the  opposite  side,  alternate  relaxation  and  compression  and  undue 
pressure  on  the  trachea  being  carefully  avoided.  From  above  downwards  and 
from  before  backwards  the  vessels  as  they  bind  or  as  they  present  must  be 
clamped  and  divided  at  their  point  of  entrance  into  the  gland,  as  far  peripherally 
as  possible.  Except  in  the  case  of  the  larger  branches  it  is  usually  unnecessary 
to  clamp  the  distal  end  of  the  cut  vessel,  hemorrhage  from  the  gland  side  being 


262 


goitre;  bronchocele;  struma 


prevented  by  the  pressure  exerted  on  the  thyroid  lobe  by  the  unremitting 
traction  towards  the  opposite  side  of  the  neck.  By  this  method  the  recurrent 
laryngeal  nerve,  usually  seen,  is  little  endangered.  In  the  course  of  the  libera- 
tion of  the  lobe  the  nerve  may  be  dragged  well  to  the  front  of  the  trachea;  of 
the  right  nerve  this  is  particularly  true.     When  in  the  immediate  neighborhood 


Fig.  395. — {Balfour,  Annals  of  Surgery.) 

of  this  nerve,  at  what  might  erroneously  be  termed  the  hilus  of  the  th>Toid  lobe, 
one  plunges  the  sharp-pointed  clamps  into  the  thyroid  gland,  seizing  the  binding 
vessels  after  they  have  disappeared  from  view  in  its  substance.  WTien  the  habit 
is  well  acquired,  little  if  any  time  is  lost  by  practising  the  clean,  bloodless  method 
of  operating  for  goitre.  The  operation  can  be  carefully  performed  in  about  the 
time  required  for  its  detailed  description." 


RESECTION'  263 

Method  D. — Angular  Incision  (Kocher). — Beginning  on  the  sternomastoid 
muscle  at  the  level  of  the  thyroid  cartilage,  make  an  incision  through  the  skin 
and  platysma,  reaching  the  median  line  and  following  the  direction  of  the  natu- 
ral folds  or  creases  of  the  skin.  Continue  the  incision  downwards  in  the  middle 
line  to  the  notch  of  the  sternum.  Reflect  the  angular  skin-flap  and  expose  the 
sternomastoid,  which  must  be  retracted  outwards.  The  rest  of  the  operation 
is  the  same  as  in  ^Method  A.  This  method  of  exposure  is  of  much  value  in  cases 
where  the  goitre  extends  far  upwards  or  downwards. 

Method  E. — v.  Mikulicz's  Method  of  Resection. — The  following  description 
is  from  v.  Mikulicz's  article,  quoted  by  Berry  ("  Diseases  of  the  Thyroid  Gland") : 
"  I  began  the  operation,  intending  to  perform  the  ordinary  one  of  removal  of  the 
left  lobe,  and  hoping  to  be  able  to  leave  the  right  intact.  In  the  course  of  the 
operation,  however,  it  became  evident  that  the  right  lobe  lay  partly  behind  the 
sternum,  and  would,  if  left,  prove  a  source  of  danger  to  the  patient.  So  instead 
of  doing  the  usual  extirpation,  I  resected  this  lobe  in  the  following  manner: 
First  of  all  it  was  isolated  as  far  as  possible  in  the  usual  way  with  blunt  instru- 
ments. The  smaller  blood-vessels  were  tied  with  double  catgut  sutures.  I 
then  tied  the  superior  thyroid  artery  and  vein  in  the  ordinary  manner  at  the 
summit  of  the  lobe;  also  the  superficial  vessels  passing  to  the  lower  part  of  the 
gland.  I  now,  by  means  of  short  snips  of  the  scissors,  freed  that  portion  of  the 
tumor  which  was  adherent  to  the  front  and  side  of  the  trachea,  but  took  care 
not  to  go  too  far  back,  so  as  not  to  come  into  collision  with  the  recurrent  laryn- 
geal nerve.  Eventually  the  whole  tumor  was  attached  only  to  the  angle  be- 
tween the  trachea  and  oesophagus,  where  it  covered  the  recurrent  nerve  and 
inferior  thyroid  artery.  This  attached  portion,  the  hilus  of  the  gland,  I  treated 
like  the  short,  thick  pedicle  of  an  ovarian  tumor.  .  .  .  While  my  assistant 
with  his  fingers  compressed  the  vessels  entering  the  hilus,  I  split  the  pedicle 
lengthwise  with  blunt  scissors  into  several  portions,  seized  each  of  these  in  a 
strong  pair  of  pressure  forceps,  and  placed  catgut  ligatures  in  each  of  the  clefts 
so  formed.  Then  the  goitrous  mass  was  cut  off  with  scissors,  leaving  a  pedicle 
of  5  to  ID  mm.  {yir'/o  inch)  in  length.  The  forceps  squeezed  out  nearly  all  the 
glandular  tissue,  leaving  in  their  grasp  little  but  connective  tissue.  The  result 
was  that  the  catgut  ligatures  could  easily  and  safely  be  placed  around  the  sepa- 
rated portions  of  the  pedicle.  Not  a  drop  of  blood  came  away  from  the  cut 
surfaces;  only  here  and  there  in  the  intervals  was  a  little  oozing;  this  slight 
hemorrhage  was  easily  stopped  by  the  application  of  a  few  ligatures.  The 
remainder  of  the  gland  had  now  shrunk  to  a  lump  about  as  large  as  a  chestnut 
which  lay  in  the  angle  between  the  trachea  and  oesophagus.  Neither  recurrent 
nerve  nor  inferior  thyroid  artery  came  into  view  on  this  side." 

The  above  operation  has  been  frequently  repeated  and  has  proved  very 
successful.  The  advantages  of  the  procedure  are:  (a)  avoidance  of  the  recur- 
rent nerve;  {h)  avoidance  of  injury  to  the  parathyroids;  (c)  retention  of  portions 
of  the  lobes  attacked,  and  hence  the  possibility  of  removing  parts  of  both  lobes. 

Donald  Balfour  (Annals  Surg.,  May,  1914)  describes  a  method  almost  the 
same  as  that  of  Mikulicz.  It  is  particularly  suitable  for  non-toxic  goitres  where 
the  operation  is  for  the  relief  of  pressure  symptoms  and  the  removal  of  deformity. 

Expose  the  thyroid  through  the  usual  collar  incision.     If  both  lobes  are  en- 


264  goitre;  bronchocele;  struma 

larged,  dislocate  them  both.  Determine  how  much  glandular  tissue  must  be 
removed  from  each  side  to  ensure  symmetry  and  cure.  Divide  the  isthmus,  if 
possible,  between  clamps.  Free  the  isthmus  and  lobe  on  one  side  from  their 
tracheal  attachments  anteriorly  and  laterally  sufficiently  to  relieve  all  pressure 
and  to  permit  of  proper  suturing  after  resection.  Do  the  same  to  the  other  half 
of  the  gland. 

Apply  a  series  of  Ochsner  forceps  around  the  area  to  be  resected:  one  forceps 
about  I  inch  from  the  upper  pole,  one  near  the  lower  pole,  three  or  four  laterally 
on  the  larger  vessels  in  the  capsule,  and  two  or  three  on  the  tracheal  side.  These 
forceps  mark  the  limits  of  the  resection  and  enable  one  to  control  bleeding  by 
traction  on  them  along  with  support  of  the  lobe  from  behind  with  the  finger. 
Make  an  incision  through  the  capsule  around  the  lobe  just  within  the  circle  of 


ligature. 
around  Isihmus 

Trachea 


Thuroidea  ima 
Vein. 


Fig.  396. — Resection-enucleation. 

forceps  (Fig.  395).  "  Wedge"  out  the  interior  of  the  gland.  Multiple  adenomas 
and  masses  of  colloid  are  easily  enucleated  by  the  finger.  The  superior  and  in- 
ferior poles  and  a  layer  of  gland  tissue  covering  the  posterior  capsule  are  left 
intact.  Bring  the  walls  of  the  wounded  gland  into  contact  and  fix  them  to- 
gether by  a  continuous  mattress  suture  of  catgut  introduced  behind  the  row  of 
Ochsner  forceps.  Remove  the  forceps.  Introduce  sufficient  stitches  to  com- 
plete the  closure  of  the  glandular  wound  and  to  assure  hemostasis. 

Method  F. — Resection-enucleation  (Kocher). — This  method  is  very  like  that 
of  V.  Mikulicz,  but  avoids  leaving  large  ligated  masses  near  the  location  of 
the  recurrent  nerve.  Kocher  has  noticed  that  when  many  large  pedicles  are 
ligated  near  the  nerve  the  necessary  contraction  of  the  tissues  by  the  ligature 
often  causes  injury  to  it. 

The  Operation. — Step  i. — Expose  the  anterior  surface  of  the  diseased  half 
of  the  thyroid  as  in  Method  A.  Crush  (with  forceps),  ligate,  and  divide  the 
isthmus  close  to  the  disease. 

Step  2. — Through  the  cut  surface  of  the  isthmus  the  goitrous  nodule  will 
present  (Fig.  396).  Beginning  at  the  isthmus  wound,  with  the  finger  or  Kocher 's 
director  penetrate  the  glandular  capsule  down  to  the  disease  and  separate  the 


ENUCLEATION  265 

former  from  the  nodule  along  the  lines  A  B  and  C  D.  Note  that  the  separation 
of  glandular  capsule  from  goitrous  nodule  is  only  along  these  two  lines.  With 
strong  forceps  crush  the  glandular  capsule  along  the  lines  of  separation,  remove 
the  forceps,  apply  ligatures  to  the  crushed  tissue,  and  divide  the  glandular 
capsule. 

Step  3. — Grasp  the  goitrous  nodule  and  overlying  glandular  capsule  and 
separate  this  mass  from  the  posterior  portion  of  the  glandular  capsule  until  all 
that  connects  the  goitrous  mass  to  the  body  is  the  outer  portion  of  the  glandular 
capsule  (B  D,  Fig.  396)  well  external  to  the  line  of  the  recurrent  nerve.  Crush 
this  portion  of  the  capsule;  ligate  and  divide  it. 

By  the  above  procedure  the  diseased  tissues  are  removed,  and  with  them  the 
anterior  portion  of  the  gland.  All  the  posterior  surface  of  the  gland  is  left, 
which  is  advantageous  because  danger  to  the  recurrent  nerve,  and  the  para- 
thyroids, is  avoided  and  much  useful  glandular  tissue  is  retained.  Hemorrhage 
is  less  than  in  enucleation.  Kocher  says  that  this  operation,  while  very  valu- 
able, is  of  more  limited  application  than  excision.  It  is  inapplicable  in  cases  of 
diffuse  follicular  colloid  degeneration. 

Method  G. — Freeman's  Method  (Surg.  Gyn.  and  Obst.,  July,  1914). — Dis- 
locate the  gland  through  the  usual  collar  incision.  Separate  ligation  of  the 
superior  thyroids  may  be  practised  if  desired.  Pull  the  lobe  forwards  so  as  to 
put  its  attachments  on  the  stretch  and  form  more  or  less  of  a  pedicle  next  to  the 
trachea. 

Thread  both  ends  of  a  12-inch  loop  of  strong  silk  or  fishing  line  through  the 
eye  of  a  probe  and  pass  it  from  behind  forwards  through  the  substance  of  the 
gland  near  its  attachments. 

Introduce  several  such  loops  of  thread  through  the  gland,  one  near  each  end 
and  one  or  more  near  the  centre.  Place  a  segment  of  strong  wire  (No.  17 
German  silver,  "orthodontia  wire")  through  the  loops  behind  the  gland  and  a 
similar  wire  between  the  ends  of  the  thread  in  front  of  the  gland.  Tie  the  threads 
over  the  anterior  wire  firmly  enough  to  control  the  circulation  without  injuri- 
ously crushing  the  glandular  tissue.  About  3^^  inch  distal  to  the  wires  cut  away 
the  lobe  in  a  more  or  less  wedge-shaped  fashion.  Suture  the  wound  with  a  con- 
tinuous catgut  stitch  to  cover  the  raw  surface  and  prevent  subsequent  bleeding. 
Pull  the  wires  out  of  the  loops  and  remove  the  latter.  Close  the  wound  as  usual. 
Freeman  has  used  this  method  successfully  in  about  twenty  goitres  of  moderate 
size  and  excessive  vascularity — as  in  Graves'  disease. 

II.   INTRAGLANDULAR   ENUCLEATION 

Step  I. — Expose  the  anterior  surface  of  the  diseased  lobe  by  Method  A  or 
D.     (See  "Excision.") 

Step  2. — Note  the  most  prominent  part  of  the  tumor,  and  at  this  point 
freely  incise  the  glandular  capsule.  Before  incising,  clamp  or  doubly  ligate 
any  prominent  vessels.  Be  sure  to  penetrate  to,  but  not  into,  the  tumor. 
It  is  not  always  necessary  to  incise  the  glandular  capsule  as  the  tumor  may 
have  so  grown  as  to  push  aside  all  the  gland  tissue  which  originally  covered  it. 
In  such  a  case  it  is  easy  to  enucleate  the  growth  by  brushing  aside  with  gauze 
all  tissue  adherent  to  it. 


266  goitre;  bronchocele;  struma 

Step  3.— With  blunt  dissection,  using  the  finger,  Kocher's  director,  or  closed 
blunt  scissors,  shell  the  tumor  out  of  its  glandular  capsule.  Sometimes  this  is 
more  easily  accomplished  if  the  fluid  contents  are  drawn  off,  as  in  the  case  of  a 
large  ovarian  cyst.  The  shelling-out  must  be  done  rapidly,  as  bleeding  is  often 
abundant.  The  surgeon  must  always  keep  his  instrument  close  against  the 
tumor-wall,  otherwise  the  vascular  glandular  capsule  will  be  injured  and  more 
bleeding  provoked. 

Step  4. — Immediately  on  the  removal  of  the  tumor  temporarily  pack  the 
cavity  with  gauze  and  pull  the  whole  cavity  forwards.  Gradually  remove  the 
gauze,  and  with  forceps,  ligatures,  and  catgut  stitches  stop  hemorrhage.  The 
hand  placed  behind  the  thyroid  can  press  the  floor  of  the  wound  cavity  forwards 
within  reach  and  control.  Hemostasis  must  be  absolute,  as  primary  union  is  of 
great  importance. 

Step  5. — Provide  for  drainage  for  twenty-four  hours.  A  tubular  drain  is 
best.  Close  the  wound  with  sutures.  For  this  purpose  Berry  uses  three  layers 
of  fine  sutures.  One  layer  obliterates  the  cavity  in  the  gland,  another  unites 
the  muscles,  and  a  third,  the  skin-wound. 

Where  large  multilocular  cysts  are  present  F.  J.  Shepherd  ties  and  divides 
the  superior  thyroid  vessels,  delivers  the  gland  and  enucleates  the  tumor. 
This  leaves  a  thin  layer  of  gland  tissue  behind,  and  there  is  no  danger  of  injur- 
ing the  recurrent  nerve.  Occasionally  Shepherd  ties  the  inferior  thyroid  as  well 
as  the  superior.  In  the  light  of  Evans'  researches  into  the  blood  supply  of 
the  parathyroids,  ligation  of  the  inferior  thyroid  artery  becames  a  matter  of 
much  greater  gravity  than  it  was  formerly  thought  to  be. 

III.   INCISION  AND   EVACUATION:   MARSUPI.ALIZATION 

In  certain  cases  of  cystic  goitre  where  repeated  attacks  of  inflammation  have 
caused  the  formation  of  many  adhesions  none  of  the  preceding  methods  are 
applicable,  and  a  simpler  operation  must  be  done. 

Step  I. — Make  an  incision  over  the  most  prominent  portion  of  the  tumor 
and  expose  a  few  inches  of  its  surface. 

Step  2. — Doubly  ligate  the  vessels  of  the  tumor  capsule  (both  fibrous  and 
glandular  capsule)  and  incise  the  tumor.  Stitch  the  edges  of  the  wound  in  the 
cyst-wall  to  the  skin. 

Step  3. — Explore  the  cyst  with  the  finger  and  shell  out  all  degenerated  col- 
loid masses.  Stop  bleeding  by  means  of  forceps,  ligatures,  hemostatic  sutures, 
hot  water,  and  packing.     Drain  the  cavity. 

The  great  objection  to  this  procedure  is  the  open  wound  which  is  left,  the 
dangers  of  subsequent  infection,  and  the  possible  persistence  of  a  fistula;  its 
advantages  are  ease  of  accomplishment  and  immediate  safety.  The  operation 
has  a  distinct  though  limited  field  of  usefulness. 

IV.   TRANSPLANTATION   OF   THYROID   OR  PARATHYROID 
GLANDULAR   TISSUE 

Payr  ("German  Surg.  Congress,"  1906)  has  made  some  remarkable  ex- 
periments on  animals  and  has  endeavored  to  prevent  the  tetany  and  cachexia 
strumipriva  which  follow  complete  thyroidectomy.     In  animals  he  implanted 


INJECTIONS    IN    GOITRE  267 

fragments  of  thyroid  gland  into  a  pouch  made  in  the  spleen.  Hemorrhage 
ceased  as  soon  as  the  ''living  tampon"  was  sutured  in  place.  Omentum  was 
stitched  over  the  splenic  wound.  After  some  days  the  rest  of  the  thyroid  gland 
was  removed  without  ill  resulting.  As  a  control  Payr  in  some  cases  subse- 
quently removed  the  spleen  and  caused  death  from  tetany. 

Encouraged  by  the  above  Payr  operated  on  a  girl  of  six  years,  a  complete 
idiot  who  had  been  treated  for  three  years  with  thyroid  tablets  unsuccessfully. 
He  removed  a  part  of  the  healthy  thyroid  from  the  patient's  mother  and  im- 
mediately implanted  it  in  the  child's  spleen.  Both  patients  recovered  from  the 
operation.  The  psychic  improvement  in  the  child  was  "incontestable."  Payr 
has  noticed  that  grafts  from  ductless  glands  generally  do  well  in  the  spleen 
while  those  from  excretory  glands  do  not  do  so  well. 

Following  Payr's  lead,  Halstead  has  endeavored  to  transplant  parathyroid 
glands  which  have  been  accidentally  deprived  of  their  vascular  supply  during 
strumectomy. 

In  a  case  of  tetany  following  thyroidectomy  a  cure  resulted  from  the  implan- 
tation of  two  parathyroid  bodies  under  the  skin  of  the  abdomen.  The  im- 
plants were  obtained  from  two  men  operated  on  for  goitre.  (W.  Davidson, 
"Beitr.  z.  klin.  Chir.,"  Ixvi,  Hft.  i.) 

V.   INJECTIONS   OF   BOILING   WATER.      (Miles  Porter,  "Journ. 
A.  M.  A."  July  12,  1913) 

Any  fairly  large  all-glass  graduated  syringe  may  be  used.  The  glass  barrel 
prevents  one  from  injecting  air;  the  more  water  the  syringe  holds  the  less  rapidly 
will  the  water  cool;  the  plunger  and  barrel  being  both  of  glass  prevents  binding 
or  breaking  due  to  unequal  expansion.  The  needle  ought  to  be  long  and  rather 
fine. 

Boil  the  syringe  and  needle  in  the  water  to  be  used  for  injection  and  keep 
the  water  boiling  until  the  time  of  injection.  When  more  than  one  injection  is 
given  at  a  treatment,  reboil  the  syringe  immediately  before  the  next  injection  to 
insure  having  the  water  used  as  near  the  boiling  point  as  possible. 

Handle  the  syringe  with  long  forceps  (the  points  of  which  have  been  heated) 
and  with  sterile  gauze  or  muslin.  After  cleaning  the  skin  anesthetize  it  at  the 
site  of  injection,  with  Schleich's  solution.  Avoiding  any  large  superficial  veins 
pass  the  long  needle  deeply  into  one  lobe  and  inject  the  boiling  water.  Porter 
has  used  from  40  to  230  minims  at  one  injection.  Partly  withdraw  the  needle 
and  make  another  injection.  With  the  long  needle  it  may  be  possible  to  make 
two  injections  into  each  lobe  and  one  into  the  isthmus  through  the  same  punc- 
ture. The  discomfort  produced  by  the  treatment  is  usually  slight  and  consists 
of  a  feeling  of  distension  and  of  pain  running  up  to  the  occiput.  In  some  cases 
the  pain  has  been  severe.  The  goitre  usually  becomes  larger  and  harder  follow- 
ing the  injection  but  later  on  decreases  much.  The  improvement  in  symptoms 
is  usually  prompt  and  progressive  for  one  or  two  weeks.  The  injections  should 
be  repeated  at  intervals  of  one  or  two  weeks.  The  greatest  number  of  injections 
given  any  one  patient  was  eleven.  Porter  has  used  the  treatment  chiefly  in 
three  classes  of  cases;  i.  Patient  too  sick  to  make  a  safe  surgical  risk.     Cases 


268  THYMUS    GLAND 

also  of  substernal  goitre,  the  removal  of  which  would  be  extra  hazardous.  2. 
Patients  with  very  mild  symptoms.  3.  When  major  surgical  procedures  have 
been  refused. 

The  author  has  had  no  personal  experience  in  the  " boiling  water"  treatment 
of  exophthalmic  goitre,  but  Porter  who  'devised  it  is  a  most  reliable  surgeon  and 
his  findings  have  been  amply  corroborated  by  others. 


CHAPTER  XXIX 
THYMUS  GLAND 

An  enlarged  thymus  gland  may  so  press  upon  the  trachea  as  to  necessitate 
operation.  Operation  may  be  either  exopexy  with  or  without  partial  excision 
or  it  may  be  one  of  complete  excision. 

The  thymus  and  thyroid  glands  being  both  branchiogenous  organs  may  be 
simultaneously  affected  by  the  same  influences.  Thus  the  cause  of  Graves'  dis- 
ease may  act  on  both  these  glands  and  the  biochemical  activity  of  each  may  have 
its  effect  on  the  production  of  the  symptoms.  Klose  thinks  that  the  fact  that 
thyroidectomy  only  gives  70-80  per  cent,  of  cures  in  Graves'  disease,  indicates 
that  there  is  another  source  of  toxin  than  the  thyroid,  viz.,  the  thymus.  (See 
H.  Klose,  "Chir.  der  Thymus-driise.  Ergeb.  d.  Chir.,"  viii,  1914.) 

The  work  of  Garre  ("Zent.  f.  Chir.,"  Dec.  6, 1913)  has  demonstrated  that  the 
thymus  may  be  responsible  for  the  symptoms  of  Graves'  disease.  He  reported 
the  following  case:  Woman  twenty-seven  suffered  for  three  months  from 
marked  Basedow's  disease  with  severe  diarrhoea.  The  trouble  followed  a  gyne- 
cologic operation.  The  thyroid  gland  was  scarcely  enlarged;  there  was  dulness 
over  the  manubrium  sterni;  lymphocytosis  46  per  cent.;  functionally  increased 
vagotonus;  negative  adrenalin  test;  fall  of  leucocytosis  to  normal  and  marked 
increased  elimination  of  nitrogen  under  a  milk  diet;  increase  of  the  symptoms 
after  intramuscular  injections  of  thymus  extract.  All  these  led  Garre  to  re- 
move the  thymus.  The  results  were  excellent.  The  diarrhoea  stopped  at  once. 
In  six  weeks  the  pulse  rate  dropped  to  below  100.  The  weight  increased  19 
pounds.  The  exophthalmos,  sweating  and  tremor  lessened.  The  blood  pic- 
ture remained  unaltered. 

v  Haberer  (German  Surg.  Congr.,  1913)  reported  the  case  of  a  man  suffering 
from  exophthalmos,  enlarged  thyroid,  violent  and  increasing  tachycardia. 
Hemithyroidectomy  did  not  benefit — neither  did  ligation  of  the  vessels  on  the 
opposite  side  which  was  done  two  years  later.  When  v.  Haberer  saw  him  his 
condition  was  precarious  from  dyspnoea  and  tachycardia.  Immediate  improve- 
ment followed  thymectomy  under  local  anesthesia,  although  the  thymus  itself 
proved  to  be  very  small.  Four  months  after  operation  the  patient  was  able  to 
return  to  work  and  was  free  from  dyspnoea,  tachycardia  and  nervousness. 

Since  it  is  very  difficult,  even  if  possible,  to  define  in  which  cases  the  thymus 
is  the  principal  offender  Klose  recommends  combined  excision  as  the  operation 
of  choice  in  Basedow's  disease  especially  in  those  cases  in  which  fear  of  a  "thy- 
mus death"  formerly  contraindicated  operation.     He  claims  (and  is  supported 


EXCISION   OF   THYMUS  269 

by  Enderlen  and  v.  Haberer)  that  removal  of  part  of  the  thymus  makes  the 
operation  of  strumectomy  for  exophthalmic  goitre  much  less  dangerous  and 
distressing  as  well  as  giving  better  ultimate  results. 

Regarding  the  technique  of  the  operation  Klose  writes,  "It  is  possible  in 
every  case  under  local  anesthesia  to  pull  forwards  the  thymus  bluntly  after 
splitting  the  deep  fascia  and  then  to  incise  the  capsule  and  enucleate  the  gland 
completely  or  in  part.  Experience  has  shown  that  complete  removal  is 
harmless  in  adults.  The  enucleation  must  of  course  be  intracapsular.  .  .  . 
v.  Haberer  urges  that  the  posterior  surface  of  the  sternum  be  used  as  a  guide  in 
order  to  avoid  trouble." 

A.  Exopexy. — Expose  the  upper  part  of  the  thymus  gland  by  a  median 
incision  above  the  sternal  notch.  Pull  the  gland  upwards  and  forwards.  An- 
chor it  with  a  few  stitches  to  the  fascia  over  the  sternum.  In  the  hands  of 
Rehn,  exopexy  gave  a  good  result.  In  a  similar  case  Fritz  Konig  resected  a 
portion  of  the  gland,  anchoring  the  remainder  to  the  sternum,  and  obtained  a 
cure  of  the  dyspnoea. 

B.  Excision  of  the  Enlarged  Thymus.  (Ehrhardt,  "Archiv  fiir  klin.  Chir. 
Ixxviii,  602.) 

Step  I. — Make  a  median  incision  from  a  point  just  below  the  larynx  to  a 
point  about  ^  inch  below  the  upper  edge  of  the  sternum.  Layer  by  layer 
divide  the  tissues,  including  the  isthmus  of  the  thyroid,  until  the  trachea  is 
fully  exposed.  At  each  expiration  a  large  part  of  the  thymus  rolls  forwards  in 
the  root  of  the  neck. 

Step  2. — Seize  the  thymus  with  forceps  and  pull  it  forwards.  Enucleate  the 
gland  by  blunt  and  sharp  dissection  attending  to  hemostasis  at  the  same  time. 
Partially  tampon  and  close  the  wound. 

Ehrhardt  operated  with  success  as  above  in  one  case. 

Veau  and  Oliver  ("Arch,  de  med.  des  enfants,"  1910,  Nov.)  operated  in 
three  cases  in  much  the  same  manner  using  chloroform  narcosis.  After  exposing 
the  gland  and  fixing  it  with  forceps  they  penetrated  the  capsule  first  on  the  left 
side  and  enucleated  the  gland,  then  they  did  the  same  on  the  right  side,  and 
closed  the  cavity  with  catgut  sutures.  Veau  and  Olivier  performed  total  extir- 
pation as  above  described  without  ill  effect,  but  if  one  fears  removal  of  the  whole 
gland  one  may  content  oneself  with  the  removal  of  one  half.  ("La  Presse  Med.," 
ix,  1910.) 

The  surgeon  must  remember  that  the  thymus  gland  may  cause  death  from 
pressure  without  the  presence  of  any  visible  or  palpable  tumor  in  the  neck. 

Chevalier  Jackson  ("  Journ.  Amer.  Med.  Assoc,"  May  25,  1907)  has  demon- 
strated an  enlarged  thymus  by  means  of  the  X-rays,  and  with  the  bronchoscope 
showed  that  pressure  from  the  thymus  produced  scabbard  deformity  of  the 
trachea.  After  tracheotomy  Jackson  measured  the  distance  from  the  trache- 
otomy wound  to  a  point  i  cm.  from  the  bifurcation  of  the  trachea  and  procured 
a  tracheotomy  cannula  of  this  length.  The  use  of  a  cannula  passing  through 
the  constricted  trachea  notably  facilitated  the  removal  of  the  thymus. 


PART  II.— THE  THORAX 


CHAPTER  XXX 
OPERATIONS  ON  THE  BREAST 

Evacuation  of  Abscess  by  Incision. — The  classical  method  of  incising  the 
breast  to  empty  an  abscess  is  exceedingly  simple.  Make  an  incision  through 
the  skin,  beginning  peripheral  to  the  areola,  along  a  line  radiating  from  the  nipple 
and  situated  over  the  inflammatory  swelling.  By  combined  sharp  and  blunt 
dissection  penetrate  the  abscess,  clean  the  cavity,  and  provide  drainage.  The 
object  of  radial  incision  is  to  avoid  transverse  and  unnecessary  division  of 
glandular  structures. 

An  abscess  forming  in  the  breast  itself  may  break  through  to  the  subcu- 
taneous or  to  the  submammary  areolar  tissues.  The  communication  between 
the  primary  focus  and  the  secondary  abscess  may  be  narrow.  Several  foci  of 
pus  may  be  present  and  only  communicate  with  each  other  through  narrow 
passages.  To  effect  drainage  and  avoid  all  deformity  Morestin  operates  as 
follows: 

From  the  base  of  the  nipple  to  the  edge  of  the  areola  (fortunately  the  areola 
is  usually  widespread  in  lactating  women)  make  an  incision  through  the  skin. 
From  this  incision  pass  the  knife  subcutaneously  into  the  superficial  collection 
of  pus.  In  withdrawing  the  knife  enlarge  the  opening  but  do  not  cut  through 
the  skin  beyond  the  areola.  With  a  probe,  forceps,  or  even  the  finger,  explore 
the  abscess  and  find  the  communication  between  it  and  the  intramammary 
focus.  With  the  knife  enlarge  this  communication  so  that  drainage  will  be 
free.  If  any  other  foci  of  pus  are  present  penetrate  them  in  similar  fashion. 
Cleanse  and  antisepticize  the  abscess.     Introduce  drains  and  apply  dressings. 

No  matter  the  site  of  the  abscess,  above,  below,  internal  or  external,  the 
operation  is  the  same.  Bleeding  is  trivial  and  ceases  spontaneously  in  a  few 
minutes.  Usually  the  drain  may  be  removed  in  from  three  to  five  days  and 
recovery  ensues  in  ten  to  twelve  days.     The  scar  is  hardly  noticeable. 

To  avoid  deformity  from  scars  it  has  been  suggested  to  use  the  principle  of 
Thomas'  operation  for  adenomata  of  the  breast.  Make  a  curved  incision  along 
the  line  of  junction  of  the  lower  edge  of  the  breast  and  the  chest-wall.  Pene- 
trate to,  but  not  through,  the  pectoral  fascia.  Separate  the  breast  from  the 
chest-wall  until  it  is  possible  to  gain  access  to  the  abscess  from  the  deep  surface 
of  the  gland.  Evacuate  the  pus.  Introduce  one  or  two  drainage-tubes  into 
the  cavity  and  bring  their  ends  out  through  the  wound.  Replace  the  mamma 
on  the  thoracic  wall.     Partially  close  the  skin-wound  by  sutures. 

271 


2  72  OPERATIONS    ON   THE   BREAST 

In  this  operation  the  incision  is  larger  and  the  dissection  is  much 
greater  than  is  required  in  simple  incision,  but  the  drainage  is  excellent 
and  the  resulting  scar  is  below  the  breast  and  hidden  by  the  natural  fold 
existing  there. 

Mastopexy. — Mastoptosis  or  pendulous  breast  is  common,  may  be  due  to 
one  or  several  of  many  causes,  may  be  harmless  except  as  a  disfigurement,  but 
it  may  give  rise  to  chronic,  painful  engorgement  and  to  various  inflammations. 
Ch.  Girard  ("Archiv  fur  klin.  Chir.,"  xcii,  829)  describes  the  various  methods 
of  treatment  adopted  for  mastoptosis  and  suggests  an  operation  which  he  has 
successfully  used. 

Step  I. — Reflect  the  breast  upwards,  as  in  the  Thomas'  operation  for  be- 
nign neoplasms,  until  the  second  costal  cartilage  is  reached. 

Step  2. — Expose  the  second  costal  cartilage  by  incising  the  pectoral  fascia 
and  bluntly  splitting  the  pectoralis  major  muscle  parallel  to  its  fibres. 

Step  3. — With  a  slightly  curved,  strong  needle  pass  a  very  strong  catgut 
suture  from  below  upwards  through  the  second  costal  cartilage.  Pass  this 
suture  through  the  fibrous  tissue  of  the  upper  pole  of  the  mamma.  Tie  the 
suture  after  tightening  it  sufficiently  to  bring  the  breast  up  into  the  desired 
position  but  still  leaving  the  loop  of  the  suture  somewhat  open  like  a  sling. 
Through  the  loop  of  the  first  suture  pass  about  four  catgut  threads  and  stitch 
each  of  these  to  different  parts  of  the  under  surface  of  the  breast.  The  result 
of  the  above  procedures  is  that  a  number  of  radiating  threads  pass  from  the 
primary  suture  in  such  a  manner  that  all  parts  of  the  breast  are  attached  to  the 
second  costal  cartilage  by  a  series  of  slings,  but  the  breast  can  still  be  lifted  up 
from  the  chest-wall. 

Step  4. — From  above  downwards  suture  the  under  surface  of  the  mamma 
to  the  pectoral  fascia. 

Step  5. — Close  the  skin  wound. 

Excision  of  Non-malignant  Neoplasms  of  the  Breast. — I.  When  the  breast 
is  the  seat  of  very  large  or  multiple  non-malignant  neoplasms,  the  whole  organ 
must  be  excised,  but  it  is  not  necessary  to  remove  the  pectoral  fascia  or  axillary 
contents.  Make  an  oblique  elHptical  incision  over  the  breast  and  including 
the  nipple.  This  incision  runs  from  above  and  outwards,  downwards,  and 
inwards;  it  begins  and  ends  just  beyond  the  confines  of  the  gland.  Through 
the  incision  dissect  the  skin  free  from  the  breast;  by  blunt  and  sharp  dissec- 
tion separate  the  breast  from  the  pectoral  fascia  and  remove  it.  Attend  to 
hemostasis.     Close  the  wound. 

The  operation  is  perhaps  the  easiest  in  surgery.  When  there  is  doubt  as 
to  the  malignancy  or  non-malignancy  of  the  disease  present,  and  histological 
examination  is,  for  any  proper  reason,  not  convenient,  then  the  above  operation 
should  not  be  performed;  the  patient  ought  to  be  given  the  benefit  of  the  doubt 
and  radical  measures  adopted. 

11.  WTien  the  breast  is  the  seat  of  one  or  perhaps  of  two  or  three  small  non- 
malignant  neoplasms,  such  may  be  excised,  leaving  the  gland  practically  intact. 

Method  A. — Fix  the  neoplasm  by  grasping  it  between  the  finger  and  thumb. 
Make  an  incision  over  the  tumor,  peripheral  to  the  nipple  areola,  along  a  line 
radiating  from  the  nipple.     Expose  the  tumor  by  this  incision  and  either  shell 


EXCISION   BREAST  273 

or  dissect  it  out  of  its  bed.  Attend  to  hemostasis.  Close  the  wound,  with  or 
without  drainage. 

Method  B. — Thomas'  operation  has  the  great  advantage  of  avoiding  visible 
scars.     It  has  been  sufficiently  described  on  page  271. 

Excision  of  the  Breast  for  Cancer. — A  few  years  ago  typical  excision  of 
the  breast  could  be  completed  in  a  few  minutes.  The  operation  consisted  in 
making  an  elliptical  incision  over  the  breast,  including  the  nipple,  in  rapidly 
reflecting  the  skin  from  the  gland,  and  in  tearing  and  cutting  the  gland  from 
the  pectoral  fascia.  Through  the  wound  the  finger  was  pushed  up  into  the 
corresponding  axilla,  and  if  any  lymphatic  glands  were  found  enlarged,  such 
were  removed.  The  operation  was  primarily  safe.  The  ultimate  results  were 
such  that  many  experienced  surgeons  claimed  recurrence  always  took  place. 
Disgusted  with  the  want  of  success  attained,  thoughtful  operators  became 
more  radical  and  more  successful.  The  typical  operation  no  longer  consisted 
in  removal  of  the  mamma  and  the  axillary  glands  if  they  were  palpably  diseased, 
but  the  mamma,  the  pectoral  fascia,  the  axillary  glands,  and  fat  were  removed 
in  one  piece.  The  primary  mortality  of  the  operation  did  not  increase  per- 
ceptibly; the  ultimate  results  were  infinitely  bettered. 

The  Operation. — The  incision  A,  B,  C  (Fig.  397)  is  made  through  the  skin. 
The  ellipse  between  B  and  C  includes  the  nipple  and  any  portions  of  skin  which 
may  be  adherent  to  the  tumor.  The  skin-flap  ABC 
E  is  reflected  downwards  well  below  the  limits  of  the 
breast  and  to  the  posterior  border  of  the  axilla  {i.e., 
to  the  edge  of  the  latissimus  dorsi).  The  skin-flap 
A  B  C  D  is  reflected  upwards  well  above  the  limits 
of  the  breast  and  so  as  to  expose  the  anterior  bound- 
ary of  the  axilla.  Beginning  below  the  breast,  one 
dissects  from  the  pectoralis  major,  the  fat  of  the 
chest-wall,  the  pectoral  fascia,  and  with  them  the 

diseased  mamma.     This  is  continued  to  a  point  well  „ 

^  riG.  397. 

above  the  breast,  to  the  base  of  the  skin-flap  A  B  C  D. 

There  is  now  a  mass  of  fat,  gland,  and  pectoral  fascia  unconnected  with  the 
chest-wall,  but  continuous  with  the  fatty  and  lymphatic  axillary  contents.  The 
chest  wound  is  to  be  protected  by  an  aseptic  pad  or  towel  and  the  surgeon 
attacks  the  axilla.  Beginning  on  the  outer  or  arm  side  of  the  axilla,  its  fatty 
contents  are  dissected  from  the  vessels  and  nerve-trunks  there  situated.  The 
first  effort  should  be  to  dissect  the  axillary  vein  free  from  its  fatty  surround- 
ings. Any  axillary  branches  of  the  vein  should  be  divided  between  two  fine 
ligatures  whenever  found.  When  this  dissection  is  being  made,  the  arm  should 
be  kept  as  close  to  the  body  as  is  consistent  with  free  access  to  the  axilla;  the 
object  attained  by  doing  so  is  that  otherwise  branches  of  the  axillary  vein 
would  be  put  on  the  stretch  and  rendered  unrecognizable,  and  further  that  in 
this  position  it  is  possible  to  retract  the  pectoralis  major  upwards,  thus  giving 
access  to  the  apex  of  the  axilla. 

The  contents  of  the  axilla  are  easily  separated  from  the  posterior  and  internal 
walls  of  the  space.  If  it  is  convenient  to  save  the  small  nerves  crossing  the 
axilla,  they  may  be  preserved;  but  if,  as  is  usually  the  case,  time  would  be  lost 

18 


2  74  '  OPERATIONS    OX    THE   BREAST 

in  so  doing,  they  should  be  sacrificed.  The  only  connection  left  between  the 
mass  to  be  removed  and  the  body  is  at  the  apex  of  the  axilla.  If  the  lymphatics 
higher  up  are  believed  to  be  healthy,  this  connection  is  divided  and  the  excision 
is  complete.  If,  on  the  other  hand,  it  is  suspected  that  the  disease  extends 
further,  then  the  pectoralis  major  is  divided  and  access  is  gained  to  the  chain 
of  lymphatics  running  up  under  the  clavicle.  These  are  removed  in  one  piece 
with  the  tumor  mass.  The  wound  in  the  muscle  is  sutured.  The  whole  wound 
is  closed,  axillary  drainage  being  provided. 

When  the  pectoral  fascia  is  being  removed  from  the  pectoralis  major, 
should  any  disease  be  found  or  suspected  to  exist  in  that  muscle  the  whole 
muscle  must  be  excised  in  one  piece  with  the  mamma. 

Halsted  has  still  further  elaborated  the  operation,  making  it  tremendously 
extensive  and  most  remarkably  successful.     His  success  is  so  great  that  the 

author  considers  the  Halsted  operation  or  some 
modification  thereof  to  be  the  preferable  treatment 
for  operable  mammary  cancer. 

Halsted  Operation. — (The  following  description 
is  compiled  from  Halsted's  articles  in  the 
"Annals  of  Surgery,"  vol.  xx,  No.  5,  and  xx\'iii. 
No.  5.) 

Principles  of  Operation. — The  pectoralis  major 
muscle,  entire  or  all  except  its  clavicular  portion, 
should  be  excised  in  every  case  of  cancer  of  the 
breast,  because  the  operator  is  enabled  thereby  to 
Fig.  398. — Halsted's  incision,     remove  in  one  piece  all  the  suspected  tissues.     The 

suspected  tissues  should  be  removed  in  one  piece. 
Step  I. — The  skin-incision  is  carried  at  once  and  ever}^where  through  the 
fat  (Fig.  398). 

Step  2. — The  triangular  flap  of  skin  A  B  C  is  reflected  back  to  its  base  line, 
C  A.  There  is  nothing  but  skin  in  this  flap.  The  fat  which  Uned  it  is  dissected 
back  to  the  lower  edge  of  the  pectoralis  major  muscle,  where  it  is  continuous 
with  the  fat  of  the  axilla. 

Step  3. — The  costal  insertions  of  the  pectoralis  major  are  severed  and  the 
splitting  of  the  muscle,  usually  between  its  clavicular  and  costal  portions,  is 
begun,  and  continued  to  a  point  about  opposite  the  scalenus  tubercle  on  the 
first  rib. 

Step  4. — At  this  point  the  clavicular  portion  of  the  pectoralis  major  and 
the  skin  overlying  it  are  cut  through  hard  up  to  the  clavicle.  This  cut  exposes 
the  apex  of  the  axilla. 

Step  5. — The  loose  tissue  under  the  clavicular  portion  of  the  pectoralis 
major  is  carefully  dissected  from  this  muscle  as  the  latter  is  drawn  upwards 
by  a  broad  sharp  retractor.  This  tissue  is  rich  in  lymphatics  and  is  sometimes 
injected  with  cancer. 

Step  6. — The  splitting  of  the  muscle  is  continued  out  to  the  humerus,  and 
the  part  of  the  muscle  to  be  removed  is  now  cut  through  close  to  its  humeral 
attachment. 

Step  7. — The  whole  mass,  skin,  breast,  areolar  tissue,  and  fat,  circumscribed 


EXCISION  BREAST  275 

by  the  original  skin  incision,  is  raised  up  with  some  force,  to  put  the  submuscular 
fascia  on  the  stretch  as  it  is  stripped  from  the  thorax  close  to  the  ribs  and  pec- 
toralis  minor  muscle.  It  is  well  to  include  the  delicate  sheath  of  the  minor 
muscle  when  this  is  practicable.  This  step  has  been  modified  by  Halsted  in  that 
he  now  ("Annals  of  Surgery,"  Nov.,  1898)  removes  the  pectoralis  minor  and 
exposes  the  subclavian  vein  at  its  inner  part. 

Step  8. — The  axilla  is  now  stripped  of  its  contents  and  its  anterior  wall  at  one 
time,  from  within  outwards  and  from  above  downwards.  The  axillary  con- 
tents are  dissected  away  with  scrupulous  care  and  with  the  sharpest  possible 
knife.  The  axillary  vein  should  be  stripped  absolutely  clean.  Not  a  particle 
of  extraneous  tissue  should  be  included  in  the  ligatures  which  are  applied  to 
the  branches,  sometimes  very  minute,  of  the  axillary  vessels.  In  liberating 
the  vein  from  the  tissue  to  be  removed  it  is  better  to  push  the  vein  away  from 
the  tissues  rather  than,  holding  the  vein,  to  push  the  tissue  away  from  it.  It 
may  not  be  necessary,  but  it  is  well  to  expose  the  artery  and  remove  the  possibly 
infected  tissue  above  it.  It  is  best  to  err  on  the  safe  side  and  remove  in  all 
cases  the  loose  tissue  above  the  vessels  and  about  the  axillary  plexus  of  nerves. 

Step  9. — Having  cleaned  the  vessels,  we  may  proceed  more  rapidly  to  strip 
the  axillary  contents  from  the  inner  wall  of  the  axilla — ^the  lateral  wall  of  the 
thorax. 

Step  10. — When  we  have  reached  the  junction  of  the  posterior  and  lateral 
walls  of  the  axilla,  or  a  little  sooner,  an  assistant  takes  hold  of  the  triangular 
flap  of  skin  and  draws  it  outwards,  to  assist  in  spreading  out  the  tissues  which 
lie  on  the  subscapularis,  teres  major,  and  latissimus  dorsi  muscles.  The 
operator  cleans  the  posterior  wall  of  the  axilla  from  within  outwards.  The 
subscapular  vessels  are  exposed  and  caught  before  being  divided.  The  sub- 
scapular nerves  may  or  may  not  be  removed. 

Step  1 1 . — Having  passed  these  nerves,  the  operator  has  only  to  turn  the  mass 
back  into  its  normal  position  and  to  sever  its  connection  with  the  body  of  the 
patient  by  a  stroke  of  the  knife  from  B  to  C,  repeating  the  first  cut  through  the 
skin. 

Step  12. — This  step  did  not  belong  to  Halsted's  original  operation,  but  has 
been  added  by  him  subsequently.  Make  a  vertical  incision  parallel  to  and  near 
the  posterior  margin  of  the  sternomastoid  muscle,  dividing  a  few  of  the  posterior 
fibres  of  the  muscle.  Expose  the  junction  of  the  internal  jugular  and  sub- 
clavian veins.  Divide  the  omohyoid  muscle  at  its  tendinous  part  and  draw  its 
two  bellies  out  of  the  way.  Remove  the  supraclavicular  fat  by  dissecting 
downwards  and  outwards  from  the  venous  junction,  and  the  infraclavicular 
fat  by  dissecting  from  below.  By  elevating  the  shoulder  the  clavicle  can  be 
raised  an  inch  or  more  away  from  the  first  rib  when  the  operation  is  so  far 
completed  as  to  make  this  desirable.  The  web  of  fibrous  tissue  which  binds 
the  subclavian  vein  loosely  to  the  clavicle  is  thus  spread  out  and  can  be  easily 
removed.  The  fingers  can  be  passed  from  the  supraclavicular  to  the  infra- 
clavicular and  to  the  subscapular  regions  under  the  clavicle,  and  any  fat  in 
the  latter  region,  near  the  internal  or  the  posterior  border  of  the  scapula  be- 
tween the  serratus  magnus  and  subscapular  muscles,  which  could  not  be  well 
reached  from  the  axilla  can  be  drawn  out  through  the  neck. 


276 


OPERATIONS  ON  THE  BREAST 


Step  13. — Review  the  whole  wound.  Unite  the  divided  omohyoid  by  a  cat- 
gut suture.  Close  the  wound  in  the  neck.  The  edges  of  the  chest  wound  are 
approximated  by  a  buried  purse-string  suture  of  strong  silk.  Of  the  triangular 
flap  of  skin  (A  B  C,  Fig.  398)  only  the  base  is  included  in  this  suture.  The 
rest  of  the  flap  is  used  as  a  lining  for  the  fornix  of  the  axilla.  The  axilla  is  never 
drained.  The  open  wound  remaining  on  the  chest  is  immediately  covered  with 
Thiersch's  skin-grafts. 

■Many  surgeons,  the  author  included,  have  devised  almost  identical  opera- 
tions for  removal  of  the  breast  and  have  found  such  satisfactory. 

Kocher's  description  of  the  operation  is  so  excellent  that  it  will  be  used  as  the 
basis  of  the  following  paragraphs.     To  Willy  Meyer,  however,  belongs  the  credit 


Fig.  399. — Kocher's  incision. 


Fig.  400. — (Kocher.) 


of  the  radical  breast  operation  in  which  the  dissection  of  the  lymphatics  precedes 
the  removal  of  the  mamma.  Meyer's  operation  was  devised  totally  independ- 
ently of  Halsted's  and  was  published  during  the  same  month  as  Halsted's. 

Step  I. — With  the  knife  make  a  few  superficial  scratches  on  the  skin  to  mark 
out  the  line  of  incision  which  is  shown  in  Fig.  399.  From  the  clavicle  to  the 
edge  of  the  anterior  axillary  fold  near  the  insertion  of  the  pectoralis  major, 
complete  the  incision  through  the  skin,  subcutaneous  tissue,  and  fascia.  Expose 
the  cephalic  vein  in  the  groove  between  the  pectoralis  major  and  deltoid,  thus 
recognizing  the  upper  edge  of  the  pectoralis.  Pass  the  finger  around  the  pecto- 
ralis major  one  to  two  finger-breadths  from  the  humerus.  Guided  by  the  finger, 
divide  the  pectoralis  major. 

Step  2. — The  pectoralis  minor  now  lies  exposed  to  view.  Divide  this  muscle 
near  the  coracoid  process,  and  expose  the  great  vessels  and  nerves  of  the  axilla. 

Step  3. — Beginning  above,  near  the  clavicle  and  coracoid  process,  dissect 


RADICAL    OPERATION 


277 


the  fat  from  the  axillary  vessels  and  nerves,  and  then  dissect  it  free  towards  the 
thoracic  wall.  By  this  means  the  most  difficult  step  of  the  operation  is  com- 
pleted while  the  surgeon  is  fresh,  without  the  annoyance  of  the  loose  mass  of 
mamma,  etc.,  getting  in  the  way,  as  in  the  Halsted  operation,  and  while  the 
chest  is  still  protected  against  chill  by  its  fatty  coverings,  which  will  be  removed 
later. 

Step  4. — Complete  the  incision  around  the  breast  (Fig.  399).  Excise  the 
mamma,  surrounding  fat,  and  both  pectoral  muscles.  The  wound  left  is 
large  (Fig.  400). 


Fig.     401. — Skin     incision.     {Meyer.} 


Step  5. — After  attending  to  hemostasis,  close  the  wound,  as  much  as  possible, 
by  sliding  the  flaps  together.  Where  the  wound  cannot  be  closed,  cover  it  with 
Thiersch's  skin-grafts.  Provide  for  the  axillary  drainage  by  a  tube  introduced 
posteriorly. 

After  such  extensive  removal  of  important  muscles  one  would  naturally 
expect  very  serious  loss  of  function,  but  such  is  not  the  case;  the  author  has  been 
assured  by  various  patients  that  they  are  able  to  attend  to  their  own  housework 
and  to  dress  their  own  hair  satisfactorily. 

In  the  "Jour.  Am.  Med.  Assoc,"  July  29,  1905,  Willy  Meyer  published  an 
excellent  series  of  drawings  illustrating  his  operation;  these  are  so  helpful  that 
they  are  reproduced  here  without  comment  (Figs.  401  to  406). 


278 


OPERATIONS    ON    Till';    liREAST 


Fig. 


402. — Insertion   of   pectoralis   major   muscle   exposed. 
Operator's  left  index  finger  encircling  its  tendon. 


{Meyer.) 


Fig.  403. — Finger   under   tendon   of   pectoralis   minor   muscle.     (Meyer.) 
\b)vo,  cut  surface  of  clavicular  portion  of  pectoralis  major  parallel  to  clavicle  is  visible.     (In  the  living, 
the  'lelly  of  the  pectoralis  major  is  not  so  thoroughly  detached  from  that  of  the  pectoralis  minor.     It  is 
done  here  to  show  the  latter's  tendon.) 


WILLY   MEYER  S    OPERATION 


279 


Fig.  404. — Subclavian   and   axillary    veins   fully    exposed.     (Meyer.) 
So  far,  glands  and  fat  tissue  not  removed;  smaller  vessels  still  in  connection  with  main  trunks, 
under  fat  towards  sulcus  bicipitalis,  its  nail  resting  on  axillary  vein. 


Finger 


Fig. 


405- 


-Operative    field,    after   removal    of    the    mass. 
Stump  of  pectoralis  minor  muscle  is  visible. 


{Meyer.) 


28o 


OPERATIONS    ON    THE  BREAST 


Fig.  406. — Showing  reformation  ui  axilla.     {Meyer.) 


Fig.    407. — Jackson's    incision.     No.  i. 


STEWART  S    OPERATION 


281 


J.  N.  Jackson  (Fig.  407),  J.  C.  Warren  and  others  have  devised  ingenious  in- 
cisions for  breast  excision  the  only  fault  of  some  of  these  is  that  perhaps  they 
may  tempt  the  surgeon  to  sacrifice  thoroughness  of  extirpation  on  the  altar  of 
aestheticism.  In  cases  of  cancer  in  the  upper-outer  quadrant  where  the  skin 
between  the  breast  and  the  axilla  is  under  suspicion,  Jackson's  incision  N°-2 
("Annals  of  Surg.,"  Aug.,  1920)  is  valual)le  and  permits  of  easy  closure  (Figs. 
408  and  409). 


Fig.  408. — Jackson's  Incision  No.  2. 


Fig.  409. — Jackson's  Incision  No.  2. 


In  about  16  per  cent,  of  cases  of  breast  cancer,  diffusion  of  the  disease  and 
perilymphangitis  cause  obstruction  of  the  lymphatics  about  the  shoulder  and 
lead  to  oedema  of  the  arm.  The  consequent  suffering  is  often  atrocious  and 
amputation  has  often  been  performed  to  give  relief.  Handley's  operation  of 
lymphangioplasty  is  of  value  in  treating  such  a  condition. 


Francis  Stewart's  Operation  (Trans.  Arm.  Surg.  Soc,  XXXIII,  1915). 

Step  I. — From  a  point  on  the  edge  of  the  sternum  remote  from  the  growth 
and  on  a  line  with  the  nipple  make  a  curved  transverse  incision  skirting  the 
upper  margin  of  the  breast  and  ending  on  the  posterior  axillary  line  ABC  (Fig. 
410).  Undermine  the  skin  upwards  to  the  clavicle  and  the  head  of  the  humerus 
and  from  the  sternum  to  the  posterior  axillary  fold.  This  gives  good  access 
to  the  axilla. 

Step  2. — Separate  the  clavicular  from  the  costal  portion  of  the  pectoralis 
major  and  divide  the  tendon  of  the  latter  close  to  the  humerus.  Divide  the 
insertion  of  the  Pectoralis  minor  and  clear  the  axilla  of  its  contents  in  the  usual 
fashion. 

Step  3. — Join  the  ends  of  the  original  incision  by  a  cut  which  skirts  the  lower 


282 


OPERATIONS    OX    THE   BREAST 


margin  of  the  breast  ADC,  Fig.  410J.  Undermine  the  skin  downwards  to  the 
edge  of  the  costal  arch  or  lower. 

Step  5. — Remo\e  the  breast,  pectoralis  major  and  minor,  etc.  Attend  to 
hemostasis. 

The  advantages  claimed  for  the  operation  are  free  exposure  of  the  subscapu- 
lar space,  avoidance  of  any  scar  running  on  to  the  arm,  convenience  of  closure 
and  of  dressing. 

Tansini's  Operation.— (D'Este,  "Rev.  de  Chir.,"  Feb.,  1912.)  Stiles  has 
shown  that  the  breast  is  a  much  larger  organ  than  is  apparent  on  ordinary 
inspection  and  palpation  (see  Fig.  411).  There  is  constant  prolongation  of  the 
breast  upwards  and  outwards  along  the  lower  border  of  the  pectoralis  major 
which  often  reaches  as  far  as  the  more  anterior  of  the  axillary  lymphatic  nodes 
Rieffel,  Poirier  and  Charpy,  v,  680). 


iWv^- 


Fig.  410. — Stewart's  Incision. 


Fig. 


411. 


Every  modern  operation  for  cancer  of  the  breast  aims  at  the  excision  of  the 
skin  over  the  breast  along  with  the  breast,  the  tissues  around  it  which  might  be 
involved  and  the  lymphatic  contents  of  the  axilla.  In  none  of  the  operations 
already  described  (Halsted's,  Meyer's,  Kocher's,  Jackson's)  except  Jackson's 
No.  2,  does  the  incision  compel  the  removal  of  the  skin  overlying  the 
axillary  prolongation  of  the  breast. 

Tansini's  method  provides  for  very  unusual  and  complete  removal  of  the 
skin  and  for  such  convenient  plastic  repair  of  the  wound  that  there  is  no  tempta- 
tion to  skimp  the  extensive  excision.  The  operation:  Step  i. — Make  the  ovoid 
incision  A  B  C  D  (Fig.  412)  through  the  skin  alone.  This  surrounds  not  merely 
the  prominent  mamma  but  the  whole  mammary  region  reaching  medially  (D) 
near  or  even  onto  the  sternum,  laterally  (B)  to  the  mid-axillary  Une,  inferiorly 
(C)  to  the  upper  margin  of  the  seventh  rib  and  superiorly  (A)  to  the  summit  of 
the  axilla.  Note  that  the  skin  between  the  breast  and  the  axilla  as  well  as 
most  of  the  skin  of  the  axilla  itself  is  enclosed  in  the  ovoid. 

Step  2. — (a)  Beginning  at  the  lower  external  part  of  the  ovoid  (near  B) 


TANSINI  S   OPERATION 


283 


dissect  the  skin  from  the  subcutaneous  fat  until  the  whole  infra-axillary  region  is 
exposed  and  the  axillary  border  of  the  lalissimus  dorsi  is  reached.  At  this  point 
penetrate  more  deeply  so  as  to  expose  the  serratus  magntis  above  and  the  upper 
digitations  of  the  external  oblique  below.  (If  necessary  remove  the  fascia  cover- 
ing these  muscles  and  some  of  their  superficial  fibres  along  with  the  mam- 
mary mass.)  Passing  upwards  and  inwards  separate  the  inferior  and  lateral 
attachments  of  the  pectoralis  major  from  the  thoracic  wall.  Attend  to 
hemostasis. 

(b)  In  similar  fashion  dissect  the  skin  downwards  and  inwards  from  the 
ovoid  incision  until  the  desired  limits  from  excision  are  reached.  What  are  these 
desired  limits?  From  a  very  thorough  study  Sampson,  Handley  (Cancer  of  the 
Breast  and  Its  Operative  Treatment,  p.  183)  has  come  to  very  definite  and  rea- 


-(Rev.  de  Chir. 


Fig.  413. — {Rev.  de  Chir.) 


sonable  conclusions.  He  writes,  "The  removal  of  a  maximal  circular  area  of 
deep  fascia  centered  upon  the  primary  growth,  is  a  step  absolutely  essential  to 
the  completeness  of  the  operation,  except  in  very  early  cases.  There  is  no  tech- 
nical difficulty  involved,  if  only  the  skin-flaps  are  sufficiently  undermined,  a 
step  whose  importance  has  been  long  emphasized  by  Mr.  Stiles  and  by  my  friend 
and  teacher,  Mr.  Jacobson,  and  one  which  is  very  thoroughly  carried  out  in  the 
surgical  practice  of  the  Middlesex  Hospital.  It  is  a  significant  fact  that  the 
operator,  who  has  the  best  pubhshed  operative  results,  lays  stress  on  the  removal 
of  a  wide  area  of  deep  fascia,  following  the  lines  laid  down  by  Stiles.  Prof. 
Cheyne  says:  "  *  *  *  the  skin  incisions  when  made  should  not  go  straight  down 
to  the  muscle.  After  the  skin  incisions  have  been  mapped  out,  the  skin  and 
just  sufl&cient  fat  to  enable  it  to  retain  its  vitaUty  should  be  dissected  up,  and 
the  muscular  fibres  should  not  be  exposed  till  just  below  the  clavicle  above,  be- 
yond the  middle  fine  in  front,  over  the  origin  of  the  abdominal  muscles  below, 


284  OPERATIONS  ON  THE  BREAST 

and  over  the  edge  of  the  latissimus  behind."  It  will  be  found  that,  judged  by 
the  standard  I  have  set  up — i.e.,  the  removal  of  a  maximal  area  concentric  with 
the  growth — the  area  of  deep  fascia  defined  by  Prof.  Cheyne  is  very  deficient 
in  a  downward  direction,  for  the  abdominal  muscles  arise  well  above  the  costal 
margin.  The  following  measurements  show  the  distance  from  the  nipple  to 
various  points  on  the  thorax  in  two  patients  with  non-pendulous  mammae: 

Patient  Patient     j    Average 

No.     I  No.    2  "vciOKC 


Nipple  to  tip  of  ensiform  cartilage '    4     in.  5     in.  4^  in. 

Nipple  to  nearest  point  of  clavicle S     in.  6 1^2  in.  5/-iin. 

Nipple  to  nearest  point  of  middle  line 3/^  in-  4/'2in-  4     i°- 

Nipple  to  nearest  point  of  edge  of  latissimus  dorsi 5      in.  %     in. 


The  distance  from  the  nipple  to  the  clavicle  may  be  taken  as  the  radius  of 
the  circle  of  deep  fascia  round  the  growth,  which  can,  in  practice,  be  removed 
without  difficulty  by  undermining  the  skin  flaps  sufficiently  and  prolonging  the 
incision  somewhat  in  a  downward  direction. 

If  the  growth  starts  under  the  nipple  the  deep  fascia  should  accordingly  be 
removed: 

Above,  up  to  the  clavicle. 

Internally,  i  to  2  inches  beyond  the  middle  line. 

ExternaJl}',  just  be3'ond  the  anterior  edge  of  the  latissimus  dorsi. 

Below,  to  a  horizontal  line  running  2  inches  below  the  tip  of  the  ensiform  cartilage. 

Coming  now  to  growths  situated  near  the  margin  of  the  breast,  it  is  probable 
that  the  want  of  coincidence  between  the  area  of  the  present  operation  and  the 
circle  of  infected  fascia  in  these  eccentric  growths  largely  accounts  for  the  bad 
prognosis  associated  with  them. 

The  area  of  tissue  removed  should  be  concentric  with  the  nipple  only  when 
the  primary  growth  is  situated  just  beneath  that  structure.  If  a  cancer  is  situ- 
ated at  the  sternal  margin  of  the  breast  it  may  be  necessary  to  excise  the  deep 
fascia  beneath  the  inner  half  of  the  opposite  breast.  If  the  growth  is  situated  at 
the  lower  margin  of  the  breast  it  may  be  requisite  to  excise  the  abdominal  deep 
fascia  far  down  towards  the  umbilicus.  If  the  growth  is  situated  in  the  axillary 
tail  of  the  mamma,  the  deep  fascia  will  require  excision  in  the  deltoid  region, 
and  far  backwards  over  the  surface  of  the  latissimus  dorsi.  Unless  these  con- 
siderations are  borne  in  mind  the  growing  edge  of  fascial  permeation  will  be  left 
behind  at  one  point  or  another. 

(c)  Dissect  upwards  and  towards  the  axilla  the  whole  mass  of  breast  fascia, 
fat  and  muscle  which  must  be  removed.  Both  pectoralis  major  and  minor  must 
be  removed  though  sometimes  the  clavicular  fibres  of  the  former  may  be  spared. 

(d)  While  the  mobilized  mass  containing  the  breast,  etc.,  is  supported  by  an 
assistant,  clear  the  axilla  of  its  fat  and  lymphatic  tissue  in  the  usual  fashion. 
In  doing  this  ligate  and  divide  the  external  mammary  (long  thoracic)  and 
acromio-thoracic  vessels,  but  save  the  subscapular  vessels  as  they  are  essential 
to  the  nutrition  of  the  flaps  to  be  used  in  the  plastic  repair  of  the  enormous 


TANSINI  S   OPERATION 


28s 


denuded  area  of  chest.  Clear  the  fat  from  the  infra-clavicular  fossa.  Along 
with  the  axillary  fat  remove  the  fat  and  cellular  tissue  lying  between  the 
scapula  and  the  thoracic  wall.  Remember  that  all  these  tissues  from  the 
interscapulo-thoracic  space,  the  axilla,  the  infra-clavicular  fossa  and  the  chest- 
wall  must  be  removed  in  one  piece.  Attend  to  hemostasia.  Cover  the  whole 
wound  with  warm  dressings. 

Step  3. — (a)  Place  the  patient  in  the  lateral  posture  or  midway  between  the 
lateral  and  ventral  postures.  Have  the  arm  held  somewhat  elevated  and 
abducted.     Recognize  the  spine,  the  axillary  border  and  the  inferior  angle  of 


Fig.  414. — {Rev.  de  Chir) 


Fig.  415. — {Rev.  de  Chir.) 


the  scapula.  Outline  the  flap  A  X  Y  (Figs,  412  and  413).  The  pedicle  of 
the  flap  should  be  7-8  cm.  (2^-33^  in.)  in  diameter.  The  incision  pene- 
trates the  skin,  the  subcutaneous  tissue  and  the  latissmus  dorsi  (as  soon  as  that 
muscle  is  encountered).  Reflect  the  flap  of  skin,  latissimus  dorsi,  teres  major 
and  a  portion  of  the  infra-spinatus.  In  separating  these  last  two  muscles  from 
the  scapula  be  careful  to  hug  the  bone,  otherwise  their  nutrient  arteries  will  be 
divided  and  disaster  invited. 


286  OPERATIONS    ON    THE    CHEST 

(b)  Mobilize  lo  some  extent  the  tongue-shaped  flap  of  skin  lying  between  the 
dorsal  and  the  thoracic  wound.  Bring  the  dorsal  flap  forward  to  cover  the 
thoracic  wound  and  suture  it  in  position  (Fig.  415).  With  the  tongue-shaped 
flap  fill  up  the  dorsal  wound.  If  any  raw  surfaces  are  left  cover  them  with 
Thiersch's  grafts. 

J.  N.  Jackson  in  about  50  cases  has  had  no  skin  recurrence.  Handley  points 
out  that  Halsted,  who  lays  special  stress  on  wide  skin  excision,  has  16  per  cent, 
of  recurrence  in  the  skin,  while  Cheyne,  who  removes  more  fascia  than  Halsted 
but  less  skin,  has  only  6.5  per  cent,  of  such  recurrence. 

At  the  International  Surgical  Congress,  1908,  Depage  reported  the  following 
statistics  collected  from  many  sources: 

Primary  mortality        I     Apparently  well  three 
•'  '  years  after  operation 

1865  to  1875 17.3  per  cent.  9.4  per  cent. 

1875  to  1885 7.0  per  cent.  10. o  per  cent. 

1885  to  1895 3.0  per  cent.  34.8  per  cent. 

1895  to  1905 2.8  per  cent.  46 . 5  per  cent. 

While  in  the  decennium  1865  to  1875  among  the  recurrences  76  percent,  were 
local  and  7.5  per  cent,  metastatic,  in  the  period  from  1895  to  1905  only  29  per 
cent,  of  the  recurrences  were  local  and  23  per  cent,  metastatic.  The  apparent 
increase  in  the  number  of  metastatic  recurrences  is  of  course  due  to  the  absence 
of  prompt  local  recurrence  permitting  the  victims  to  live  long  enough  to  exhibit 
metastases. 


CHAPTER   XXXI 

OPERATIONS   ON   THE   CHEST 

WOUNDS   OF  THE  LUNGS   AND   PLEURA 

Wounds  of  the  lungs  and  pleurae  are  commonly  the  result  of  stabs,  bullet 
wounds,  tearing  by  the  fractured  ends  of  ribs,  and  surgical  operations.  The 
dangers  are  hemorrhage,  shock,  pneumothorax  and  above  all  infection.  The 
shock  is  largely  an  incident  of  the  pneumothorax;  owing  to  pulmonary-  retrac- 
tion due  to  pneumothorax,  the  heart  and  great  vessels  lose  their  normal  sup- 
I)ort  on  one  side,  are  displaced,  often  flop  around  and  act  in  an  ineflicient  fashion. 
The  teaching  of  physiologists  leaves  the  impression  that  the  visceral  and  parietal 
pleurae  are  kept  in  apposition  entirely  by  atmospheric  pressure;  that  puncture 
of  the  pleura  inevitably  ])roduccs  pneumothorax  and  more  or  less  complete 
retraction  or  collapse  of  the  lung.  This  teaching  has  dominated  surgery  to  too 
great  an  extent.  Undoubtedly  atmospheric  pressure  is  a  very  great  factor  in 
retaining  the  normal  ai)i)osition  of  the  pleurae  but,  as  Maccwen  has  shown,  a 
large  flap  of  the  chest  wall,  including  the  parietal  pleura,  may  be  lifted  up,  ex- 
posing a  corresponding  surface  of  lung  without  pulmonary  collapse.     The  failure 


RESPIRATION    WITH    OPEN    THORAX  287 

of  collapse  is  due  to  molecular  adhesion  between  the  two  pleuraj  aided  by  the 
existence  between  them  of  a  thin  layer  of  serous  fluid,  i.e.,  the  apposed  surfaces 
of  pleura  are  moist.  If  the  finger  is  passed  around  the  wound  and  separates  the 
visceral  from  the  parietal  pleura  air  enters  and  a  certain  amount  of  collapse 
occurs,  but  if  the  elastic  chest  wall  is  pressed  inwards  so  that  the  parietal  pleura 
is  allowed  to  come  once  more  into  free  contact  with  the  visceral,  then  the  lung 
again  expands.  These  remarks  of  course  apply  only  to  the  healthy  pleura,  as 
in  a  pleura  roughened  by  ridges  and  masses  of  exudates  conditions  are  entirely 
different. 

The  above  principles  and  observations  of  Macewen's  were  the  basis  of  suc- 
cessful treatment  in  a  number  of  serious  wounds  reported  by  him.  ("  Brit.  Med. 
Journ.,"  July  7,  1906.) 

Elsberg  (''Med.  Record,"  May  23,  1908)  finds  that  the  weight  of  the  heart 
pulls  it  backwards  and  makes  tense  the  pleural  covering  of  the  anterior  medi- 
astinum when  the  patient  is  in  the  dorsal  decubitus  and  thus  prediposes  to 
pneumothorax  when  the  pleura  is  wounded.  If  the  patient  is  placed  in  the 
ventral  position  pneumothorax  is  much  less  likely  to  arise.  Lilienthal  has 
applied  Elsberg's  findings  with  success  in  twenty-one  cases  in  which  the  pleural 
cavity  was  opened  and  no  interference  with  the  mechanism  of  respiration  re- 
sulted. [LiUenthal's  cases  comprised  a  number  of  empyemas,  two  liver  ab- 
scesses, five  subphrenic  abscesses  and  one  left-sided  bronchiectasis.] 

Methods  of  Keeping  up  Respiration  when  the  Thorax  is  Freely  Opened. — I.  For 
many  years  the  French  have  insisted  that  special  means  for  keeping  up  respira- 
tion are  entirely  unnecessary,  and  their  experience  during  the  Great  War  up- 
holds them.  Pierre  Duval  writes  (Surg.,  Gyn.  and  Obst.,  Jan.  7,  1919)  "Com- 
plete pneumothorax  is  not  associated  with  any  particular  danger,  and,  indeed, 
it  is  necessary  for  the  manipulation  of  the  lung.  Complete  pneumothorax  does 
not  cause  any  respiratory  trouble  or  increase  of  arterial  pressure,  and  causes 
less  shock  than  a  laparotomy."  The  French  practice  of  making  a  wide  opening 
in  the  chest  allows  any  manipulation  of  the  lung  without  danger. 

Morris  H.  Clark  (personal  communication)  agrees  absolutely  with  the 
French  view.  He  uses  gas  oxygen  anesthesia  with  the  Connell  apparatus  ex- 
actly as  if  the  thorax  was  uninjured  and  has  not  encountered  any  trouble  which 
could  conceivably  have  been  lessened  by  the  employment  of  differential  or 
intratracheal  apparatus.  If  the  surgeon  desires  any  special  inflation  of  the 
lung,  e.g.,  when  the  last  sutures  are  being  tied  it  is  easy  to  produce  any  degree 
of  such  by  applying  the  face  piece  more  firmly  and  either  increasing  the  inflow 
of  the  combined  gases  or  decreasing  the  outflow  from  the  mask. 

II.  Mechanical  and  according  to  the  French  view,  unnecessary  means  of 
keeping  up  respiration  during  operation.  Many  believe  that  when  one  side  of 
the  thorax  is  freely  opened  respiration  becomes  much  embarrassed;  when 
both  sides  are  freely  opened  it  becomes  impossible  under  ordinary  circum- 
stances. Matas  and  a  number  of  others  devised  more  or  less  complicated  means 
by  which  air  from  a  bellows,  or  its  equivalent,  could  be  pumped  through  the  nose, 
the  mouth  or  a  tracheal  cannula  alternately  into  and  out  from  the  lungs  ("Trans. 
Am.  Surg.  Assoc,"  vol.  xix).  Richter  ("Surg.,  Gyn.,  Obstet.,"  Nov.,  1908) 
modified  the  pump  method.     In  his  apparatus  the  necessary  air  is  stored  in  a 


288  OPERATIONS   ON   THE   CHEST 

tank  under  high  pressure.  As  required,  air  is  conducted  from  the  lank  to  a  rub- 
ber balloon  where  it  can  be  kept  at  a  moderate  pressure.  From  the  balloon  the 
air  is  led  through  a  rubber  tube  to  a  tracheal  cannula  and  so  into  the  lungs.  An 
ingenious  and  simple  electric  valve  permits  air  to  flow  into  the  lungs  at  proper 
and  regulated  intervals,  and  between  these  intervals  permits  it  to  escape.  An- 
other device  permits  the  administration  of  an  anesthetic.  Richter  demon- 
strated his  method  to  the  members  of  the  Society  of  Chnical  Surgery.  Meltzer 
and  Auer  have  described  a  method  of  artificial  respiration  which  they  name 
"respiration  by  the  continuous  intratracheal  insufflation  of  air."  A  small  tube 
is  passed  through  the  larynx  into  the  trachea  almost  to  the  bifurcation,  and  by 
means  of  a  foot-bellows  or  electric  motor  air  mixed  with  ether  is  blown  continu- 
ously through  the  tube  under  pressure  of  15  or  20  mm.  of  mercury.  The 
lungs  are  kept  moderately  distended,  the  blood  is  aerated  and  the  excess  air 
escapes  alongside  the  tube.  The  method  has  been  used  successfully  by  Carrel 
and  Elsberg  ("Annals  Surg.,"  July,  1910)  in  many  operations  on  the  thoracic 
viscera.  The  author  has  used  the  Meltzer-Auer  method  in  experimental  work 
on  rabbits,  using  instead  of  the  foot-bellows  a  simple  hydrostatic  air  compressor 
extemporized  by  Sutton.  Elsberg  suggests:  "the  tube  that  is  to  be  introduced 
into  the  trachea  should  be  a  fairly  rigid  one  of  rubber  with  an  opening  at  its 
lower  end.  It  should  be  as  long  as  an  ordinary  stomach-tube.  Tubes  of  various 
sizes  should  be  kept  on  hand.  The  tube  to  be  used  in  a  given  case  should  fill  up 
about  one-half  of  the  lumen  of  the  trachea.  One  can  obtain  a  sufficiently  accu- 
rate idea  of  the  size  to  be  used  by  estimating  the  diameter  of  the  trachea  at 
the  foot  of  the  neck. "  Lilienthal  and  Elsberg  have  applied  the  method  success- 
fully in  the  human  being. 

Lilienthal  is  no  convert  to  the  French  view.  He  considers  that  the  medi- 
astinum can  be  so  steadied  by  traction  on  the  lung  during  operations  on 
certain  war  wounds  that  ordinary  exploration  and  removal  of  foreign  bodies 
can  be  safely  accomplished  without  any  form  of  differential  pressure.  The 
same  is  true  in  old  infected  conditions.  In  all  other  forms  of  thoracic  surgery 
including  full  exploration  of  the  thorax  in  trauma,  in  resection  of  lobes  and  in 
operations  upon  the  oesophagus  or  other  intrathoracic  organs,  he  is  convinced 
that  the  omission  of  some  form  of  differential  pressure  will  greatly  jeopardize  the 
patient.  The  apparatus  is  most  simple.  If  ether  is  used  it  is  put  in  a  suitable 
bottle  with  two  short  tubes  penetrating  the  stopper  but  not  extending  below 
the  surface  of  the  ether.  A  foot  bellows  or  even  a  Paquelin  bulb  suffices  to 
furnish  the  current  of  air.  A  tube  (about  Fr.  14)  leads  from  the  bottle  to  the 
patient,  and  should  be  marked  33^^  inches  from  its  distal  end.  The  tube  is 
introduced  into  one  nostril  not  further  than  the  mark.  If  Nitrous  Oxide  Oxygen 
is  used,  no  bellows  is  required,  the  force  of  the  current  being  regulated  by 
means  of  a  stop-cock,  and  the  gas  passes  through  a  wash  bottle. 

Albert  Ehrenfried  ("Boston  Med.  and  Surg.  Journ.,"  April  13, 1911)  endeav- 
ored to  construct  a  simple,  portable  apparatus  independent  of  electric  currents, 
etc.,  by  which  ether  might  be  administered  according  to  the  Meltzer-Auer 
method. 

The  apparatus  (Fig.  416)  "consists  of  a  Wolff  bottle  with  three  necks,  sitting 
within  a  copper  water  jacket,  and  a  foot-bellows.     By  means  of  the  cocks  on  the 


INTRA-TRACHEAL   ANESTHESIA 


289 


outside  of  the  jacket,  the  stream  of  air  from  the  bellows  can  be  carried  through 
the  hot  water,  over  the  top  of  the  ether  (contained  in  the  Wolff  bottle),  or 
through  the  ether  when  a  particularly  strong  vapor  is  desired.  Air  and  ether 
vapor  may  be  mixed  in  any  proportion.  Connected  with  the  dehvery  end  of  the 
apparatus  is  a  safety  valve  and  pressure  regulator  consisting  of  a  bottle  of  mer- 
cury into  which  a  tube  is  plunged.  The  depth  of  the  tube  in  the  mercury,  which 
is  adjustable,  represents  the  maximum  of  pressure  which  is  allowed  within  the 
apparatus;  if  for  any  reason,  such  as  a  spasm  of  the  glottis,  the  pressure  should 
rise,  the  valve  "blows  off"  automatically  and  danger  from  interstitial  emphy- 
sema is  avoided.  In  our  early  experience  we  employed  a  dial  manometre, 
registering  in  millimetres  of  mercury,  to  record  the  pressure,  but  we  have  found 


Fig.  416. — Ehrenfried's  intratracheal  etherization  apparatus. 


that  the  pressure  bottle  answers  as  well  for  all  practical  purposes.  The  appara- 
tus is  provided  with  a  device  to  prevent  droplets  of  condensed  ether  being  car- 
ried into  the  larynx.  The  air  or  mixture  is  supplied  at  a  practically  constant 
temperature  of  about  ten  degrees  above  room  temperature,  if  the  operation  is  to 
last  over  half  or  three-quarters  of  an  hour,  the  contents  of  the  water  jacket  should 
be  replaced.  The  air  supplied  may  be  filtered  and  moistened.  For  an  intra- 
tracheal tube  we  use  a  French  lisle  catheter,  22  to  24  F.,  moistened  in  hot  water 
to  render  it  pliable,  a  new  and  sterile  one  for  each  case.  Soft  rubber  tubes  have 
the  advantage  of  standing  sterilization  by  boiUng  better,  but  they  are  less  easy  to 
introduce.  The  chief  difficulty  with  this  method  of  anaesthesia  so  far  has  been 
the  introduction  of  the  tube.  We  now  use  a  simple  introducer,  a  laryngeal  for- 
ceps with  sleeves  attached  for  grasping  the  tube  near  its  extremity,  similar  in 
principle  to  the  introducer  of  Doyen.  After  considerable  pains  to  produce  the 
proper  curve — working  on  frozen  sections  and  cadavers — we  have  made  an  in- 

19 


290  OPERATIONS    ON    THE   CHEST 

strument,  Fig.  417,  which  can  be  guided  into  the  larynx  in  a  matter  of  seconds, 
with  the  mouth-gag  in  place  and  the  left  forefinger  on  the  epiglottis,  without 
the  necessity  of  using  a  head  mirror  or  electric  illumination,  or  changing  the 
patient  on  the  table  to  and  from  the  Rose  position,  as  is  necessar\'  with  the  direct 
laryngoscope." 

Samuel  Robinson  ("  Surg.,  Gyn.,  Obstet.,"  May,  191 2)  describes  his  appa- 
ratus by  which  ether  may  be  administered  by  insuflflation.  He  uses  as  tne  intra- 
tracheal tube  a  soft-rubber  catheter  introduced  by  means  of  Cotton's  introducer, 
Fig.  418.  With  the  same  apparatus  positive  pressure  may  be  obtained  by  the 
mask  method  (Robinson's  mask  or  Habberley's  intrabuccal  clamp).  Robinson 
devised  a  positive  and  negative  pressure  cabinet,  but  finds  cabinets  cumber- 
some, expensive  and  possessing  no  advantage  over  the  mask. 

Danis  ("La  Presse  Med.,"  Dec.  25,  191 2)  describes  an  hyper-pressure  appa- 
ratus very  similar  to  Robinson's  which  has  been  used  successfully  by  Lambotte. 
The  use  of  positive  pressure  by  any  mask  method  appeared  to  the  author  to  be 
dangerous  on  account  of  vomiting,  but  Robinson  remarks  that  "its  temporary 
removal  in  case  of  such  unusual  emergencies  as  vomiting  and  instrumentation 
has  not  been  found  to  interfere  with  its  successsful  employment." 


^^^^ws^ 


Fjg.  417. — Ehrenfrieds  introducing  Fig.  418. — Ehrenfried's  modification  of 

forceps.  Cotton-Boothly  introducing  cannula. 

Sauerbruch  was  the  first  to  devise  a  cabinet  by  means  of  which  the  thorax 
could  be  freely  opened  and  respiration  kept  up  under  the  force  of  either  negative 
or  positive  pressure.  Brauer  constructed  a  rather  clumsy  apparatus  for  keeping 
up  respiration  under  positive  pressure.  Willy  Meyer  and  his  brother  (an 
engineer)  have  constructed  a  very  efl5cient  cabinet  for  both  negative  and  positive 
pressures.  It  would  be  out  of  place  to  describe  here  the  structure  and  methods 
for  the  employment  of  any  of  the  pneumatic  cabinets,  each  of  which  has  its 
advantages  and  disadvantages;  it  will  be  sufficient  to  give  the  principles  on 
which  they  work. 

Negative  Pressure  Cabinet. — The  surgeon,  his  assistants  and  the  patient's 
body  are  inside  the  cabinet.  The  patient's  head  protrudes  through  a  hole  in 
the  wall  of  the  cabinet,  his  neck  being  surrounded  by  an  air-tight  collar.  By 
means  of  an  air  pump,  controlled  by  a  manometre,  the  air  pressure  inside  the 
cabinet  is  lowered  sufficiently  to  permit  of  respiration  after  the  thorax  is  opened. 

Positive  Pressure  Cabinet. — Same  as  negative  pressure  cabinet  except  that  the 
patient's  body  is  outside  while  his  head  and  the  anesthetist  are  inside  the  cabi- 
net. By  means  of  an  air  pump  the  pressure  of  the  air  inside  the  cabinet  is 
increased. 


im;ni;  1  RA  1  INC.  woinds  291 

A.  Treatment  of  Wounds  Penetrating  the  Chest.— Treatment  of  wounds 
penetrating  the  chesl  varies,  (</ )  with  the  character  of  the  wound,  (b)  with  the 
surroundings  of  the  patient  and  the  facilities  for  operating  and  giving  post- 
operative care,  (c)  with  the  ideals  and  of  course  with  the  technical  skill  of  the 
surgeon. 

A  bad  sucking  wound*  causes  terrible  respiratory  and  cardiac  distress  and 
must  be  occluded  in  one  way  or  another  at  once.  If  the  circumstances  permit, 
this  occlusion  should  be  etTected  by  a  formal  and  definite  surgical  operation 
I)lanned  to  obviate  infection  and  late  complications  but  first  of  all  to  save  life. 

The  ideals  of  some  surgeons  are  to  provide  immediate  safety  hoping  that 
good  fortune  will  ward  off  com{)lications  or  if  complications  arise  that  they  may 
be  remedied  later.  Other  surgeons  having  their  eyes  fixed  on  the  late  results 
strive  after  perfection  and,  theoretically  at  least,  operate  freely  on  every  chest 
wound.  On  closer  examination  of  the  actual  work  of  the  latter  class  of  surgeons 
it  will  be  found  that  they  commonly  mix  their  theoretical  ideals  with  common 
sense  and  modify  their  conduct  accordingly. 

G.  E.  Cask  (Brit.  Med.  J.,  April  12,  1Q19)  points  out  that  in  war  the  deaths 
from  chest  wounds  in  patients  who  have  been  brought  off  the  field  occur  in 
Casualty  Clearing  Stations  (Evacuation  Hospitals)  within  a  few  hours,  from 
the  severity  of  the  wound,  shock  and  hemorrhage,  or  after  two  or  three  days 
from  sepsis.  In  Base  Hospitals  the  deaths  are  all  from  sepsis.  The  sources  of 
infection  are  {a)  missiles,  clothing,  splinters  of  bone,  etc.,  (b)  sucking  wounds 
which  always  suck  in  infection,  (c)  an  infected  parietal  wound  from  which  in- 
fection spreads  inwards  by  continuity  finding  a  suitable  field  for  growth  in  a 
hemothorax,  (d)  a  foreign  body  in  the  lung.  His  indications  for  operation  are 
(a)  Ragged  wound  of  soft  parts,  (b)  compound  fracture  of  the  ribs,  (c)  continued 
bleeding  internal  or  external,  (d)  Suction  of  air  into  thorax  (open  thorax),  (e) 
retention  of  large  foreign  body,  (/)  pain  out  of  proportion  to  the  apparent 
severity  of  the  wound;  often  this  is  due  to  an  in-driven  splinter  of  bone,  (g) 
Rapidly  increasing  pneumothorax  due  to  a  valvular  opening  into  the  pleura 
(valvular  pneumothorax). 

Cask  recommends  operating  as  soon  as  possible  after  recovery  from  initial 
shock. 

There  will  almost  always  be  a  great  difference  between  the  wounds  of  civil 
life  and  those  so  common  in  war.  Fragments  of  shells,  rocks,  bone,  clothing 
and  dirt  of  all  kinds  from  the  highly  fertilized  fields  of  France  driven  into  the 
thorax  rendered  the  chest  wounds  of  the  Great  War  much  more  dangerous  than 
the  injuries  common  in  civil  life  and  yet  from  the  more  serious  wounds  great 
lessons  may  be  learned  regarding  the  care  of  the  less  serious. 

In  any  serious  chest  wound  an  opiate  is  essential.  Rest  is  obligatorv-.  Do 
not  let  the  patient  lie  on  the  healthy  side  as  to  do  so  interferes  with  the  respira- 
tory movement  of  that  part  of  the  chest  and  also  favors  the  entrance  of  air 
into  the  wound  and  conduces  to  separation  of  the  two  layers  of  the  wounded 
pleura.     Exercise  pressure  on  the  injured  side  of  the  chest  and  if  necessary  on 

*A  sucking  wound  is  one  in  which  the  opening  in  the  pleura  is  large  enough  to  admit 
air  by  suction  in  quantities  as  great  or  greater  than  that  which  enters  the  lung  through 
the  larvnx. 


292  OPERATIONS    ON    THE    CHEST 

the  hypochondrium  to  support  the  diaphragm.  If  a  sucking  wound  is  present 
occlude  it  with  a  moist  pad  until  it  can  be  properly  treated. 

Clean-cut  stab  wounds  of  the  chest  may  generally  be  treated  "expectantly," 
any  complications  being  attended  to  as  they  arise.  Most  wounds  of  the  chest 
wall  ought  to  be  explored  and  devitalized  tissues  and  foreign  bodies  removed, 
in  fact  the  classical  "debridement"  ought  to  be  carried  out.  If  one  or  more 
ribs  are  injured  their  jagged  ends  should  be  pared  and  smoothed.  If  the  pleura 
has  been  opened  and  there  is  no  evident  injury  to  the  lung  or  intrapleural 
bleeding  the  pleural  wound  ought  to  be  closed  at  once.  Often  closure  of  the 
pleura  alone  is  impossible,  if  this  is  so  the  sutures  must  include  muscle  as  well, 
or  even  pericostal  sutures  may  be  employed. 

Through  and  through  gunshot  wounds  may  generally  be  left  alone  except 
for  debridement  of  the  superficial  wounds.  Except  in  very  severe  wounds  of  the 
chest  wall  any  hemorrhage  into  the  pleura  usually  comes  from  the  lung  and 
not  from  the  intercostal  vessels.  Hemorrhage  into  the  closed  pleura  is  either 
fatal  very  promptly  or  not  at  all  (except  from  infection);  it  practically  never 
kills  after  72  hours. 

If  blood  effused  into  the  closed  pleura  remains  sterile  and  is  in  quantity, 
clot  deposited  on  the  \dsceral  layer  very  rapidly  becomes  tough,  compresses 
the  lung  and  prevents  expansion.  Later  organization  of  the  clot  makes  the 
compression  permanent.  When  the  blood  is  chiefly  fluid  and  there  is  little 
clot,  aspiration  may  be  done  on  the  second  or  third  day  with  little  or  no  danger 
of  the  hemorrhage  recurring  and  usually  leads  to  cure. 

As  the  diaphragm  occupies  an  abnormally  high  position  in  hemothorax  ex- 
ploratory- aspiration  should  be  done  high  up  and  not  low  as  when  for  ordinary- 
pleural  effusion. 

When  the  quantity  of  blood  is  small  even  if  the  proportion  of  clot  is  con- 
siderable, aspiration  sufl&ces,  as  the  area  of  lung  compressed  is  so  small  that  the 
patient  by  exercise  so  aids  thoracic  movements  that  the  clot  becomes  absorbed. 
If  the  hemothorax  is  large  and  several  aspirations  fail  to  produce  recovery 
there  is  excess  of  clot  and  thoracotomy  with  removal  of  the  clot  is  obUgatory. 
Should  the  thoracotomy  be  too  long  delayed  and  the  clot  become  organized, 
then  decortication  or  its  equivalent,  viz.  criss-cross  incisions  through  the  layer 
of  scar  tissue  imprisoning  the  lung,  should  be  practiced.  After  treating  the 
hemothorax  close  the  chest  wall  without  drainage.  If  an  infected  hemothorax 
is  seen  early.  Cask  advises  major  thoracotomy,  cleansing  of  the  cavity  and 
closure  of  the  chest.  He  remarks  that  drainage  of  the  chest  is  like  amputa- 
tion of  a  limb,  sometimes  necessary  but  still  a  surgical  failure. 

When  the  lung  is  much  lacerated  or  gross  masses  of  foreign  bodies  are  driven 
into  it  and  are  easily  located  thoracotomy  is  necessary.  This  may  be  done  by 
resection  of  a  long  segment  of  rib,  preferably  the  fourth  rib,  from  the  mid-clavicu- 
lar to  the  posterior  axillary  line  (Lockwood,  War  Med.,  August,  1918.)  A 
rib  spreader  aids  in  giving  good  access. 

Lilienthal  (Journ.  A.  M.  A.,  March  22,  191 9)  prefers  intercostal  thoracotomy, 
making  a  long  intercostal  incision  usually  in  the  seventh  interspace  and  sepa- 
rating the  ribs  from  3  to  5  inches  by  means  of  a  powerful  retractor.  When  the 
injured  lung  is  exposed,  he  seizes  and  brings  it  into  the  wound.     As  soon  as  the 


PENETRATING   WOUNDS  293 

lung  is  stabilized  by  pulling  on  it  in  this  purposeful  fashion  any  dangerous 
mediastinal  trapping  ceases. 

Wounds  of  the  lung  should  be  treated  by  excising  evidently  devitalized 
tissues  and  closing  the  wound  with  sutures.  Closure  of  the  visceral  pleura  is 
very  important. 

If  typical  debridement  is  impossible  because  the  wound  is  a  tunnel,  Cask 
(Brit.  Med.  J.,  April  12,  1919)  recommends  cleaning  the  tunnel  with  gauze 
and  suturing  the  ends  of  the  tunnel.  If,  as  is  uncommon,  an  open  bronchus 
is  found  at  operation  it  should  be  crushed  and  ligated  with  catgut.  Remove 
all  clots  and  foreign  bodies  from  the  pleural  cavity  with  instruments  and  by 
swabbing  with  most  gauze.  Just  before  closing  the  chest,  systematically 
swab  the  whole  of  the  pleural  cavity  both  visceral  and  parietal  surfaces  with 
gauze  wrung  dry  out  of  hot  saline  solution  and  then  with  gauze  wrung  out  of 
warmed  ether. 

Close  the  chest  completely  with  sutures. 

If  there  is  much  gaping  of  the  parietal  pleural  wound  the  lung  may  be  sutured 
to  it  and  the  muscles  sutured  over  the  gap  thus  filled.  The  skin  wound  should 
be  carefully  closed. 

Before  closing  the  thoracic  wound  Brewer  (Personal  communication)  some- 
times, guided  by  the  hand  inside  the  chest,  rapidly  incises  the  skin  and  resects 
a  short  segment  of  a  rib  at  a  place  suitable  for  drainage  but  does  not  penetrate 
the  pleura  there.  The  object  of  this  trivial  procedure  is  that  should  it  later 
become  necessary  to  drain  the  pleura  it  can  be  done  without  an  anesthetic  and 
without  disturbing  the  real  thoracotomy  incision. 

Lockwood  (Loc.  cit.)  recommends  that  "Injuries  of  the  heart  or  pericardium 
can  be  best  dealt  with  by  a  parasternal  flap  of  the  fourth  and  fifth,  or  the  fifth 
and  sixth,  costal  cartilages  depending  on  the  probable  site  of  the  lesion  (the 
divided  cartilages  unite  rapidly) ;  and  this  route,  in  addition,  gives  free  access 
to  the  pleural  cavity. 

Where  the  missile  has  passed  across  the  pleural  cavity  and  lodged  in  the 
mediastinum,  especially  high  up,  it  is  wiser  to  enter  the  mediastinum  through 
the  sternum.  The  missile  should  be  removed,  its  bed  and  track  thoroughly 
cleaned,  and  the  pleural  opening  closed  to  prevent  any  leakage  from  the  medias- 
tinum into  the  pleural  cavity.  This  serves  a  double  purpose — it  obliterates  a 
pocket  in  which  pleural  effusion  might  accumulate,  and  shuts  off  from  the  pleural 
cavity  a  source  of  reinfection.  It  is  difficult  to  deal  with  the  mediastinum 
through  the  usual  costal  incision. 

During  the  after  treatment  any  accumulation  of  the  fluid  should  be  removed 
by  aspiration. 

Do  not  let  the  patient  lie  on  the  healthy  side.  To  do  so  directly  interferes 
with  the  motion  of  that  part  of  the  chest;  it  also  favors  the  entrance  of  air  into 
the  wound  and  conduces  to  separation  of  the  two  layers  of  the  wounded  pleura. 

B.  Treatment  of  Pneumothorax  Resulting  from  Fracture  of  a  Rib. — The 
indications  for  operative  treatment  are  great  respiratory  distress  and  cyanosis 
with  embarrassed  heart  action.     The  methods  of  treatment  are  two: 

(a)  Aspiration. — This  gives  immediate  relief.  If  the  wound  in  the  lung 
closes  and  becomes  sealed  against  the  further  escape  of  air,  the  reHef  is  perma- 


294  OPERATION'S    ON    THE    CHEST 

nent.  If  the  lung  wound  remains  open,  e.g.,  from  its  size,  from  a  shred  of  vis- 
ceral pleura  being  pushed  into  it,  etc.,  the  symptoms  will  j)romptly  recur  and 
operation  becomes  urgent. 

(b)  Expose  the  fractured  rib  or  ribs  by  incision;  excise  enough  of  one  or 
more  ribs  to  gain  access  to  the  wound  in  the  lung.  Keep  up  pressure  on  the 
thoracic  wall.  An  advantage  of  incomplete  or  of  no  anaesthesia  is  that  the 
patient  may  be  made  to  cough,  sneeze,  struggle,  etc.,  and  so  force  the  lung  to- 
ward? the  wound.     Treat  the  wound  exactly  as  in  the  case  of  a  stab  wound. 

C.  Emphysema  Resulting  from  a  Fractured  Rib.— The  emphysema  may  or 
may  not  be  accompanied  by  marked  pneumothorax.  Macewen  (loc.  cit.)  has 
shown  that  the  emphysema  results  from  the  lung  tissue  being  hooked  on  to 
the  spiculae  at  the  fractured  end  of  the  rib  and  a  free  path  being  established 
between  the  injured  lung  and  the  lacerated  subcutaneous  tissues.  Logically 
the  operative  treatment  is  identical  with  that  for  any  other  lung  wound. 

OPERATIONS   ON  THE     PLEUR.^L   CAVITY 

Empyema  resulting  from  infected  wounds  and  from  disease  of  ribs,  etc., 
calls  for  early  operation  first  to  treat  the  jirimary  condition  and  second  to  treat 
the  empyema. 

When  empyema  is  an  accident  or  epiphenomenon  in  the  course  of  acute 
pulmonary  infections  early  radical  operation  is  very  objectionable. 

Operation  should  never  be  adopted  before  the  twelfth  day  of  the  disease 
and  only  exceptionally  as  early  as  that  (Dodge). 

During  the  early  stages  the  exudation  is  sero-fibrinous  in  broncho-pneu- 
monia associated  with  hemolytic  streptococci.  If  this  exudation  is  causing 
distress  it  may  be  removed  by  aspiration,  repeated  as  may  be  necessary.  Some 
recommend  that  oxygen  or  filtered  air  be  introduced  to  take  the  place  of  the 
fluid  removed.  When  the  pulmonary  lesions  are  well  or  nearly  well  and  the 
symptoms  of  slight  dyspnoea  with  neither  cyanosis  nor  bloody  expectoration 
are  in  direct  proportion  to  the  amount  of  fluid  in  the  pleura,  then  a  cutting 
operation  promises  much  and  is  obligatory.  A  respiratory  rate  of  45  to  50 
per  minute  accompanied  by  notable  cyanosis,  oliguria  and  circulatory  disturb- 
ances usually  contraindicates  operation  as  the  pulmonar\-  trouble  is  the  real 
criminal  and  the  pleuritic  is  of  minor  importance.  In  other  words,  if  the  pleural 
effusion,  whether  it  be  sero-fibrinous  or  purulent,  is  merely  a  concomitant  of  a 
general  acute  infection,  operation  is  wrong  until  the  primary  and  more  serious 
trouble  is  overcome  when  operation  may  become  not  merely  beneficial  but 
imperative. 

In  ordinary  pneumococcic  j)neumonia  empyema  as  a  complication  is  usually 
late  and  the  pulmonary  condition  may  well  permit  of  its  early  drainage.  .Aspira- 
tion by  itself  is  sometimes  curative  in  such  cases  especially  in  children. 

Exploratory  FHmcture. — The  existence  of  fluid  in  the  pleural  cavity  is 
diagnosed  or  suspected;  by  exploratory  puncture  its  presence  and  character  are 
determined.  Choose  a  point  on  the  chest-wall  corresponding  to  the  location  of 
the  suspected  fluid.  Fluoroscopy  is  often  of  great  value  in  locating  the  fluid. 
Clean  the  skin  thoroughly.     Choose  a  hypodermic  syringe  with  a  long  and  not 


THORACENTESIS  295 

too  line  needle  and  sterilize  them.  Insert  the  needle  into  the  {)leural  cavity 
at  a  point  just  above  a  rib.  This  avoids  danger  of  injuring  the  intercostal 
vessels.  Slowly  withdraw  the  piston  of  the  syringe.  If  fluid  is  found,  preserve 
it  for  examination;  if  it  is  not  found,  the  operation  should  be  repeated  at  several 
p)oints  and  the  needle  examined  after  each  withdrawal  lest  it  should  have  be- 
come plugged.     No  dressings  are  required. 

Thoracentesis.— The  object  of  the  operation  is  the  removal  of  fluid  from 
the  pleural  cavity.  The  operation  may  be:  (a)  Exploratory.  The  fluid  with- 
drawn is  examined  microscopically.  If  tuberculosis  is  suspected,  the  examina- 
tion should  include  the  inoculation  of  guinea-pigs,  (b)  Therapeutic.  In  adults 
when  the  fluid  is  not  infected  the  operation  is  curative.  In  children  even  when 
the  fluid  is  infected  a  cure  often  results. 

Strict  asepsis  must  be  maintained  otherwise  a  simple  effusion  into  the  pleural 
cavity  may  be  converted  into  an  empyema,  or  to  the  bacteria  which  have 
already  produced  an  empyema  there  may  be  added  others  which  may  markedly 
increase  the  intensity  and  gravity  of  the  disease.  The  patient  should  be 
placed  in  a  semi-erect  posture,  if  necessary  being  jfropped  up  with  pillows.  If 
he  is  weak,  give  him  a  stimulant  of  strychnine  or  alcohol. 

The  favorite  points  for  operation  are  the  eighth  intercostal  space  near  the 
angle  of  the  scapula  and  the  sixth  near  the  midaxillary  line.  Remember  that 
in  hemothorax  the  fluid  is  usually  at  a  higher  level  than  in  hydro-  or  pyothorax. 
Clean  the  patient's  skin.  If  desired,  inject  a  few  drops  of  a  2  per  cent,  solution 
of  novocaine  or  procaine  into  the  skin  at  a  point  over  the  rib  near  its  upper 
edge.  With  a  fine  knife  make  a  puncture  through  the  skin  at  this  point.  Pull 
the  skin-wound  upwards  so  that  the  needle  of  a  Potain  aspirator  (thoroughly 
disinfected)  can  now  be  introduced  and  made  to  pass  into  the  chest  in  contact 
or  nearly  so  with  the  upper  edge  of  the  rib.  The  object  of  puncturing  the  skin 
with  the  knife  is  that,  the  skin  being  tough,  so  much  force  is  required  to  push 
the  aspirating  needle  through  it  that,  the  skin  once  passed,  the  needle  is  liable 
to  be  jerked  into  the  tissues,  x^nother  reason  is  that  disinfection  of  the  deep 
layers  of  the  skin  being  practically  impossible,  the  needle  cutting  its  way 
through  may  conceivably  become  infected  and  do  harm. 

In  whatever  way  the  skin  is  penetrated,  the  puncture  through  it  should  not 
be  opposite  that  through  the  deep  structures;  a  valvular  wound  is  desired.  The 
needle  is  made  to  hug  the  upper  edge  of  a  rib  so  as  to  avoid  injuring  intercostal 
vessels.  Having  introduced  the  needle,  aspiration  is  begun.  If  fluid  does  not 
come,  this  may  be  due  to  the  needle  having  become  clogged  with  tissue  or  a  clot 
of  fibrinous  material.  A  stillette  passed  through  the  needle  will  free  its  lumen. 
If  obetruction  to  the  lumen  is  not  the  cause  of  failure  to  obtain  fluid,  the  needle 
should  be  partially  withdrawn  and  reintroduced  in  another  direction.  Working, 
as  one  does,  in  the  dark,  several  punctures  may  be  necessary  before  the  fluid  is 
found  or  one  is  satisfied  that  it  is  absent.  Another  cause  of  failure  is  discussed 
under  the  name  "pleurisy  blocquees." 

When  the  fluid  flows,  let  it  flow  slowly.  If  the  patient  coughs  or  has  a  feel- 
ing of  oppression,  stop  the  flow  until  he  recovers.  The  same  must  be  done  if  the 
pulse  alters  markedly  or  the  patient  becomes  faint.  As  the  fluid  escapes  the 
patient  may  be  lowered  in  his  bed.     If  the  effusion  is  great,  it  is  wise  to  stop 


296  OPERATIONS    ON    THE    CHEST 

the  operation'  before  the  fluid  is  nearly  all  removed.     The  remainder  may  be 
absorbed.     The  sudden  complete  emptying  of  the  sac  is  likely  to  do  harm. 

Morriston  Davies  (Lancet,  Dec.  28,  191 2;  Brit.  Med.  Jr.,  April  25,  1914) 
finding  it  impossible  to  remove  any  appreciable  quantity  of  pleuritic  fluid, 
especially  in  cases  where  its  presence  would  interfere  with  skiagraphy  of  the 
lungs,  has  overcome  all  difficulties  by  replacing  the  abstracted  fluid  through  the 
introduction  of  oxygen.  He  draws  oflf  the  fluid  by  an  aspirator  in  the  usual  man- 
ner but  as  soon  as  the  first  symptoms  of  drag  on  the  intrathoracic  organs  are 
noticed,  viz.,  discomfort,  pain  or  cough,  he  permits  about  100  c.c.  of  oxygen  to 
flow  into  the  chest  through  a  needle  introduced  two  or  three  interspaces  above 
the  aspirating  needle.  The  two  processes  of  aspiration  and  oxygen  replacement 
are  alternated  until  all  the  fluid  is  removed.  The  apparatus  used  for  nitrogen 
pneumothorax  acts  admirably  for  the  introduction  of  the  oxygen. 

Kenneth  Mackenzie  (Trans.  Am.  Surg.  Assoc,  1914)  uses  warm  sterile 
liquid  paraffin  instead  of  the  oxygen.  His  technique  seems  unnecessarily  elab- 
orate but  promises  well.  When  it  can  be  demonstrated  that  no  more  pus  is 
forming  the  parafSn  may  be^withdrawn  very  gradually — only  two  or  four  ounces 
being  removed  at  a  time  at  intervals  of  two  or  three  days  governed  by  X-ray 
examination  until  the  pleura  is  free  and  occupied  by  a  completely  expanded  lung. 

Pleurisy  Blocquees. — Occasionally  all  the  physical  signs  of  fluid  being  in 
the  pleura  are  present,  the  aspirating  needle  is  inserted  but  no  fluid  flows. 
Examination  of  the  needle  shows  no  plugging  of  its  lumen.  Dufour,  in  1905, 
showed  that  old  pleuritic  effusions  exist  which  cannot  be  aspirated  by  ordinary 
means  while  Mosny  and  Stern  ("La  Presse  Med.,"  Dec.  11,  1909)  demonstrated 
the  same  regarding  recent  acute  pleurisies.  The  reason  for  the  failure  of 
aspiration  is  that  the  fluid  happens  to  be  in  a  cavity  with  rigid  walls,  e.g.,  a  cavity 
whose  wall  may  consist  of  hepatized  lung,  the  chest-wall  and  pleuritic  adhesions. 
If,  as  occasionally  happens,  the  tension  of  the  fluid  is  about  equal  to  that  of  the 
atmosphere,  then  only  a  small  amount  of  the  fluid-will  escape  through  the  as- 
pirating needle;  if  the  tension  of  the  fluid  is  less  than  that  of  the  atmosphere,  no 
fluid  will  escape.  If  a  second  hollow  needle  is  passed  alongside  the  aspirating 
needle,  atmospheric  air  will  be  admitted  into  the  cavity  and  aspiration  becomes 
easy. 

Thoracotomy. — The  objects  to  be  attained  by  thoracotomy  are: 

I.  Exploration  and  the  performance  of  various  operations  by  the  transpleural 
route.  For  this  purpose  a  long  intercostal  incision  is  excellent.  Make  a  very 
long  incision  in  an  intercostal  space  down  to  but  not  through  the  pleura.  Open 
the  pleura  in  the  same  manner  as  the  peritoneum  is  opened  in  laparotomy. 
Le  Fort  (Rev.  de  Chir.,  May  and  June,  191 7)  insists  that  the  pleura  be  opened 
widely,  that  collapse  of  the  lung  against  the  vertebrae  is  a  fable  only  occurring 
in  cadavera,  that  a  small  pleural  opening  is  dangerous  as  it  may  occasion  a 
condition  identical  to  valvular  pneumothorax.  After  the  pleura  is  opened 
Carrel's  technique  may  be  used  (Trans.  Am.  Surg.  Assoc,  1914,  p.  452).  "The 
operating  field  was  walled  off  by  two  kinds  of  towels.  The  first  kind  was  made 
of  Japanese  silk  which  had  been  previously  boiled  in  water,  dried,  and  sterilized 
in  the  autoclave,  like  ordinary  pieces  of  dressing.  The  second  kind  of  towel  was 
composed  of  absorbent  cotton  and  of  black  Japanese  silk.     These  towels  were 


THORACOTOMY  297 

made  in  the  following  way:  Two  pieces  of  fine  black  Japanese  silk  were  sewed 
together  at  the  edges.  Between  these  two  pieces  was  placed  a  layer  of  absorbent 
cotton  about  i  cm.  thick,  and  the  whole  towel  was  knotted  throughout,  thus 
forming  a  pad.  These  towels  were  sterilized  in  the  autoclave.  Both  kinds  of 
towel  above  described  were  used  for  walling  off  the  operating  field.  When  the 
incision  of  the  superficial  part  of  the  thoracic  wall  was  completed  and  the  hemo- 
stasis  secured,  the  pleural  cavity  was  opened  by  means  of  a  small  incision  made 
in  the  middle  of  the  intercostal  space.  A  dry,  white  Japanese  silk  towel  was 
introduced  into  one  end  of  the  incision,  while  a  second  one  was  introduced  at  the 
other  end.  These  towels  afterward  served  as  a  protection  to  the  anterior  and 
posterior  parts  of  the  pleural  cavity.  Next,  the  incision  of  the  thoracic  wall  was 
completed  and  the  thoracic  cavity  was  opened  wide,  the  lungs  being  meanwhile 
completely  protected  by  the  towels  already  introduced.  Immediately  after 
this  the  black  silk  and  cotton-padded  towels  were  laid  on  the  upper  and  lower 
edges  of  the  wound  and  introduced  into  the  cavity  in  such  a  manner  that  they 
respectively  protected  the  upper  and  lower  parts  of  the  pleura.  Next,  a  Gosset 
retractor  was  applied  and  the  edges  of  the  wound  were  retracted  as  much  as  was 
necessary  for  the  purpose  of  the  operation.  The  edges  of  the  padded  towels 
were  arranged  in  such  a  way  as  to  circumscribe  the  operating  field  and  to  leave 
this  alone  exposed  to  the  air  and  to  the  sight  of  the  operator.  Additional 
padded  towels  could  be  used  afterw^ard,  if  necessary,  in  order  to  secure  a  more 
complete  walling  off  of  the  operating  field.  By  means  of  this  procedure  the 
pleural  cavity  appeared  to  be  almost  completely  protected  against  the  infection 
produced  by  the  atmospheric  germs  as  well  as  against  all  .possible  infection  or 
irritation  caused  by  the  handling  of  the  serous  membrane  by  the  hands  of  the 
operators,  by  the  rough  sponging  with  gauze,  and  by  other  operative  trauma- 
tisms. Moreover,  when  hemorrhage  occurred  the  blood  was  prevented  from 
flowing  into  other  parts  of  the  thoracic  cavity." 

The  Friedrich,  Sauerbruch,  de  Quervain  or  Lilienthal  self-retaining  retractors 
or  rib  spreaders  serve  well  to  open  the  wound  widely.  After  completing  the 
operation  close  the  wound  by  interrupted  buried  sutures  each  of  which  sur- 
rounds the  rib  above  and  below  the  intercostal  wound  (pericostal  sutures).  As 
the  last  of  these  sutures  is  being  tied  have  the  anesthetist  cause  the  lung  to 
expand  so  as  to  drive  all  air  out  of  the  pleural  cavity  or  aspirate  the  air  from  the 
cavity.  Witzel  has  filled  the  pleura  with  boracic  acid  solution,  closed  the 
wound  and  then  removed  the  solution  by  aspiration. 

II.  The  second  and  infinitely  the  more  common  object  of  thoracotomy  is 
to  drain  the  pleural  cavity.  Local  or  general  anesthesia  may  be  employed, 
preferably  local.  Make  an  incision  two  inches  in  length  parallel  to  the  ribs 
at  a  point  just  anterior  to  the  edge  of  the  latissimus  dorsi  muscle  and  corre- 
sponding to  the  sixth,  seventh,  or  eighth  intercostal  space.  Along  the  lower 
border  of  the  space  cut  through  the  intercostal  muscles.  Attend  to  hemostasis. 
Make  a  small  opening  through  the  parietal  pleura.  Too  rapid  evacuation  of  the 
pus  is  dangerous,  as  it  too  suddenly  alters  conditions  of  intrathoracic  pressure. 
As  the  pus  flows,  enlarge  the  opening  with  forceps  or  the  finger.  Explore  the 
empyema  cavity  with  the  finger  and  remove  all  shreds  of  tissue  or  clots  of  fibrin 
floating  in  the  cavity.     If  such  are  left  behind,  they  are  liable  to  interfere  with 


?98 


OPERATIONS    ON    THK    CHEST 


(Irainaj^c  and  (k'lay  rccowr}'.  Drain  by  means  of  lubes  ])assc'(l  into  the  pk-ural 
cavity.  Not  much  of  the  tube  should  project  into  the  pleura.  The  tubes 
may  be  rigid  or  soft.  To  prevent  the  tube  slipping  into  (he  pleura  either  stitch 
it  to  the  skin  or  transfi.x  it  with  a  large  safety-pin  or  l)otli.  If  necessary  (it  rarely 
is  necessary),  partially  close  the  skin-wound  with  sutures.  .Surround  the  outer 
end  of  the  drain  with  stt'rile  gauze  in  bird-nest  fashion.  This  prevents  direct 
pressure  on  llic  tube.  Ai)])ly  abundant  dressings.  Some  surgeons  place 
oiled  silk  over  the  mouth  of  the  drainage-tube  to  act  as  a  valve,  allowing  the 
escape  but  not  the  entrance  of  air  into  the  pleura.  This  is  unnecessary.  After 
the  pleura  has  been  penetrated,  a  counteropening  may  seem  desirable.  To 
make  this,  pass  a  forceps  through  the  wound,  through  the  cavity,  and  with 
its  point  elevate  the  tissues  at  the  position  selected.  Cut  down  on  the  forceps 
and  push  them  through  the  new  wound.  Grasp  a  perforated  rubber  tube  in 
the  jaws  of  the  forceps  and  pull  the  tube  through  the  cavity.  This  provides 
efficient  through-and-through  drainage.  Ochsner  is  a  great  advocate  of 
through-and-through  drainage.     If  at  any  time  it  is  desired  to  withdraw  the 

tube  and  introduce  another,  fasten  a  stout 
thread  to  the  end  of  it  and  in  withdrawing 
the  tube  pull  the  thread  through  the  cavity; 
with  this  thread  in  situ  it  is  easy  to  introduce 
another  tube.  Later  the  tube  may  be  replaced 
by  a  few  strands  of  silkworm-gut.  Tubular 
drainage  must  be  kept  up  until  all  discharge 
has  ceased.  In  cases  of  pneumococcic  infection 
recovery  is  usually  rapid,  the  lung  expanding  and 
obliterating  the  empyema  cavity.  When  the 
infection  is  streptococcic,  many  weeks  may 
elapse  before  the  infected  cavity  becomes  oblit- 
erated. Some  surgeons,  to  make  drainage  more 
perfect  and  continuous,  connect  the  drainage- 
tube  to  a  pipe  passing  through  the  dressings  and  attached  to  a  Bunsen's 
air  pump  (Fig.  419).  This  ingenious  measure  is  not  often  required. 
During  the  after-treatment  of  cases  of  thoracotomy  the  patient  should  be  placed 
in  the  position  found  at  the  operation  to  be  most  favorable  for  drainage.  This 
position,  especially  if  disagreeable,  need  not  be  kept  up  continuously  but  adopted 
at  intervals  for  a  short  time.  It  is  wise  to  encourage  the  patient  to  sit  up  and 
move  about  at  as  early  a  date  as  possible.  Fresh  air  is  of  great  value  in  treatment. 
Rutherford  Morison  thinks  that  an  incision  parallel  to  the  ribs  is  likely 
to  kink  the  tube  (a)  during  respiratory  movements,  {h)  from  altered  position 
after  completion  of  operation.     He  operates  as  follows: 

1.  Verify  presence  of  pus  with  hypodermic  syringe. 

2.  Make  a  vertical  incision  down  to  rib  and  across  intercostal  space. 

3.  Push  a  sinus  forceps  (a  closed,  fine-pointed  hemostat  is  satisfactory) 
into  pleural  cavity.     Alongside  the  forceps  introduce  a  director. 

4.  Open  the  forceps  parallel  to  the  ribs  and  pull  them  out  while  open,  but 
leave  the  director  in  situ.     (This  method  avoids  hemorrhage.) 

5.  Guided  by  the  director,  introduce  drainage-tube. 


Fig.  419. — Bunsen's  air  pump. 


THORACOT(JMY  299 

Continue  tubular  drain  until  there  is  no  more  pus  than  can  be  accounted 
for  by  external  wound.  After  removal  of  tube  introduce  director  daily  so  as 
to  discover  if  pus  reforms  necessitating  reintroduction  of  tube. 

Thoracotomy  by  Puncture. — Make  a  small  incision  through  the  skin.  Intro- 
duce a  large  trocar  into  the  empyema  cavity.  Through  the  trocar  pass  a  large 
rubber  catheter.  Withdraw  the  trocar  leaving  the  catheter  in  place.  Con- 
traction of  the  muscles  around  the  catheter  grip  it  until  no  air  can  enter  along- 
side it. 

B.  F.  Stevens  (Southwestern  Med.,  May,  1919)  advises  that  a  few  ounces 
of  pus  be  allowed  to  escape  every  two  hours  until  in  24  hours  almost  all  has 
been  evacuated.  After  this  he  advises  the  instillation  of  Dakin's  solution  every 
two  hours;  the  old  solution  being  allowed  to  escape  before  the  fresh  is  put  in. 
Except  when  being  used  by  the  attendant  the  catheter  drain  is  to  be  kept 
closed  by  a  clamp.  The  claim  is  made  that  by  this  method  pus  can  be  got  rid 
of  in  from  3  to  10  days  and  that  the  entire  treatment  is  usually  completed 
in  3  weeks. 

W.  T.  Dodge  (Journ.  A.  M.  A.,  June  21,  1919)  after  great  experience  during 
the  epidemics  of  1918  "relegates  to  the  boneyard  all  of  the  many  fancy  treat- 
ments of  empyema  evolved  by  the  faddists  who  have  been  privileged  to  observe 
a  series  of  cases  for  a  limited  period  of  time."  He  has  come  back  to  the  long 
established  methods  of  free  drainage  which  if  adequately  carried  out  render 
the  use  of  antiseptics  such  as  Dakin's  solution  entirely  superfluous. 

Moschowitz  (Surg.,  Gyn.  and  Obst.,  April,  1919)  is  a  strong  upholder  of 
thoracotomy  without  rib  resection,  generally  in  the  eighth  interspace  just  behind 
the  posterior  axillary  line.  When  the  patient  is  put  to  bed  "a  simple  instilla- 
tion and  suction  apparatus  (Fig.  420)  is  attached  to  the  drainage  tube  by  means 
of  a  T-tube;  at  a  convenient  point  a  second  attachment  is  made  for  a  bottle  to 
receive  the  discharge  escaping  from  the  empyema  cavity.  Once  an  hour,  or 
more  or  less  frequently  as  indicated,  the  syphon  part  of  the  apparatus  is  dis- 
continued by  clamping,  and  the  instilling  part  of  the  apparatus,  a  Dakin  con- 
tainer, is  opened,  and  the  requisite  amount  of  solution  is  allowed  to  run  in. 
After  the  lapse  of  five  minutes  the  suction  apparatus  is  reopened,  and  the  solu- 
tion plus  secretions  syphoned  out.  The  suction  is  continued  until  the  next 
period  of  instillation." 

By  the  above  means  the  cavity  is  kept  perfectly  dry  and  the  wound  does 
not  require  to  have  the  dressings  changed  for  a  week  or  10  days.  After  this 
period  the  apparatus  and  drainage  tube  are  removed,  the  skin  cleaned  with 
alcohol  and  the  cavity  is  flushed  with  Dakin's  solution  through  a  soft  rubber 
catheter  (about  2  2°F.)  until  the  return  flow  is  clean.  During  the  flushing  the 
patient  is  turned  from  the  lateral  to  the  prone  position  and  vice  versa.  After 
this  from  i  to  4  Carrel  tubes  are  introduced  to  the  various  parts  of  the  cavity; 
a  short  drainage  tube  "with  one  fenestra  guarded  by  a  safety  pin,  so  called 
'safety  valve,'  is  finally  introduced,  to  permit  a  free  escape  of  the  Dakin  solu- 
tion and  secretions."  The  vicinity  of  the  wound  is  protected  by  sterile  vaseline 
gauze  strips  and  the  skin  further  away  is  covered  by  stiff  zinc  oxide  ointment. 
Dry  gauze  dressings  are  applied  through  which  the  Dakin  tubes  emerge  above. 
Hourly  instillations  of  Dakin's  solution  are  made  in  quantity  equal  to  about 


300 


OPERATIONS    ON    THE    CHEST 


half  the  capacity  of  the  cavity.  Every  24  hours  the  dressings  and  tubes  are 
changed.  When  sterility  is  attained  (smears  and  cultures  from  cavity)  and 
maintained  for  several  days  treatment  is  discontinued,  the  wound  heals  if  left 
alone  and  permanent  recovery  ensues.  If  the  cavity  has  not  become  truly 
sterile  the  wound  will  reopen. 

In  a  few  cases  of  healed  empyema  Moschowitz  notes  a  very  definite  closed 
pneumothorax  which  disappeared  after  about  a  month  by  expansion  of  the  lung. 

The  cases  which,  according  to  Moschowitz  cannot  be  remedied  by  long 
continued  Carrel-Dakin  teratment  are:  (i)  Cases  complicated  by  large  pleuro- 
pulmonary  fistulas.  (2)  Cases  with  retained  foreign  bodies,  (3)  cases  with  side 
pockets  or  lateral  branch  sinuses  (4)  cases  with  necrotic  ribs. 


Fig.  420. — {Report  U.  S.  Empyema  Commission.) 


Thoracotomy  with  resection  of  a  segment  of  rib  is  usually  much  preferable 
to  simple  intercostal  incision.  In  the  latter  the  space  is  limited,  finger  explora- 
tion is  difficult  or  impossible,  and  when  the  tube  is  introduced,  it  is  very  liable 
to  be  pinched  between  the  ribs  and  rendered  useless.  Removal  of  a  segment  of 
one  or  more  ribs  does  no  permanent  harm  and  the  operation  is  exceedingly  easy. 
Excision  of  a  segment  of  rib  is  rarely  required  in  children  and  as  rarely  should  it 
be  omitted  in  adults.  In  operating  on  non-localized  empyema  the  incision  may 
be  made  over  the  sixth  or  seventh  rib  in  the  mid-axillary  line,  or  over  the  ninth 
rib  just  external  to  the  angle  of  the  scapula,  which  is  the  best  position.  In 
cases  of  localized  empyema  the  opening  must  of  course  be  made  over  the  encap- 
sulated pus.  When  incision  is  made  in  the  mid-axillary  line,  the  patient  must  be 
brought  to  the  edge  of  the  table  over  which  the  affected  side  may  protrude  a 
little.     When  the  posterior  site  of  operation  is  chosen,  place  the  patient,  with  the 


COSTECTOMY  3OI 

sound  side  uppermost,  in  a  position  midway  between  the  lateral  and  ventral — i.e., 
lying  half  over  on  his  belly.  The  sound  side  must  never  be  undermost,  other- 
wise respiration  will  be  impeded.  The  surgeon  under  these  circumstances  stands 
in  front  of  the  patient  and  reaches  the  site  of  the  operation  by  leaning  over  him. 
These  are  the  classical  instructions  always  insisted  on  but  rarely  carried 
out,  except  in  trivial  cases  or  by  beginners  who  are  much  hampered  by  them. 
They  are  impracticable.  In  Friedrich's  most  extensive  pneumolysis,  the 
patient  lies  on  the  sound  side.  The  researches  of  Schafer  (Transactions, 
Section  on  Surg,  and  Anat.,  American  Med.  Assoc,  1908)  on  artificial  respiration 
and  the  experiments  and  observations  of  Elsberg,  clearly  show  that,  when  pos- 
sible, the  prone  position  is  the  position  of  choice  for  operations  on  the  chest. 
C.  E.  Corlette  (The  Med.  Journ.  of  Australia,  March  i,  1919)  strongly  recom- 
mends the  semiprone  position  for  operations  for  empyema  and  pulmonary  hyda- 
tids, with  the  side  to  be  opened  at  the  edge  of  the  table  and  downwards.  If 
the  operator  is  seated  this  posture  is  very  convenient  for  operations  on  the 
lower  part  of  the  thorax.     In  the  case  of  hydatids,  where  drowning  is  a  real 


Fig.  421. — Rib  shears. 

peril,  not  only  is  this  peril  reduced  to  a  minimum  but  the  downward  and  out- 
ward rush  of  water  brings  the  parasitic  cyst  well  into  the  wound  and  greatly 
facilitates  its  extraction. 

The  Operation. — i.  Make  an  incision  two  to  three  inches  in  length  along  the 
long  axis  of  the  chosen  rib  and  divide  the  periosteum  along  a  line  midway 
between  the  upper  and  lower  borders  of  the  rib. 

2.  With  a  curved  periosteal  elevator  separate  the  periosteum  from  the  bone 
both  externally  and  internally.  The  intercostal  vessels  are  separated  from 
the  bone  with  the  periosteum.  In  recent  cases  much  care  must  be  exercised 
when  detaching  the  periosteum  from  the  deep  surface  of  the  bone  lest  the 
pleura  be  prematurely  opened;  in  cases  of  long  duration  there  is  so  much 
pleural  thickening  that  no  accident  is  likely  to  happen. 

3.  Divide  the  exposed  rib  at  the  posterior  end  of  the  wound  with  bone 
forceps  or  rongeurs.  For  this  purpose  a  costotome  (Fig.  421)  is  convenient 
but  not  necessary.  Grasp  the  portion  of  bone  to  be  removed  in  the  Jaws  of  a 
sequestrum  forceps,  steady  and  bring  it  forwards,  and  divide  it  anteriorly 
with  bone  forceps.    Two  inches  of  bone  should  be  removed. 

4.  Make  a  small  incision  through  the  deep  layer  of  periosteum  and  the 
pleura.    Let  the  pus  flow  out  slowly.     Interrupt  its  flow  from  time  to  time 


302  OPERATIONS    OX   THE    CHEST 

by  plugging  the  wound  with  gauze.  Too  rapid  evacuation  means  pulmo- 
nary congestion,  and  this  is  liable  to  cause  fatal  anaemia  of  the  brain.  Proceed 
as  in  thoracotomy.  If  the  cavity  is  large,  it  is  easy  to  resect  portions  of  two 
ribs  subperiosteally  through  the  same  external  incision.  If  this  is  done,  the 
intercostal  muscles  and  vessels  should  be  ligated  behind  and  in  front  of  the 
pleural  incisions  and  the  two  horizontal  openings  into  the  pleura  united  by 
a  vertical  cut  to  form  an  I  -shaped  wound  (Fig.  422). 

When  the  effects  of  an  empyema  are  very  menacing  Lilienthal  performs  a 
simple  thoracotomy  under  local  anesthesia  and  introduces  a  drainage  tube. 

When  this  simple  operation  has  led  to  im- 
provement he  makes  an  incision,  under 
local  anaesthesia,  usually  along  the  seventh 
interspace  from  the  angle  of  the  rib  to  its 
costal  cartilage.  Before  opening  the  pleura 
he  administers  nitrous  oxide  and  oxygen 
and  under  that  anesthetic  opens  the  pleura 
freely — introduces  a  rib  spreader  which 
separates  the  seventh  and  eighth  ribs  for 
a  width  of  several  inches  and  gives  a 
Fig.  422.— Thoracotomy.  perfect  view  of  the  interior  of  the  chest. 

Adhesions  between  the  visceral  and  costal 
pleurse  must  not  be  attacked  but,  with  the  finger,  the  lung  ought  to  be 
separated  from  the  diaphragm.  In  doing  this  it  is  not  uncommon  to  open 
abscesses  which  would  otherwise  have  been  overlooked.  Should  the  lung 
fail  to  expand,  this  failure  is  due  to  its  being  compressed  and  held  down  by 
organized  exudates  on  its  pleura.  Lilienthal  now  follows  Fowler  and  Delorme 
by  incising  the  compressing  membrane  throughout  the  whole  length  of  the  lung 
and  strips  it  off.  The  lung  now  expands.  If  decortication  seems  too  risky  he 
follows  Ransohoff  in  making  criss-cross  incisions  through  the  compressing  mem- 
brane and  so  obtains  expansion.  In  closing  the  wound  he  sutures  the  divided 
latissimus  dorsi  and  serratus  magnus  but  not  the  intercostal  muscles. 

This  method  of  Lilienthal's  appeals  to  the  author  as  being  conservatively 
radical. 

Chevrier*s  Method.  Principles. — The  principles  underlying  drainage  of  the 
pleura  in  empyema  are  admitted  by  all  to  be  the  insertion  of  a  proper  tube 
through  the  chest  wall  at  the  lowest  point.  That  this  principle  is  not  carried 
into  practice  is  shown  by  the  various  devices  used  to  obtain  siphonage  of  the 
pus.  A  glance  at  Figs.  423,  424  and  425  will  show  why  an  opening  in  the 
posterior  axillary  line  at  the  level  of  the  sixth  rib  or  even  one  in  the  scapular 
line,  cannot  give  proper  drainage  whether  the  patient  is  recumbent  or  seated, 
whereas  an  opening  at  the  costal  angle  (Fig.  425)  must  permit  sufficient 
emptying  of  the  vertebrocostal  gutter  in  the  recumbent  posture. 

The  'low  point,'  i.e.,  the  proper  site  for  pleural  drainage,  is  in  the  costo- 
vertebral gutter  at  the  reflexion  of  the  pleura  from  the  chest  wall  on  to  the  dia- 
phragm. Normally  the  pleural  reflexion  is  very  low  in  the  chest  (about  the 
eleventh  intercostal  space)  but  in  disease  the  costo-diaphragmatic  cul-de-sac 


C'lIEVRIKk  S    rUINCIPLES 


303 


is  pushed  upwards  to  a  varying  degree  (Figs.  426  and  427)  and  in  each  case 
must  be  found  by  exploration  during  the  operation. 

Step  I. — Just  external  to  the  mass  of  the  erector  spinae  muscles  explore  for 


Fig.  423. — Segment  of  the  6th  rib  has  been  excised  in  posterior  axillary  line.     Retention 
of  fluid  when  patient  is  recumbent.     {Chevncr,  La  Pr.  Med.,  Jan.  9,  1919.) 

pus  with  an  aspirating  needle.  This  is  best  done  under  guidance  of  the  fluoro- 
scope  as  this  permits  the  puncture  being  made  "if  not  at  the  exact  inferior  limit 
of  the  effusion  at  least  in  its  lower  zone.' 


Fig.  424. — Segment  of  the  6th  rib  has  been  excised  in  posterior  axillary  line.     Retention  of 
fluid  when  patient  is  erect.     (Chevrier,  La  Pr.  Med.,  Jan.  9,  1919.) 

Step  2. — ^Leaving  the  needle  in  place  make  an  incision  over  the  rib  immedi- 
ately above  the  puncture,  the  patient  being  in  the  lateral  decubitus  lying  on 


304 


OPERATIONS    ON    THE.  CHEST 


the  healthy  side.     The  incision  must  begin  at  the  outer  border  of  the  spinal 
mass  of  muscles  and  run  outwards  j)ara]lel  to  the  rib.     Incise  the  latissimus 


Fig.  425. — Diagram  showing  retention  of  fluid  when  opening  is  made  in  posterior  axillary 
line  or  in  scapular  line.  No  retention  when  opening  is  at  the  bottom  of  the  vertebro-costal 
gutter.     {Chevrier,  La  Pr.  Med.,  Jan.  9,  1919.) 

dorsi  and  sometimes  the  serratus  posticus  inferior,  over  the  rib.     Expose  the 
external  fibres  of  the  ilio-costal  muscle  at  the  median  end  of  the  wound,  and 


r  ■  -'^'^  y. 


Fig.  426. — Diagram  showing  the 
normal  subpleural  areolar  tissue  between 
the  pleural  reflexion  and  the  diaphragm. 
{Chevrier^  La  Pr.  Med.,  Jan.  9,  1919.) 


Fig.  427. — Diagram  showing  elevation 
of  the  pleural  cul-de-sac  due  to  (a)  oedema 
and  infiltration  of  the  subpleural  areolar 
tissue  and  (b)  thickening  of  the  pleura 
by  false  membranes.  {Chevrier,  La  Pr. 
Med.,  Jan.  9,  1919.) 


beginning  at  this  landmark  divide  the  periosteum  of  the  rib.     Excise  a  segment 
of  rib.     Incise  the  pleura.     With  the  finger  plug  the  opening  so  as  to  regulate 


BERARD  S   OPERATION  305 

the  escape  of  pus  and  so  prevent  coughing  and  other  rellexes  due  to  too  rapid 
evacuation.  As  pus  ceases  to  flow  turn  the  patient  gradually  on  to  his  back 
until  evacuation  is  complete  when  he  is  to  be  returned  to  the  lateral  decubitus. 

Step  3. — Explore  the  pleura  with  the  finger  and  find  the  low  point.  Guided 
by  the  finger  inside  the  chest,  open  the  thorax  at  this  point  and  if  necessary 
excise  a  segment  of  rib.  Through  this  second  opening  introduce  two  short 
tubes  of  wide  caliber.     Dress  but  do  not  drain  the  first  opening. 

Step  4. — Disinfection  of  the  Pleura. — Many  surgeons  having  opened  the 
chest  in  the  classical  site  (6th  rib;  posterior  axillary  hne)  introduce  Dakin's 
solution  through  small  tubes.  The  opening  being  ill-suited  for  drainage  per- 
mits retention  of  the  solution  which  bathes  the  parts  below  the  opening  but 
not  those  at  a  higher  level.  Chevrier  advises  the  use  of  gaseous  disinfection 
which  reaches  every  part  of  the  cavity  and  obviates  the  use  of  the  Carrel  tubes. 

Conduct  compressed  air  or  better  oxygen  from  a  cyhnder  to  the  bottom  of  a 
flask  containing  ether  or  ether  with  a  little  formalin.  Let  the  air  bubble  through 
the  ether  and  conduct  it  thus  charged  with  volatile  antiseptic,  into  the  pleural 
cavity. 

Berard  and  Dunet  (La  Pr.  Med.,  April  3,  1919)  consider  that  except  in  the 
tuberculous,  slow  recovery  means  defective  drainage  and  emphasize  the  im- 
portance of  considering  the  posture  which  will  be  assumed  by  the  patient  after 
operation  before  selecting  the  site  for  drainage.  Most  patients  early  assume  the 
sitting  posture  and  for  such  they  find  the  low  point  in  the  pleura  to  be  anterior 
or  antero-lateral  at  the  level  of  the  loth  or  nth  rib  about  5  inches  from  the 
middle  Hne. 

Berard's  Operation.  Step  i. — Open  the  pleura  in  the  ninth  interspace  in 
the  posterior  axillary  hne  except  in  sacculated  empyema  where  the  incision  is 
made  over  the  pus  as  found  by  the  exploring  needle.  Let  the  pus  escape  slowly. 
If  the  condition  of  the  patient  is  precarious  do  not  proceed  further  for  a  few 
days.     If  the  condition  of  the  patient  permits  proceed  at  once  to 

Step  2. — Through  the  opening  pass  a  curved  forceps  through  the  empyema 
cavity  to  what  would  be  the  low  point  if  the  patient  were  sitting.  This  point 
varies,  e.g.,  pneumococcal  infection  as  a  rule  produces  much  false  membrane 
and  adhesion  with  obliteration  of  parts  of  the  pleural  cavity  while  streptococcal 
infection  does  not.  Guided  by  the  forceps  excise  a  segment  of  rib  at  the  low 
poinfei.  Remove  any  masses  of  fibrin,ous  material.  Introduce  one  or  two  large 
drains. 

Step  3. — Introduce  one  or  more  Carrel  tubes  through  the  original  incision. 
Apply  dressings.  Connect  the  drains  by  tubing  to  a  receiver.  Keep  the  patient 
absolutely  quiet  for  24  hours.  Dress  the  wound  after  the  lapse  of  24  hours. 
If  the  discharge  is  pure  pus  irrigation  will  be  of  value.  Dakin's  solution,  nitrate 
of  silver  or  salt  solution  may  be  employed  through  the  Carrel  tubes.  About 
150  or  200  c.c.  may  be  used  every  3  hours  except  at  night.  Each  day  remove, 
clean  and  replace  both  the  Carrel  and  drainage  tubes. 

If  an  empyema  persists  for  a  very  long  time  or  if,  after  an  apparent  cure  the 
drainage  track  reopens  several  factors  may  be  to  blame,     (i)  Defective  drain- 
age.    (2)  Imperfect  sterilization.     (3)  Presence  of  foreign  bodies  in  the  pleura, 
e.g.,  lost  drainage  tube,  etc.     (4)  Osteomyelitis  of  ribs.     (5)  Secondary  en- 
20 


306  OPERATJOXS    ON    THE    CHEST 

capsulaled  abscesses  of  the  pleura  which  have  escaped  drainage.  (6)  Sub- 
pleural  pulmonary  abscesses  such  as  Moschowitz  considers  ihe  cause  of  most, 
if  not  of  all  empyemata.  (7)  Small  intrapulmonary  abscesses  draining  into 
the  pleura  giving  rise  to  pleuro-pulmonary  fistulae.  (8)  Broncho-cutaneous 
listulae  where  a  portion  of  lung,  the  site  of  an  open  bronchus,  has  become  ad- 
herent to  the  chest  wall  near  the  point  of  drainage  and  the  tract  between  the 
bronchus  and  the  skin  has  become  covered  by  epithelium. 

In  all  these  conditions  it  may  be  necessary  to  perform  some  free  exploratory 
operation  such  as  Lilienthal's  and  during  the  operation  correct  the  conditions 
present.  Pleuro-pulmonary  fistulae  often  heal  of  themselves  or  after  steriliza- 
tion and  perhaps  direct  suture.  To  obliterate  a  broncho-cutaneous  fistula 
requires  mobilization  of  the  affected  portion  of  the  lung  by  Schede's  thoraco- 
plasty or  some  modification  thereof,  plus  excision  of  the  fistulous  tract  and 
closure  of  the  open  bronchus,  but  as  Lilienthal  writes  ''lung  fistulas  from  tuber- 
culosis, bronchiectasis  or  multiple  abscess  of  the  lung  should  be  let  alone,  for 
they  constitute  safety  valves."  .  .  .  "Plastic  closure  of  lung  fistulae  is  indi- 
cated when  secretion  is  scanty?  Encapsulated  abscesses  of  the  pleura  at  some 
distance  from  the  original  empyema  region  require  direct  and  efficient  drainage 
through  an  opening  made  by  resecting  a  segment  of  rib.  Reaccumulation  of 
pus  in  empyema  demands  proper  drainage  and  as  already  stated  a  formal  ex- 
ploratory operation  may  be  necessary. 

The  cure  of  an  empyema  by  drainage  depends,  first,  on  the  free  escape  of 
the  pus;  and  second,  on  expansion  of  the  lung  obliterating  the  pleural 
cavity  with  or  without  more  or  less  complete  adhesion  of  the  parietal  and  visceral 
layers  of  the  pleura.  When  the  lung  is  unable  to  expand  and  approach  the 
chest-wall,  obliteration  of  the  cavity  may  be  obtained  by  bringing  the  chest 
wall  to  the  lung.     To  accomplish  this  is  the  object  of  thoracoplasty. 

Fluoroscopy  has  superseded  all  other  means  of  observing  the  expansile 
power  of  the  lungs. 

Wilm's  Operation  for  Empyema.—See  p.  318. 

Estlanders  Operation. — Make  a  subperiosteal  resection  of  three  or  four  ribs 
(about  4  inches  of  each)  through  separate  incisions,  exactly  as  in  thoracotomy 
with  resection  of  rib.  Instead  of  using  separate  skin-incisions  the  ribs  may  be 
exposed  by  a  U-,T-,  H-,  or  I-shaped  incision,  the  soft  parts  being  reflected  as  a 
flap  or  flaps,  and  then  the  ribs  resected  subperiosteally.  This  operation  permits 
a  falling-in  of  the  chest-wall,  but  in  many  cases  the  parietal  pleura  is  so  thick 
and  hard  that  it  is  inelastic,  and  the  desired  retraction  of  the  chest  cannot  take 
place.     To  obtain  proper  retraction  the  following  procedure  has  been  adopted: 

Schede's  Operation  (Thoracoplasty).— Beginning  at  the  origin  of  the  pec- 
toralis  major  at  the  level  of  the  axilla  make  an  incision  which  goes  downwards 
in  a  curve  to  the  bottom  of  the  pleural  sac, — i.e.,  the  tenth  rib  in  the  poste- 
rior axillary  line,  crosses  the  chest- wall  from  the  front  to  the  back,  and  ascends 
to  the  level  of  the  second  rib  at  a  point  between  the  spine  and  the  scapula. 
Reflect  upwards  the  huge  flap  thus  outlined,  and  include  in  it  all  the  tissues 
superficial  to  the  ribs  and  intercostal  muscles.  Resect  subperiosteally  all  the 
ribs  over  the  cavity,  from  their  tubercles  to  their  insertion  into  the  costal 
cartilages.     To  do  this  it  is  best  to  divide  the  rib  at  its  middle  with  bone  for- 


TlIOkACOl'LASTV  307 

ceps,  and,  grasping  the  divided  end  of  one  of  the  fragments  with  sequestrum 
forceps,  dissect  it  out  of  its  periosteal  bed.  The  other  fragment  is  removed 
in  the  same  fashion. 

Bardenheuer  has  been  compelled  to  excise  even  the  first  rib,  the  clavicle,  and  the  scapula 
before  he  could  obtain  a  satisfactory  result. 

Make  a  large  incision  through  the  thickened  pleura  to  permit  of  thorough 
exploration.  This  exploration  tells  how  many  ribs  must  be  excised  and  to 
what  extent.  Excise  all  the  periosteum,  intercostal  muscles,  and  thickened 
pleura  over  the  empyema  cavity.  There  is  not  liable  to  be  much  hemorrhage 
from  the  intercostal  vessels,  owing  to  their  being  more  or  less  obliterated  by 
the  disease,  but  the  patients  are  usually  debilitated,  the  operation  is  very  severe, 
and  hence  it  is  necessary  to  clamp  and  ligate  all  the  intercostal  vessels.  Hem- 
ostasis  must  be  very  carefully  attended  to.  Some  surgeons  carefully  scrape 
away  all  diseased  granulation  tissue,  but  all  that  is  necessary  is  gentle  wiping 
with  gauze  pads.  Replace  the  flap  of  soft  parts.  This  flap,  at  least  if  the 
disease  has  been  extensive,  will  not  by  any  means  cover  the  defect,  as  its  under 
or  raw  surface  must  be  in  contact  with  the  outer  surface  of  the  retracted  lung. 
Fasten  the  flap  in  position  with  sutures  and  properly  applied  gauze  pads,  so 
as  to  insure  good  contact  between  flap  and  lung.  The  remainder  of  the  cavity 
must  be  filled  with  sterile  (not  iodoform)  gauze  and  may  subsequently  be 
covered  by  Thiersch's  skin-grafts  or  by  flaps  of  skin.  No  poisonous  antiseptics 
should  be  used  during  the  operation,  and  the  use  of  iodoform  gauze  is  forbidden, 
owing  to  the  great  absorbing  power  of  the  tissues  in  question.  Karewski 
finds  vioform  gauze  as  efficacious  as  iodoform,  and  perfectly  safe  as  regards 
poisoning.  Instead  of  replacing  the  reflected  flap,  Cheyne  and  Burchard 
recommend  packing  the  whole  cavity  with  gauze  for  a  time,  to  permit  of  free 
drainage  and  of  the  formation  of  a  layer  of  granulations  on  the  deep  surface  of 
the  flap. 

As  has  been  said,  the  operation  is  very  severe,  and  the  patients  are  always 
debilitated;  hence  is  is  often  wise  to  refrain  from  completing  the  operation 
at  one  sitting,  but  to  proceed  step  by  step,  e.g.,  excising  the  ribs  and  indurated 
pleura  from  over  the  lower  part  of  the  empyema,  and  after  this  procedure 
has  been  recovered  from,  to  advance  higher. 

The  incision  described  is  that  of  Schede,  but  an  infinite  variety  of  cuts  have 
been  advocated;  as  Kiimmel  says,  almost  )^  the  letters  of  the  alphabet  have 
been  imitated  in  forming  incisions. 

Delorme,  Fowler,  Beck,  and  others  believe  that  the  obstruction  to  oblitera- 
tion of  the  empyema  cavity  is  not  so  much  the  rigid  chest-wall  as  the  stiff,  indu- 
rated, shrunken  visceral  pleura  which  imprisons  and  compresses  the  lung. 
These  surgeons  temporarily  resect  the  thoracic  wall,  free  the  lung  from  its  prison 
by  "decortication,"  and  close  the  chest.  Jordan  and  Krause  combine  the 
method  of  decortication  with  Schede's  operation.  Most  surgeons  use  decortica- 
tion as  an  aid  to  incision  of  the  thoracic  wall,  but  discard  the  temporary  resection. 

PHilmonary  Decortication. — George  R.  Fowler  ("Med.  News,"  June  15, 
1901;  "Am.  Year-Book  of  Med.  and  Surg.,"  1902)  performed  this  operation  in 
1893  with  very  gratifying  results.     He  writes:  "An  elliptical-shaped  incision 


308  OPERATIONS    ON    THE    CHEST 

was  made  to  include  the  orifice  of  the  sinus,  the  soft  parts  cleared,  and  about  3}'^ 
inches  each  of  the  fifth  and  sixth  ribs  removed  ....  Commencing  at  the 
site  of  the  opening  in  the  chest-wall,  the  pleura  was  isolated  by  blunt  dissection 
in  the  direction  of  the  diaphragm  until  the  latter  was  reached.  It  was  then 
peeled  off  the  latter  until  its  limit  towards  the  median  line  was  reached,  where 
it  was  found  to  rest  against  the  displaced  pericardium,  from  which,  after  much 
difficulty,  it  was  finally  detached.  This  dissection  was  greatly  impeded  by  the 
movements  of  the  diaphragm  as  well  as  those  of  the  heart.  The  dissection  was 
completed  by  lifting  the  mass  and  finally  detaching  it  from  the  lung  above. 
Considerable  expansion  of  the  lung  followed  at  once,  and  in  the  course  of  twenty- 
eight  days  this  was  so  far  complete  that  the  normal  vesicular  murmur  was  pres- 
ent to  the  level  of  the  seventh  rib.  .  .  .  Save  for  a  slight  sinking-in  of  the 
chest-wall  at  the  site  of  the  resection  of  the  ribs  there  is  nothing  to  suggest  the 
previous  existence  of  an  empyema." 

Fowler  formulates  the  following  conclusions: 

"i.  Decortication  of  the  lung  is  an  operation  adapted  to  all  cases  of  old 
empyema  in  which  extensive  and  preoperatively  discoverable  tuberculous  lesions 
of  the  lungs  are  not  present,  and  in  which  the  patient's  condition  will  permit  of  a 
major  operation. 

"2.  It  may  be  advantageously  substituted  for  Estlander's  operation.   .  .  . 

"3.  It  should  replace  Schede's  operation  in  all  cases. 

"4.  The  method  by  extirpation  of  the  diseased  portion  of  the  pleural  mem- 
brane, including  the  visceral,  cortical,  and  diaphragmatic  portions,  is  the  opera- 
tion of  choice. 

"  5.  Failing  this,  visceral  pleurectomy  should  be  selected. 

"  6.  Pleurotomy,  with  simple  detachment  of  the  visceral  layer  of  the  diseased 
pleural  membrane,  gives  sufficiently  good  results  to  warrant  the  surgeon  in 
resorting  to  this  procedure  in  cases  in  which  the  condition  of  the  patient  will  not 
permit  of  the  application  of  the  other  and  more  desirable  methods. 

"7.  Whatever  operative  method  is  adopted,  as  complete  access  to  the  cavity 
of  the  chest  as  possible  should  be  obtained,  and  rapid  closure  of  the  opening  in 
the  chest-wall  afterwards  secured,  since  the  complete  re-expansion  of  the  lung 
must  depend  largely  upon  the  normal  respiratory  movements. 

"8.  Pulmonary  or  respiratory  exercises  should  not  be  neglected  in  the  after- 
treatment.   ..." 

Delorme  in  1894  performed  an  operation  very  similar  to  that  of  Fowler 
("Amer.  Year-Book  of  Med.  and  Surg.,"  1902),  and  did  it  successfully  under 
spinal  cocainization.  Out  of  twenty-nine  cases  of  decortication  by  the  Fowler 
method  the  functional  results  were  eleven  cured,  six  improved,  nine  unimproved, 
three  died;  as  regards  the  cure  of  the  empyema,  seventeen  were  cured,  nine  un- 
improved, three  died. 

Delorme  has  devised  a  method  of  temporary  resection  of  the  chest-wall,  by 
forming  and  reflecting  a  flap  consisting  of  the  whole  chest-wall;  this  being  done, 
he  decorticates  the  lung,  cleans  the  empyema  cavity,  and  replaces  the  flap  of 
chest-wall,  providing  of  course  for  drainage.  This  operation  has  not  found 
much  favor. 

Roux  in  operating  finds  that  a  long  incision  through  the  indurated  visceral 
pleura  answers  the  same  purpose  as  decortication. 


PULMONARY   DECORTICATION   AND    DISCISSION 


309 


Ransohoff  (Transactions  Am.  Surg.  Assoc,  1914)  makes  use  of  discission, 
i.e.,  a  number  of  criss-cross  incisions  through  the  sclerosed  visceral  pleura  and 
finds  this  thoroughly  satisfactory. 

Lilienthal's  Major  Noncollapsing  Thoracoplasty  (Annals  of  Surg.,  July, 
1919).*  Place  the  patient  on  his  sound  side  over  a  pillow  to  give  a  scoliotic 
posture.     Hips  flexed.     Pillow  between  the  flexed  knees. 

Step  I. — ^In  the  sixth  or  seventh  interspace  make  an  incision  from  the  costal 
angle  to  the  cartilage.  Parts  of  the  latissimus  dorsi  and  serratus  magnus  are 
divided.  If  possible  avoid  the  old  drainage  wound.  Divide  the  intercostal 
structures  in  the  middle  of  the  wound  for  about  two  inches  close  to  the  upper 


Fig.  428. — {Lilienthal). 


border  of  the  lower  rib.  Enlarge  the  intercostal  incision  in  both  directions 
until  large  enough  to  permit  separation  of  the  ribs  by  blunt  traction  and  exposing 
enough  of  the  interior  to  work  safely  and  keep  clear  of  the  lung.  Enlarge  the 
wound  to  the  full  size  of  the  skin  incision.  Separate  the  ribs  slowly  with  a  rib 
retractor.  Usually  a  separation  of  three  inches  is  possible.  In  old  empyema 
cases  the  chest  wall  is  so  fixed  by  fibrous  tissue  that  it  is  necessary  to  divide 
from  one  to  three  ribs  upwards  (occasionally  downwards)  at  the  posterior  end 
of  the  wound.  The  blades  of  the  retractor  can  now  be  separated  6  inches  or 
more  (Fig.  428).  (When  ribs  have  been  divided  it  is  wise  to  cut  away  about  3^2 
or  ^  inches  of  the  anterior  portion  of  each  to  prevent  postoperative  pain  and 
trauma  by  the  grinding  together  of  the  cut  ends.) 

*Anesthesia  — intrapharyngeal  (p.  288). 


3IO  OPERATIONS   ON    THE   CHEST 

Step  2. — Every  pari  of  the  empyema  cavity  lies  exposed.  Incise  the  vis- 
ceral pleura  from  apex  to  base  but  do  not  wound  the  lung.  This  incision  widens 
as  the  lung  expands.  Peel  off  the  visceral  pleura  or  if  this  is  too  difficult  make 
numerous  criss-cross  incisions  through  the  visceral  pleura  (Ransohoff's  discis- 
sion) which  permits  thorough  expansion.  Inspect  the  whole  cavity,  hunting 
for  secondary  pockets.  Treat  with  great  respect  adhesions  of  the  lower  lobe 
to  the  diaphragm  as  the  attenuated  flat  pulmonary  flap  is  often  mistaken  for 
the  diaphragm  or  vice  versa.  As  a  rule  it  is  unnecessary  to  peel  any  part  of 
the  lung  from  the  chest  wall  and  dangerous  because  of  hemorrhage  and  opening 
avenues  for  infection. 

Step  3. — When  it  is  evident  that  no  more  expansion  can  be  secured,  clean  the 
original  drainage  tract  and  pull  a  tube  through  it  from  within  out.  Suture  the 
large  wound  in  three  layers  using  chromicized  catgut  for  the  buried  sutures. 
Do  not  use  pericostal  sutures,  even  although,  as  is  not  uncommon,  it  is  impossi- 
ble to  bring  the  muscles  close  together.  Drainage  from  the  imperfectly  closed 
muscle  wound  takes  place  into  the  thorax  and  thence  out  by  the  tube. 

After  Treatment. — Begin  blowing  exercises  early,  even  within  24  hours. 
After  3  days  treat  the  cavity  by  the  Carrel-Dakin  method  injecting  not  more 
than  one-half  ounce  of  fluid  every  two  hours.  The  usual  time  of  heahng  is 
about  four  weeks  from  the  day  of  operation.  In  a  personal  communication 
Lilienthal  reported  41  cases  with  one  death.  In  two  or  three  cases  not  enough 
time  had  elapsed  to  justify  an  opinion  as  to  permanent  result,  in  all  the  others 
a  cure  was  obtained. 

Roux-Berger  finds  that  secondary  retraction  and  immobilization  of  the 
lung  are  liable  to  occur  after  decortication.  Therefore  after  freeing  the  lung 
thoroughly  by  an  operation  entirely  similar  to  Lilienthal's  he  fixes  the  lung  to 
the  chest  wall  (pneumopexy)  by  strong  and  ample  sutures.  When  this  is  done 
drainage  is  permissible  if  desirable. 

The  after-tjreatment  of  cases  in  which  any  of  the  ordinary  methods  of 
thoracoplasty  has  been  used  is  prolonged ;  often  a  year  or  more  elapses  before  a 
cure  is  obtained,  and  during  this  time  several  subsidiary  and  plastic  operations 
may  be  necessary.  One  would  naturally  expect  that  ultimately  great 
deformity,  especially  scoliosis,  would  be  present,  and  that  the  lung  deprived 
of  its  thoracic  wall  would  be  useless.  This  is,  however,  not  the  case.  Wonder- 
fully little  deformity  persists;  the  lung  expands  and  becomes  a  useful  organ. 
In  many  cases  there  is  very  evident  reformation  of  ribs.  As  Karewski  says, 
we  must  not  be  too  sparing  in  removing  large  portions  of  ribs,  especially  in 
children,  when  this  is  demanded,  as  the  lungs  can  still  expand,  and  thus  thoracic 
deformity  may  be  avoided  or  reduced  to  a  minimum. 

Resection  of  the  thoracic  wall  does  not  per  se  cause  much  deformity.  The 
deformity  depends  on  the  amount  of  intrathoracic  changes.  It  is  not  the  re- 
moval of  the  chest-wall  but  the  shrinking  of  its  contents  which  is  to  blame 
(Th.  Gluck,  Archiv  fur  klin.  Chir.,"  Ixxxiii,  587). 

When  empyema  affects  both  pleural  cavities  the  following  operations  may  be 
performed:  (i)  Double  aspiration;  (2)  incision  on  one  side,  aspiration  on  the 
other;  (3)  incision  on  both  sides;  (4)  resection  and  aspiration;  (5)  resection  and 
incision;   (6)   resection  on  both  sides   (resection  may  include  decortication). 


ARTIFH'IAI.    PNF.UMOTHORAX  31I 

Hellin  ("Berliner  klin.  Woch.,"  1905,  No.  45)  recommends  the  operation  of 
incision  with  drainage  in  double  empyema;  operation  to  be  limited  to  one  side 
at  a  time,  and  aspiration  to  be  done  one  or  two  days  prior  to  the  incision. 
Local  anaesthesia  is  usually  sufficient. 

OPERATIVE  TREATMENT  OF   PHTHISIS   PULMONALIS 

Excision  of  portions  of  the  lung  for  tuberculosis  has  been  of  little  or  no  value. 
The  same  is  true  regarding  the  treatment  of  phthisical  cavities  by  means  of  aspi- 
ration and  of  injections.  When  nature  cures  tuberculosis  she  does  so  by  con- 
verting the  granulation  tissue  into  mature  scar  tissue.  If  a  phthisical  cavity 
becomes  obliterated,  it  is  by  the  contraction  of  scar  tissue,  and  this  contraction 
causes  a  deformity  or  sinking  in  of  the  chest-wall. 

Establishment  of  Artificial  Pneumothorax. — In  pulmonary  tuberculosis  if 
the  visceral  and  parietal  pleurae  are  not  too  much  adherent  the  lung  may  be  col- 
lapsed and  put  at  rest,  temporarily,  by  filling  the  pleural  cavity  with  some  non- 
irritating  gas  which  is  not  too  readily  absorbed.  Carson  in  1840  suggested  the 
treatment  but  his  work  was  forgotten  until  Forlanini  and  Murphy  independently 
adopted  the  same  idea  and  recommended  the  use  of  nitrogen.  Brauer  enthu- 
siastically advocated  the  method.  Nitrogen  displacement  is  of  special  value  in 
early  progressive  lesions,  in  cases  where  there  is  persistent  fever,  where  there  is 
profuse  or  repeated  hemorrhage  and  where  there  is  cavity  formation  in  one  lung. 

The  dangers  incident  to  the  operation  are  (a)  shock.  This  is  most  notice- 
able in  early  cases  and  may  be  lessened  by  the  careful  use  of  local  anaesthesia ; 
(b)  embolism  from  puncture  of  a  vein;  (c)  when  the  disease  is  very  extensive,  a 
comparatively  small  injection  of  gas  may  cause  suffocation  as  the  functional 
capacity  of  the  lung  is  very  small. 

In  cases  where  the  pleura  is  widely  and  strongly  adherent  the  pleural  cavity 
is  so  obliterated  that  the  operation  is  impossible;  in  other  cases,  where  there  are 
localized  adhesions,  introduction  of  gas  may  be  of  great  value  but  it  is  difficult  to 
place  the  point  of  the  needle  in  the  pleural  cavity  and  to  be  sure  that  it  is  there. 
Brauer,  under  local  anaesthesia,  makes  an  incision  down  to  the  pleura  and  inspects 
it.  A  transparent  pleura  with  the  lung  surface  moving  to  and  fro  beneath  it 
exposes  a  field  in  which  it  is  easy  to  complete  the  injection  without  danger  to  the 
lung.  Most  operators  discard  the  exploratory  incision  and  content  themselves 
with  thoracentesis.  It  is  wise  to  keep  the  patient  quietly  in  bed  for  at  least 
twenty-four  hours  and  to  give  a  hypodermic  injection  of  morphine  gr.  3^^  with 
atropine  gr.  H5O)  about  half  an  hour  before  the  operation. 

The  best  site  for  puncturing  the  chest  is  somewhere  in  the  anterior  or  mid- 
axillary  line  in  the  fifth,  sixth,  or  seventh  intercostal  space.  The  patient  is 
usually  placed  in  a  semi-recumbent  position  and  turned  slightly  on  to  the  sound 
side.  Novocaine  is  used  as  the  local  anesthetic  and  special  attention  must 
be  given  to  anesthetizing  the  pleura.  The  proper  use  of  a  local  anesthetic 
is  of  very  great  importance  in  preventing  pleural  reflex  and  shock.  In 
very  nervous  patients  suffering  from  early  unilateral  disease  Woodcock  and 
Clark  (Brit.  Med.  J.,  Dec.  12,  1914)  advise  that,  at  the  first  sitting  ,  after  going 
through  all  the  ritual  of  preparation  nothing  be  done  beyond  injecting  the  local 
anesthetic.     After  four  days  the  process  is  carried  further  and  the  nitrogen 


312  OPERATIONS    ON   THE    CHEST 

needle  is  pushed  in  until  oscillation  of  the  manometre  shows  that  it  is  in  the 
pleural  cavity.     At  the  third  sitting  a  small  amount  of  gas  is  introduced. 

After  the  anesthetic  has  been  injected,  puncture  the  skin  with  a  tenotome 
and  introduce  the  nitrogen  needle.  Floyd's  needle  is  good  (Fig.  429).  The 
puncture  must  be  made  slowly  and  deliberately  until  digital  sense  indicates  that 
the  correct  depth  has  been  reached  when  the  trocar  is  to  be  withdrawn,  the  mid- 
dle cock  closed  and  the  lateral  opening  connected  with  the  manometre  of  Sam- 
uel Robinson's  apparatus  (Fig.  430).  Before  making  this  connection,  isolate  the 
manometre  from  the  nitrogen  circuit.  If  the  needle  is  in  the  pleural  cavity  the 
negative  intrathoracic  pressure  is  indicated  by  the  manometre  and  as  this  pres- 
sure varies  with  the  respiratory  movements  so  also  does  the  manometre  oscil- 
late. "If  the  needle  point  is  partly  obstructed  by  contact  with  the  adhesions  or 
lung  tissue,  this  oscillation  may  not  be  more  than  0.5  cm.  Such  trifling  oscil- 
lation is  also  found  when  the  pleural  space  entered  is  one  of  small  capacity  on 


Fig.  429. — (5.  Robinson.  Art/:.  In:.  J/u/./ 

account  of  neighboring  adhesions;  but  whether  this  oscillation  be  a  complete  or 
restricted  one,  its  presence  is  an  unerring  guide  that  nitrogen  may  then  be  safely 
introduced.  If  the  oscillation  has  been  small,  the  amount  of  nitrogen  injected  is 
correspondingly  low.  A  free  oscillation  of  from  3  to  4  cm.  is  evidence  of  greater 
lung  mobility,  and  the  extent  of  the  pneumothorax  produced  is  correspondingly 
greater"  (Robinson,  Arch.  Int.  Med.,  IX,  467).  The  needle  may  require  con- 
siderable manipulation  or  its  site  of  insertion  may  require  to  be  changed  before 
the  pleural  cavity  is  safely  penetrated.  As  soon  as  it  is  certain  that  the  needle  is 
in  the  pleura,  close  its  connections  with  the  manometre  and  open  those  with  the 
nitrogen  bottle  and  permit  the  nitrogen  to  flow  slowly  into  the  chest.  The 
amount  of  nitrogen  introduced  varies  with  the  case  and  with  the  ideas  of  the 
surgeon.  Forlanini  begins  with  a  very  small  injection,  Robinson  with  a  larger. 
"If  the  nitrogen  flow  under  moderate  pressure  is  apparently  unrestricted,  600 
to  800  or  even  1000  c.c.  may  be  injected  at  the  first  operation"  (Robinson). 
The  feelings  of  the  patient  and  any  symptoms  of  distress,  etc.,  which  he  may 
manifest  must  guide  us  frequently  as  to  the  amount  of  injection.  Several  injec- 
tions at  intervals  of  a  week  or  of  several  weeks  may  be  necessary  before  a  com- 
plete pneumothorax  is  established. 

Morriston  Davies  writes  (Brit.  Med.  J.,  April  25,  1914):  "^ly  experience  is 
that  the  nitrogen  is  absorbed  from  the  pleural  cavity  much  more  quickly  during 


NITROGEN    INJECTIONS 


313 


the  earlier  than  during  the  later  months  of  treatment,  and  it  is  essential  therefore 
that  the  first  few  refills  should  be  done  at  more  frequent  intervals  than  the  sub- 
sequent ones.  During  the  first  six  months  of  the  treatment  1  run  a  fresh  supply 
of  nitrogen  every  six  weeks,  but  after  that  I  allow  an  interval  of  eight  weeks  to 
elapse.  There  is  no  necessity  for  the  patient  to  be  confined  to  bed  at  these  times, 
but  I  make  him  lie  down  for  three  or  four  hours  after  the  injection.  Those  who 
are  at  work  are  allowed  to  return  to  it  the  next  day,  and  suffer  little  or  no  incon- 
venience from  the  increase  in  pressure.     The  amount  of  nitrogen  required  to 


Fig.  430.- — (5.  Robinson,  Arch.  Int.  Med.) 


replace  that  which  has  been  absorbed  varies  from  500  to  1000  c.c.  At  the  end  of 
a  year  I  allow  the  lung  to  re-expand  so  as  to  be  able  to  make  fresh  clinical 
and  radiographical  observations,  but  as  a  rule  it  is  advisable  to  maintain  the  dis- 
placement for  at  least  eighteen  months.  If,  during  the  earlier  period  of  time,  the 
lung  is  allowed  to  expand  and  the  two  pleural  membranes  to  come  into  contact 
with  each  other,  there  is  considerable  risk  that  they  will  become  adherent." 

Figure  430,  showing  Robinson's  apparatus,  illustrates  the  principles  em- 
ployed in  all  forms  of  apparatus.  Two  bottles  of  3500  c.c.  capacity  are  em- 
ployed. One  is  stationary  and  filled  with  water  containing  2  drams  of  pyrogallic 
acid  to  take  up  any  oxygen  which  may  enter  in  conjunction  with  nitrogen. 
Nitrogen  gas  is  then  forced  into  the  stationary  bottle  {A)  displacing  the  water 
back  to  bottle  {B).     At  completion  of  this  displacement  the  apparatus  is  ready 


314  OPERATIOXS    OX    THE    CHEST 

for  use.  On  opening  certain  cocks  the  water  in  bottle  B  replaces  the  nitrogen  in 
bottle  A,  gradually  filling  it.  The  difiference  in  the  water  levels  of  the  two 
bottles  represents  the  pressure  under  which  the  nitrogen  is  injected,  the  rapidity 
of  its  injection  being  regulated  by  the  size  of  the  opening  in  any  one  of  the 
cocks.  When  bottle  B  is  full,  the  maximum  pressure  is  obtained,  amounting 
to  about  14  c.c.  of  water.  As  the  water  levels  approach  one  another  bottle  B 
may  be  raised  as  in  Fig.  430,  thus  maintaining  the  pressure  until  most  of  the 
nitrogen  has  been  displaced,  when  the  pressure  is  necessarily  reduced.  With 
this  hydrostatic  mechanism  the  pressure  may  be  varied  at  will,  never  attain- 
ing the  dangerous  limit.  The  arrangement  of  cocks  d,  e,  and  /  corresponds  to 
the  substitution  of  a  three-way  cock  at  point  g.  In  other  words,  with  cock 
d  closed  and  e  and  /  open,  a  direct  connection  is  established  between  the 
thoracic  cavity  and  the  manometre.  With  cock  /  closed  and  c,  d,  and  e  open, 
connection  is  made  between  the  confined  nitrogen  and  the  manometre,  thus 
recording  the  pressure  represented  by  the  difference  in  water  levels  of  bottles 
A  and  B.  With  cock  e  closed  and  all  others  open  the  nitrogen  passes  directly 
from  bottle  A  into  the  pleural  cavity. 

Numerous  attempts  have  been  made  to  permit  atmospheric  pressure  to 
obliterate  phthisical  cavities  by  the  resection  of  the  bony  chest-wall  directly 
over  the  cavities.  These  attempts  have  failed  because  of  insufficient  sinking 
in  of  the  chest-wall. 

Friedrich  (in  conjunction  with  his  colleague  Brauer),  recognizing  the  danger 
of  pneumothorax,  and  that  adhesions  between  the  lung  and  the  chest-wall  can 
easily  prevent  sufficient  collapse  of  the  lung  when  gases  are  put  into  the  pleura, 
came  to  the  conclusion  that  a  very  free  removal  of  the  rigid  chest-wall  without 
opening  the  pleura  would  be  of  value.  This  procedure  he  has  carried  out  and 
has  named  pneumolysis.  The  cases  in  which  pneumolysis  is  justifiable  must 
present  the  following  conditions:  (a)  The  disease  must  be  mostly  confined  to  one 
lung;  the  opposite  lung  can  rarely  be  intact,  (b)  The  disease  must  be  progressing 
in  spite  of  proper  and  thorough  medical  and  climatic  treatment.  (Friedrich's 
cases  were  sent  from  sanatoriums  where  they  had  been  under  observation  for 
several  months  or  years.)  (c)  The  general  condition  must  be  fair  in  order  to 
withstand  the  severe  operation. 

In  most  of  the  cases  operated  on  by  Friedrich  from  120  to  200  c.c.  of  sputum 
containing  bacilli  was  expectorated  in  24  hours,  and  fever  was  present  up  to  the 
time  of  operation. 

Preparatory  Treatment. — For  three  days  administer  digitalis  hypodermatic- 
ally.  Attend  to  the  bowels  without  weakening  the  patient.  Give  nutritious, 
easily  digested  food.  In  adults  (not  in  the  young)  administer  morphine  an  hour 
before  operation. 

The  Operation. — AnoBsthesia. — In  adults  inject  as  much  as  500  c.c.  or  more  of 
Schleich's  No.  2  solution  but  minus  morphine  and  plus  8  drops  of  adrenalin 
to  the  100  c.c.  The  injection  is  made  along  the  line  of  incision  and  under  the 
flap  to  be  elevated.  Most  of  the  solution  escapes  during  the  operation.  Some- 
times Friedrich  lightly  freezes  the  skin  along  the  line  of  incision  with  a  spray 
of  ethyl  chloride.  After  the  skin  and  muscle  flap  is  reflected  chloroform  is 
administered. 


PNEUMOLYSIS 


315 


In  the  young  (under  sixteen  years)  chloroform  is  used  from  the  beginning  in 
von  Braun's  apparatus.  In  a  case  seen  by  the  author  only  seven  grams  of 
chloroform  sufl'iced. 


Fig.  431. — (Friedrich.) 


Fig.  432.^ — (Friedrich.) 

Lay  the  patient  on  his  sound  side.  Let  an  assistant  hold  the  arm  (well 
protected)  and  be  ready  to  elevate  it  over  the  patient's  head. 

Step  I. — Make  the  huge  U-shaped  incision  shown  in  Figs.  431  and  432. 
It  the  female  the  breast  is  avoided.     (Fig.  433.) 


3l6  OPERATIONS    ON    THE   CHEST 

Step  2. — Reflect  the  flap  outlined.  The  flap  contains  skin,  all  the  muscles 
down  to  the  ribs,  and  the  scapula.  Obtain  free  access  to  every  rib  from  the 
tenth  up  to  and  including  the  second. 

Step  3. — If  local  anaesthesia  has  been  used,  administer  chloroform  now. 

Step  4. — Beginning  at  the  tenth  rib  proceed  as  follows:  (a)  Reflect  the 
periosteum  upwards  and  downwards  from  the  whole  external  surface  of  the 
rib.  {b)  Near  the  middle  of  the  rib  separate  the  periosteum  from  the  lower  edge 
of  the  bone  (for  this  purpose  a  nick  with  a  knife  is  usually  necessary  before 


Fig.  433. — {Friedrich.) 

the  elevator  can  pass  under  the  rib).  With  gauze,  finger  and  elevator  carefully 
separate  the  periosteum  plus  the  intercostal  vessels  from  the  groove  under  the 
rib.  Complete  the  separation  of  the  periosteum  from  the  deep  surface  of  the 
rib,  and  pass  Friedrich's  curved  elevator  completely  around  the  rib.  The 
curved  elevator  being  round  the  rib,  pull  it  (the  elevator)  with  force  back  to  or 
beyond  the  angle  of  the  rib  and  forwards  to  the  junction  of  the  rib  and  costal 
cartilage.  Divide  the  rib  at  its  junction  with  the  cartilage  bj^  means  of  a 
costotome.  Seize  the  end  of  the  rib  and  pull  it  outwards.  Pass  a  finger  along 
the  visceral  side  of  the  rib  to  its  head,  to  protect  the  pleura.  Twist  the  rib 
until  it  comes  away.  (Sometimes  the  head  of  the  rib  is  torn  from  its  connec- 
tions; sometimes  the  neck  of  the  bone  is  fractured.) 


PNEUMOLYSIS  317 

Step  5. — Repeat  Step  4  on  each  rib  until  the  second  is  removed. 

Step  6. — With  gauze  and  sharp  dissection  remove  the  intercostal  muscles 
from  the  pleura.  The  twisting  away  of  the  ribs  obliterates  the  intercostal 
arteries. 

(Duration  of  operation  up  to  end  of  Step  6  was  twenty-five  minutes  in 
the  case  seen  by  the  author.) 

Step  7. — Apply  ligatures.  Replace  the  flap  and  unite  the  divided  muscles 
with  catgut.     Place  a  drain  along  the  deep  wound  corresponding  to  the  heads 


Fig.  434. — {Friedrich.) 

of  the  ribs.  Close  the  skin  wound.  Apply  abundant  dressings.  Opera- 
tion on  the  right  side  is  much  more  dangerous  than  on  the  left  because  of 
cardiac  dislocation. 

After-treatment. — Administer  hypodermatically  i  c.c.  camphor  oil  forty  per 
cent.  (40  per  cent.)  every  hour  by  day  and  every  two  hours  by  night.  Give 
digitalis  freely.  Each  night  inject  i3^  L.  salt  solution  in  the  inguinal  region. 
The  salt  solution  has  a  most  favorable  influence  on  respiration.  Administer 
oxygen  frequently. 

Of  eight  cases  only  two  died  and  these  had  advanced  secondary  lesions 
elsewhere. 

Of  course,  after  recovery,  medical  and  climatic  treatment  must  be  continued. 


3l8  OPERATIONS    OX    THE    CHEST 

Figs.  433  and  434  show  the  extent  of  compensatory  emphj-sema  established 
in  the  sound  lung  and  the  great  displacement  of  the  heart. 

In  a  few  weeks  the  sputum  has  diminished  from  150  or  200  c.c.  to  20  or  even 
5  c.c.  and  the  patients  have  lost  their  fever  and  gained  weight.  The  operation 
is  sub  jiidice  but  seems  to  be  of  considerable  promise. 

Wilms'  Operation. —  (Wilms.  "!Muench.  med.  Woch.,"  191 1,  No.  15;  Kolb, 
"Muench.  med.  Woch.,'"  1911,  No.  47.)  In  cases  of  unilateral  chronic  tuber- 
culosis of  the  upper  lobes  of  the  lung  and  in  total  empyema  Wilms  endeavors  to 
diminish  the  thoracic  cavity  by  resecting  3-4  cm.  of  several  ribs  near  their 
angles,  supplemented  when  necessary  by  resection  of  the  costal  cartilages. 
The  weight  of  the  arm,  among  other  factors,  causes  very  great  lessening  of  the 
upper  thoracic  cavity  after  operation;  the  lower  thorax  is  not  so  well  obliterated, 
hence  in  empyema  it  may  be  necessary  to  excise  completely  some  of  the  lower 
ribs  in  a  secondary  operation. 

Wilms'  operation  like  Friedrich's  aims  at  pneumolysis  and  obHteration  of 
the  pleural  cavity,  while  Freund's  operation  of  chondrotomy  aims  at  restora- 
tion or  improvement  of  thoracic  motion  and  at  an  increased  thoracic  ca\'ity. 

Use  a  local  anesthetic  (Wilms). 

Step  I. — Make  an  incision  parallel  to  the  spine,  over  the  angles  of  the  ribs, 
from  the  first  rib  downwards  as  far  as  may  be  necessary.  Reflect  the  skin  so  as 
to  expose  about  4  cm.  of  the  subjacent  muscles. 

Step  2. — Split  the  fibres  of  the  trapezius  and  rhomboideus  muscles  over  the 
second  rib.  Retract  the  muscle  vigorously  so  as  to  expose  about  4  cm.  of  the 
first,  second,  and  third  ribs.  Excise  subperiosteally  about  3-4  cm.  of  these 
ribs.  In  similar  fashion  split  the  muscles  over  the  fifth  rib  and  through  that 
opening  excise  3-4  cm.  of  the  fourth,  fifth  and  sixth  ribs.  SpUt  the  muscles 
over  the  seventh  rib  and  excise  through  this  opening  portions  from  any  of  the 
lower  ribs  which  prevent  falling  in  of  the  chest- wall. 

Step  3. — Make  an  incision  parallel  to  and  1-2  cm.  from  the  edge  of  the  ster- 
num and  excise  the  whole  of  the  costal  cartilages  of  the  ribs  which  have  been 
divided  posteriorly. 

Step  4. — Apply  dressings  held  in  place  by  adhesive  straps  firmly  applied. 
Have  the  patient  lie  on  the  atfected  side. 

Sauerbruch's  operation  is  very  similar  to  that  of  Wilms'.  The  incision 
is  made  about  3  finger-breadths  external  to  the  vertebral  spines,  its  lower  end 
being  extended  outwards  above  the  tenth  rib.  Through  this  incision  the 
scapula  is  reflected  outwards  and  portions  of  ribs  are  resected  from  the  ninth  and 
tenth  upwards  to  and  including  the  first.  Of  the  lower  ribs,  6  to  10  cm.  of  the 
upper  3  to  6  cm.  should  be  removed.  It  is  necessary  to  resect  the  ribs  in  the 
back  close  to  the  transverse  processes  of  the  corresponding  vertebrae  and  it  is 
important  to  resect  small  portions  of  the  tenth  or  even  of  the  eleventh  rib  since 
only  in  this  way  can  the  diaphragm  be  relaxed  and  also  mobilized  and  the  lung 
deprived  of  its  inspiratory  power  (Henschen,  Trans.  Am.  Surg.  Assoc,  1914). 
Sauerbruch  (Technik  der  Thoraxchirurgie)  has  also  modified  the  Friedrich  opera- 
tion by  operating  in  two  stages.  He  first  resects  the  ribs  from  the  fourth  or 
fifth  to  the  eighth  exactly  as  in  Friedrich's  method.  After  a  few  weeks  he 
resects  the  remaining  upper  ribs  as  follows :     Place  the  patient  on  his  back  with 


LIGATION    PIILMONARY    ARTERY  .S  '  9 

the  shoulders  sHghtly  elevated.  Abduct  and  elevate  the  arm  as  much  as  possible. 
Make  a  skin  incision  from  without  inwards  along  the  clavicle.  Continue  its 
inner  end  downwards  corresponding  to  the  course  of  the  internal  mammary 
artery.  Retlect  the  flap  of  skin  and  pectoralis  outwards  so  as  to  expose  the 
inner  two-thirds  of  the  upper  ribs.  Subperiosteally  resect  the  second  rib  as 
extensively  as  possible — without  injuring  the  pleura.  This  permits  the  apex 
of  the  lung  to  sink  inwards  away  from  the  first  rib.  After  raising  the  periosteum 
carefully  and  slowly,  gnaw  through  the  first  rib  with  a  narrow-bladed  rongeur* 
forceps,  at  the  same  time  pushing  the  subclavian  vein  with  the  finger  out  of 
harm's  way.  After  dividing  of  the  rib  remove  as  much  as  possible  of  its  median 
and  lateral  segments.  Resect  the  third  and  fourth  ribs.  Replace  the  reflected 
flap  and  suture  it. 

Tuffier,  Extrapleural  Implantation  of  Fat.^ — Lipotamponade. — In  cases  of 
apical  tuberculosis  Tuffier  operates  as  follows:  Make  a  free  incision  through  a 
suitable  intercostal  space  down  to  but  not  through  the  parietal  pleura.  By 
blunt  dissection  separate  the  unopened  pleura,  corresponding  to  the  apex,  from 
the  endothoracic  fascia.  Push  the  apex  of  the  lung,  covered  by  the  pleura, 
downwards,  thus  creating  a  large  extrapleural  cavity.  Fill  this  cavity  with  a 
free,  i.e.,  non-pedunculated  mass  of  fat.  Close  the  wound.  Tuffier  has  found 
the  operation  useful  and  Wilms  has  had  similar  results.  Instead  of  fat,  Baer 
has  used  paraffin  for  the  tamponade.  Wilms  thinks  that  in  chronic  phthisis 
with  contraction  the  apical  compression  is  insufficient;  therefore  he  combines 
it  with  his  own  operation  of  rib  resection  in  the  lower  thorax. 

Ligation  of  Branches  of  the  Pulmonary  Artery .^When  one  of  the  principal 
branches  of  the  pulmonary  artery  is  tied  there  results  induration  and  later 
contraction  of  the  territory  supplied,  but  without  pneumonia.  Sauerbruch  has 
taken  advantage  of  this  in  the  treatment  of  bronchiectasis.  To  get  the  full 
benefit  of  this  therapy  it  is  necessary  to  complement  it  by  subsequently  mobiliz- 
ing part  of  the  chest-wall  by  means  of  a  more  or  less  limited  resection  of  ribs. 
The  arterial  branches  going  to  the  left  lower  and  right  upper  lobes  of  the  lungs 
are  specially  suitable  for  ligation  (Schumacher).  To  ligate  the  artery  of  the  left 
lower  lobe,  place  the  patient  on  his  right  side  with  a  pillow  so  placed  as  to  make 
the  left  chest  very  prominent.  Pull  the  left  arm  upwards  and  backwards. 
Make  a  long  incision  in  the  fifth  intercostal  space.  Use  differential  pressure  ap- 
paratus or  intratracheal  insufflation.  Be  specially  careful  in  opening  the  pleura 
because  of  the  probable  presence  of  adhesions.  Separate  the  upper  and  lower 
lobes  of  the  lung  in  the  interlobar  fissure  and  expose  the  pedicle  of  the  lower 
lobe  in  which  there  lie  the  pulmonary  artery  and  vein  and  the  bronchus.  The 
bronchus  lies  between  the  two  vessels  and  the  artery  is  the  most  superficial. 
Do  not  depend  on  pulsation  in  orientation  as  it  is  fallacious.  Once  the  artery 
is  found  pass  a  ligature  round  it  from  the  bronchus  side.  For  one  or  two  days 
after  operation  the  breathing  is  shallow  because  of  the  pain. 

Willy  Meyer  has  experimentally  ligated  the  pulmonary  artery  within  the 
pericardium  so  as  to  avoid  the  difficulties  of  Sauerbruch's  method  when  adhe- 
sions are  present  (Trans.  Am.  Surg.  Assoc,  1913).  Such  operations  are  some- 
times supplemented  with  unilateral  section  of  the  phrenic  nerve  in  the  neck 


320  OPERATIONS    OX   THE   CHEST 

whereb}-  half  the  diaphragm  is  paralyzed  and  pushed  up  into  the  chest  by  the 
intra-abdominal  pressure. 

Exposure  of  the  Phrenic  Nerve  in  the  Neck.^ — Make  an  incision  along  the 
posterior  edge  of  the  lower  two-thirds  of  the  stcrnomastoid  muscle.  Doubly 
ligate  and  divide  the  external  jugular  vein.  Retract  the  stcrnomastoid  for- 
wards. Recognize  the  scalenus  anticus  muscle  as  it  runs  downwards  to  be 
inserted  into  the  scalene  tubercle  on  the  first  rib.  Low  down  in  front  of  this 
muscle  is  the  subclavian  vein;  behind  the  muscle  is  the  subclavian  artery.  The 
phrenic  nerve  runs  from  above  downwards  and  inwards  obliquely  on  the  an- 
terior or  superficial  surface  of  the  scalenus  anticus  and  is  somewhat  overlapped 
by  the  internal  jugular  vein. 

FREUND'S    OPERATION    FOR   ALVEOLAR    PULMONARY    EMPHY- 
SEMA AND   APIC.\L  PHTHISIS 

In  1859  Freund  demonstrated  two  important  conditions  of  the  thorax 
which  were  primar}^  (direct  or  indirect)  causes  of  pulmonary  disease. 

1.  Impeded  development  of  the  first  costal  cartilage  caused  stenosis  of  the 
upper  aperture  of  the  thorax  and  this  symmetrical  or  asymmetrical  stenosis 
influenced  the  structure  and  function  of  the  apex  of  the  lung  so  as  to  render 
it  susceptible  to  tuberculosis.  If  pseudarthrosis  developed  in  this  stenosed  and 
immobile  costal  ring  and  permitted  motion,  then  a  natural  cure  of  the  apical 
tuberculosis  supervened.  For  fifty  years  Freund  urged  operation  to  produce 
such  pseudarthrosis  and  for  fifty  years  his  colleagues  shook  their  heads  to  his 
pleadings. 

2.  Degeneration  of  the  costal  cartilages  causing  their  enlargement  and 
immobility  in  a  position  of  inspiration  (previously  observed  by  Dupuytren) 
caused  a  widening  of  the  lower  thoracic  opening  and  a  flattening  and  atrophy 
of  the  diaphragm. 

The  resulting  permanent  dilatation  of  the  thorax  led  to  permanent  disten- 
tion of  the  lung,  i.e.,  to  alveolar  emphysema. 

Freund  formulated  the  following  indications  for  operation:  When  steno- 
sis of  the  upper  aperture  is  demonstrated  and  there  is  repeated  catarrhal  trouble 
in  the  apex  of  the  lung,  operation  is  proper  as  a  prophylactic  measure;  when 
under  similar  conditions  an  apical  tuberculosis  is  present  but  does  not  extend 
below  the  second  rib,  then  a  curative  operation  is  indicated. 

An  operation  is  indicated  in  the  early  stages  or  in  fully  developed  alveolar 
emphysema  before  the  occurrence  of  secondary  affections  with  atrophy  and 
great  rarefication  of  the  lung  tissue  and  atrophy  of  the  diaphragm,  when  rigid 
dilatation  of  the  chest-wall  is  demonstrable.     ("Archiv  fiir  klin.  Chir.,"  xcii, 

974-) 

Von  Hansemann  ("Archiv  fiir  klin.  Chir.,''  xcii,  993)  considers  Freund's 
operation  very  advisable  in  typical  cases  of  apical  phthisis  where  there  is 
stenosis  of  the  upper  opening  of  the  thorax  and  where  the  disease  does  not 
extend  lower  than  the  second  or  third  rib. 

Mohr  emphasizes  the  fact  that  Freund's  operation,  in  alveolar  emphysema, 
is  directed  not  against  the  pulmonary  dilatation  but  against  the  dilated  and 
rigid  thorax  which  causes  the  emphysema.     Operation  must  be  followed  by 


FREUND  S    OPERATION 


321 


proper  gymnastic  exercises  so  that  the  muscles  used  in  respiration  receive  proper 
education  and  training.  Before  deciding  on  operation  it  is  important  to  study 
the  condition  of  the  heart,  etc.,  lest  relief  of  the  thoracic  rigidity  might  affect 
disastrously  cardiac  compensation.  Mohr's  experience  with  Freund's  opera- 
tion is  considerable  and  he  has  been  much  impressed  with  its  value. 

Freund's  suggestion  has  been  carried  out  successfully  by  O.  Hildebrand, 
Bramann  and  Haasler,  Passler  and  Seidel,  Goodman  and  Wachsmann, 
Friedrich,  etc. 

The  value  of  Freund's  operation  was  substantiated  by  the  reports  of  many 
operators  at  the  German  Surgical  Congress  of  1910. 

The  operation  may  be  done  under  local  or  general  anaesthesia.  Cardiac 
insufficiency,  asthma,  chronic  bronchitis  and  albuminuria  according  to  Friedrich 
are  not  necessarily  contraindications  to  operation. 


Fig.  435. — Freund's  operation. 


The  Operation. 

Step  I. — Make  the  somewhat  curved  incision  A  B  (Fig.  435).  Expose  the 
ribs  and  costal  cartilages  for  i3^  to  2}^  inches  at  their  junction. 

Step  2. — Excise  about  i]4,  to  23^^  inches  of  the  ribs  and  cartilages  at  their 
junction.     This  is  done  to  the  2d,  3d,  4th,  5th,  and  6th  ribs. 

When  the  operation  is  done  for  apical  phthisis  the  first  rib  ought  also  to  be 
removed. 

Carefully  remove  the  periosteum  and  perichondrium  corresponding  to  the 
excised  portion  of  rib.  This  is  done  to  prevent  reformation  of  rib.  Andrews 
obliterates  the  groove  left  by  each  cartilage  with  a  circular  stitch  of  catgut  in 
order  to  prevent  reformation  of  cartilage  from  fragments  of  perichondrium 
which  may  have  escaped  removal.     He  removes  only  segments  of  four  ribs. 

Axhausen  ("Zentralblatt  fiir  Chir.,"  May  14,  1910)  notes  the  difi&culty  of 
excising  the  periosteum  and  perichondrium  left  after  removal  of  the  ribs,  and 
21 


322  OPERATIONS    ON    THE    CHEST 

suggests  overcoming  this  difficulty  by  applying  the  thermocautery  to  the  mem- 
brane instead  of  endeavoring  to  excise  it. 

On  purely  theoretical  grounds  it  seems  to  the  author  that  it  would  be  wise 
to  reflect  a  flap  of  periosteum,  base  outwards,  from  the  anterior  surface  of  the 
ribs,  corresponding  to  the  segment  to  be  removed,  and  after  removal  of  the 
segment  of  rib  to  carefully  cover  the  cut  end  of  the  rib  with  the  periosteal  flap. 

In  one  of  Friedrich's  cases  (local  anaesthesia)  the  patient  drew  attention 
to  the  immediate  relief  obtained  in  his  diaphragmatic  respiration  as  soon  as  a 
rib  was  divided. 

E.  Douay  (These  de  Doctorat.  Paris,  Ref.  Journ.  de  Chir.,  XV,  303,  Sept., 
1 919)  denies  Freund's  theories  regarding  the  causes  of  emphysema.  In  his 
opinion  the  patients  are  suffering  from  a  thoraco-visceral  dyspneic  syndrome 
with  associated  alterations  in  the  thorax,  lungs  and  heart.  If  rigid  dilatation 
of  the  thorax  is  an  element  in  the  respiratory  embarrassment  of  the  emj)hy- 
sematous,  a  much  more  important  factor  is  dilatation  of  the  right  heart  of 
which  the  first  sign  is  dilatation  of  the  right  auricle.  Douay  (supported  by 
Delbet)  considers  operation  proper  (i).  In  emphysema  with  considerable 
dilatation  of  the  thorax  and  diaphragmatic  embarrassment.  (2)  In  emphysema 
with  partial  thoracic  rigidity  due  to  sterno-chondral  ankylosis.  (3)  In  emphy- 
sema with  circulatory  disturbances  and  cyanosis  due  to  dilatation  of  the  heart 
especially  auricular,  whether  thoracic  dilatation  or  rigidity  be  present  or 
absent. 

When  operation  is  performed  for  dilatation  of  the  right  auricle  it  should 
consist  of  excision  of  the  3rd,  4th,  5th  and  occasionally  the  2nd,  and  6th  costal 
cartilages  along  with  their  peri-chondrium. 

Henschen  ("Archiv  fiir  klin.  Chir.,'  xcvi,  Hft.  4)  considers  Freund's  chon- 
drotomy  the  logical  operation  in  cases  of  thoracic  stenosis  where  the  stenosis  is 
due  to  ossification  of  the  first  costal  cartilage  and  explains  the  location  of  apical 
tuberculosis  in  adults.  This  form  of  stenosis  Henschen  calls  "Hart's  anomaly 
of  the  aperture."  It  differs  essentially  from  Freund's  anomaly  where  a  primary 
want  of  development  of  the  cartilage,  or  of  the  rib  itself,  substitutes  an  antero- 
posterior oval  for  the  normal  transverse  oval  of  the  thoracic  aperture,  and  where 
a  flattening  of  the  paravertebral  portions  of  the  rib  causes  subapical  compression 
of  the  lung  with  all  its  ill  effects.  For  this  condition  Henschen  advises  para- 
vertebral decompressive  excision  of  the  first  rib. 

Henschen's  Operation. — Place  the  patient  in  the  semiprone  position  with 
the  healthy  side  undermost.  Put  a  pillow  under  the  upper  chest  in  such  a 
manner  that  the  arm  (of  the  affected  side)  can  be  laid  over  it  and  strongly  pulled 
outwards  and  downwards,  the  pillow  acting  as  a  fulcrum  to  the  arm. 

2.  From  the  dorsal  spine  of  the  sixth  and  seventh  cervical  vertebrae  make  an 
incision  through  the  skin  outwards  to  the  acromial  end  of  the  clavicle.  At  a 
point  on  this  line  3  to  4  finger-breadths  external  to  the  spines  of  the  vertebrae 
make  an  incision  parallel  to  the  vertebra  and  about  3  inches  long.  Part  of  this 
vertical  cut  is  above  and  part  below  the  horizontal  incision.  Reflect  the  skin 
flaps  thus  outlined. 

3.  Split  the  exposed  portion  of  the  trapezius  in  the  line  of  the  horizontal 
wound;  divide  the  rhomboid  and  the  superior  serratus  posticus;  divide  fully 


COSTAL    OSTEITIS  323 

half  of  the  levator  anguli  scapuli.     With  a  retractor  pull  the  upper  angle  of  the 
scapula  strongly  downwards. 

4.  With  the  finger  identify  the  tubercle  of  the  first  rib  and  bluntly  isolate 
a  segment  of  the  rib  for  a  distance  of  about  2-3  cm.  outwards  from  the  tubercle. 
Subperiosteally  resect  this  segment  of  rib.  If  the  second  rib  aids  in  producing 
the  stenosis  excise  part  of  it  also  through  the  same  wound.  Apply  a  thermo- 
cautery to  the  periosteum  to  prevent  reformation  of  bone. 

5.  Attend  to  hemostasis.     Close  the  wound.     Dress'. 

Torek's  Interpleural  Pneumolysis  (Surg.,  Gyn.,  Obst.,  July,  1914,  p.  i). — 
When  injections  of  nitrogen  are  unavailable  because  of  the  presence  of  adhesions, 
Torek  endeavors  to  produce  collapse  of  the  lung  without  the  dangers  of  the 
Friedrich  operation.  He  operates  as  follows:  Anaesthesia  by  intratracheal 
insufllation.  Trendelenburg's  posture  to  prevent  discharges,  possibly  expressed 
from  the  diseased  lung,  gravitating  into  the  healthy  lung. 

Step  I. — Make  a  6-inch  incision  through  the  6th  or  7th  intercostal  space 
at  the  postero-lateral  aspect  of  the  chest.  Attend  to  hemostasis  before  the 
pleura  is  incised. 

Step  2. — Incise  the  parietal  pleura.  Separate  the  ribs  with  retractors. 
Gently  with  the  finger,  and  later  with  the  whole  hand,  separate  the  adhesions 
between  the  visceral  and  parietal  pleurae.  Some  firm  strands  may  require 
cutting.  When  the  separation  is  completed  the  lung  will  collapse  as  much  as 
the  degree  of  its  infiltration  or  consolidation  permits. 

If  any  superficial  pulmonary  cavities  have  been  opened  during  the  opera- 
tion demonstrate  their  openings,  if  necessary,  by  having  the  anesthetist  inflate 
the  lung.  Close  any  such  openings  by  inversion  sutures  after  the  lung  has 
collapsed  again. 

Step  3. — Close  the  pleural  cavity  without  drainage.  Close  the  chest  by 
pericostal  sutures.     Close  the  skin  wound. 

As  the  air  in  the  pleural  cavity  may  become  absorbed  it  may  be  necessary 
subsequently  to  fill  the  cavity  with  nitrogen  gas. 

OPERATIVE  TREATMENT  OF   COSTAL  TUBERCULOUS   OSTEITIS 
AND  OF  THE  RESULTING  ABSCESSES 

The  most  common  and  least  efl&cacious  treatment  of  the  above  affection 
is  incision,  thorough  scraping  with  a  sharp  spoon,  and  iodoformization.  This 
treatment  is  often  insufficient,  and  when  we  remember  that  the  excision  of  a 
segment  of  a  rib  is  easy  and  harmless,  then  we  can  have  little  hesitation  in 
adopting  more  radical  and  effectual  methods. 

Let  it  be  assumed  that  we  have  to  treat  an  unopened  abscess,  not  adher- 
ent to  the  skin,  originating  from  a  tuberculous  focus  in  a  rib.  Cheyne  rec- 
ommends an  operation  on  the  following  lines:  Make  a  vertical  or  oblique 
incision  through  the  skin  over  the  abscess.  The  incision  ought  to  extend 
at  either  end  beyond  the  abscess  itself.  Retract  the  edges  of  the  wound  and 
dissect  back  the  skin  from  over  the  abscess  until  the  whole  swelling  is  freely 
exposed.  Instead  of  the  above,  a  curved  incision  may  be  used  and  a  more 
or  less  U-shaped  flap  of  skin  elevated  to  expose  the  swelling.  If  possible, 
without  rupturing  the  abscess,  dissect  it  free  from  its  surroundings  except  where 


324  OPERATIONS    ON   THE   CHEST 

it  is  attached  to  the  offending  rib.  Expose  the  offending  rib  or  ribs  at  each 
side  of  the  abscess  and  subperiosteally  divide  them  in  such  a  manner  that 
the  whole  mass,  abscess  cavity  and  rib,  is  removed  en  masse,  leaving  the  pos- 
terior layer  of  periosteum  in  situ.  On  the  normal  cadaver  this  operation 
is  difficult  to  do  without  puncturing  the  pleura,  but  in  cases  in  which  it  is  in- 
dicated, although  caution  must  be  exercised  to  avoid  this  accident,  the  accident 
is  unlikely  to  happen,  as  the  disease  has  caused  thickening  of  the  tissues.  After 
removal  of  the  abscess  and  segment  of  rib,  examine  carefully  the  remaining 
periosteum ;  if  it  is  diseased,  curette  and  swab  it  with  liquid  carbolic  acid  (neu- 
tralizing the  acid  by  wiping  with  alcohol)  or  cautiously  excise  the  diseased 
tissue.  Attend  to  hemostasis  and  close  the  wound,  after  having  provided  for 
drainage.  If  it  is  impossible  to  excise  the  abscess  intact,  evacuate  it  either 
by  incision  and  careful  cleansing  or  by  aspiration  or  puncture.  If  aspiration 
or  puncture  has  been  employed,  close  the  puncture  in  the  abscess  wall  with  a 
clamp  or  a  purse-string  suture  before  continuing  the  dissection.  The  same 
principles  of  treatment  must  be  applied  in  cases  of  osseous  disease  with  sinus 
formation. 

When  an  infective  disease,  such  as  tuberculosis  or  typhoid,  attacks  one 
or  more  of  the  costal  cartilages,  repeated  operations  may  be  necessary  before 
recovery  takes  place.  Roux  considered  such  cases  almost  incurable  until 
he  attacked  them  as  follows:  Through  healthy  tissue  make  an  incision  all 
around  the  focus  of  disease.  Divide  the  skin,  muscles,  cartilage,  and,  if  neces- 
sary, the  bone.  When  this  cut  has  become  sclerosed,  proceed  to  excise  the 
disease.  The  wall  of  sclerotic  tissue  provided  by  the  primary  operation  pre- 
vents spread  of  the  disease  in  the  now  resistant  cartilage  ("Rev.  de  Chir.," 
No.,  1904). 

Axhausen  ("Archiv  fiir  klin.  Chir.,"  xcix,  219)  after  removing  the  disease 
covers  the  healthy  stump  of  cartilage  either  with  a  pedunculated  flap  of  muscle 
or  by  inverting  the  skin  wound  over  the  cartilage  and  suturing  the  skin  to  the 
tissues  under  the  cartilage.  The  whole  principle  of  treatment  is  to  leave  no 
dead  space  opposite  the  divided  costal  cartilage.  Experience  shows  that  cover- 
ing the  end  of  the  cartilage  with  flaps  of  perichondrium  does  not  fulfil  the  re- 
quirements. Costal  cartilage  transplanted  to  repair  deformities  in  the  nose 
and  elsewhere,  easily  survives,  but  it  is  always  in  complete  apposition  with  the 
surrounding  tissues,  i.e.,  it  does  not  abut  on  dead  spaces. 

Moschcowitz  (Annals  Surg.,  Aug.,  1918)  urges  removal  of  the  whole  costal 
cartilage  which  is  diseased  so  that  not  even  a  trace  of  exposed  cartilage  is  \asible 
because  cartilage  exposure  in  an  infected  wound  does  not  heal  and  practicaly 
always  forms  a  sinus.  If  the  disease  and  infection  is  slight  the  surgeon  may 
do  less  excision  and  close  the  wound  without  drainage,  especially  without  gauze 
drainage. 

EXCISION  OF  TUMORS   OF  THE  CHEST- WALL  AND   OF  THE 

PLEURA 

Malignant  tumors  of  the  thoracic  wall  are  seldom  attacked  unless — e.g., 
in  the  course  of  an  amputation  of  the  breast — a  tumor  is  accidentally  found 
to  be  attached  to  the  thorax,  a  state  of  affairs  not  known  before  the  operation 


EXCISION   TUMORS  325 

was  begun.  Parham  has  successfully  removed  a  sarcoma  of  the  chest-wall. 
Rixford  ("Annals  of  Surg.,"  1906,  No.  i)  has  removed  several  carcinomata 
affecting  the  chest-wall.  Deruginsky  ("Annals  of  Surg.,"  1906,  No.  5)  re- 
sected a  portion  of  the  chest-wall  and  the  diaphragm  for  primary  sarcoma  of 
the  pleura;  the  patient  survived  long  enough  to  die  from  recurrence.  Osteo- 
mata  of  the  ribs  ought,  other  things  being  favorable,  always  to  be  removed, 
because  of  the  disastrous  effects  of  their  growth.  The  technique  of  the  operation 
is  very  similar  to  that  for  the  removal  of  tuberculous  foci,  and  is  along  the  fol- 
lowing lines: 

1.  Make  an  incision  all  around  the  tumor,  preserving  as  much  skin  as  possi- 
ble without  cutting  too  near  the  disease. 

2.  Free  the  tumor  from  its  surroundings,  sacrificing  all  muscular  tissue 
attached  to  it. 

3.  Subperiosteally  divide  all  the  ribs  to  which  the  tumor  is  adherent. 

4.  Note  if  the  pleura  is  adherent  to  the  tumor;  if  it  is,  then  excise  the  ad- 
herent portions  along  with  the  tumor.  Endeavor  to  avoid  the  sudden  entrance 
of  air  into  the  pleura.  Let  the  primary  opening  into  the  pleura  be  small,  so 
that  the  air  enters  slowly;  with  a  moist  pad  of  gauze  close  the  opening  at  inter- 
vals so  that  the  conditions  of  internal  and  external  pressure  may  have  time  to 
adjust  themselves.  As  the  pleural  wound  is  enlarged,  progressively  pack 
gauze  (sterile)  into  the  pleural  cavity.  Many  French  surgeons  advise  wide 
opening  of  the  pleura  at  once.  The  gauze  packs  shut  off  the  rest  of  the  cavity 
from  the  field  of  operation.  Before  the  pleura  is  opened,  warn  the  anesthetist 
to  let  the  patient  come  out  of  deep  anaesthesia.  Coughing  on  the  part  of  the 
patient  is  now  desirable,  as  the  violent  distention  of  the  lung  helps  to  guard 
against  dangerous  pneumothorax.  When  the  packing  of  gauze  has  been 
thoroughly  done,  violent  disturbances  of  respiration  do  not  continue  long. 
After  the  tumor  has  been  removed,  the  gauze  must  be  withdrawn  and  the  lung, 
which  is  generally  "coughed  into"  the  wound,  is  caught  and  fixed  to  the  thorax 
with  a  few  stitches.  The  pneumopexy  is  of  special  importance  when  part  of  the 
lung  demands  removal. 

When  a  segment  of  lung  is  affected  by  the  tumor,  it,  of  course,  is  adher- 
ent to  it,  and  thus  it  is  easy  to  apply  sutures  all  around  the  diseased  area. 
Dollinger  advises  that  pneumothorax  be  slowly  produced  the  day  prior  to 
operation.  Delageniere,  after  taking  similar  precautions,  has  operated  for 
two  hours  in  the  open  thorax  without  ill  effect.  The  safety  of  slowly  produced 
pneumothorax  is  evidenced  by  J.  B.  Murphy's  work  on  phthisis  pulmonaUs. 
One  of  the  many  methods  of  operating  under  differential  pressure  may  be 
adopted  with  good  effect.  After  removal  of  all  the  disease,  even  perhaps  of 
part  of  the  diaphragm,  close  the  wound  with  sutures,  providing  efl&cient  drainage. 

If  so  much  skin  has  been  removed  that  complete  closure  is  impossible, 
and  if  there  has  been  no  suturing  of  the  lung  to  the  thoracic  wall  (pneumo- 
pexy), part  at  least  of  the  gauze  packing  must  be  left  in  place  until  adhesions 
form.  In  every  case  the  dressings  must  be  hberal,  air-tight,  and  left  undisturbed 
as  long  as  possible.  Emmet  Rixford  recommends  closure  of  the  wound,  under 
the  above  circumstances,  by  means  of  a  flap  taken  from  the  abdomen  or  from 
the  chest-wall  of  the  opposite  side.     The  lung  soon  expands,  and  air  left  in  the 


326  OPERATIONS    ON    THE    CHEST 

pleura  rapidly  disappears.  (The  preceding  description  of  excision  of  tumors  is 
largely  taken  from  Karevvski's  admirable  clinical  lectures.)  Ri.xford's  paper  on 
** Excision  of  Portions  of  the  Chest-wall  for  Malignant  Tumors"  ("Annals  of 
Surgery,"  Jan.,  1906)  substantiates  in  almost  every  particular  the  advice  given 
above. 

Pneumotomy. — Incision  of  the  lung  may  be  demanded  for  the  removal  of 
foreign  bodies  (see  p.  292)  or  to  provide  for  drainage  in  cases  of  pulmonary 
gangrene,  abscess  (whether  tuberculous  or  j)yogenic  in  origin),  and  large  bron- 
chiectatic  cavities;  also  for  the  treatment  of  echinococcic  cysts. 

Operation  is  clearly  indicated  when  the  gangrenous  area  or  the  abscess 
is  limited  in  extent,  not  multiple  and  is  fairly  accessible.  It  is  usually  con- 
sidered improper  to  operate  when  the  aflfected  lung  is  widely  diseased — e.g., 
when  there  are  large  bronchiectatic  cavities  requiring  drainage  in  both  upper 
and  lower  lobes — but  Th.  Gluck's  experience  shows  that  such  may  properly 
be  attacked.  The  mortality  of  pulmonary  gangrene  treated  non-surgically 
is  80  per  cent.;  treated  surgically,  29  per  cent.  (McArthur). 

G.  Picot  considers  the  mortality  more  than  75  per  cent,  without  operation. 
When  operation  is  performed  early,  some  statistics  show  a  mortality  of  but  17 
per  cent.,  but  operation  should  only  be  undertaken  where  there  is  a  single,  cir- 
cumscribed focus,  and  the  patient  has  good  resisting  power.  Picot  considers 
"radiography  preceded  by  radioscopy"  to  be  the  most  valuable  method  of 
diagnosis,  as  exploratory  puncture  is  fallacious  and  dangerous,  while  ordinary 
clinical  tests  have  led  to  innumerable  errors  in  localization. 

The  abscess  is  carefully  localized  by  the  usual  methods  of  physical  diagno- 
sis. During  the  first  week  of  the  existence  of  gangrene  the  X-ray  will  show 
a  shadow,  but  after  this  time  putrefaction  leads  to  cavity  formation  and  the 
rays  show  a  light  area.  After  cleaning  the  skin  over  the  site  of  the  lesion  it 
is  commonly  advised  to  explore  in  the  following  manner:  The  long  and 
delicate  needle  of  an  exploring  syringe  is  pushed  in  the  direction  in  which 
the  pus  is  believed  to  exist.  The  needle  ought  to  be  attached  to  the  syringe 
by  means  of  rubber  tubing  which  has  been  divided  and  reunited  by  the  in- 
terposition of  a  small  glass  bulb  or  tube.  When  the  point  of  the  needle  has 
penetrated  the  lung  to  the  suspected  area,  slight  suction  is  made  with  the 
syringe.  If  any  pus  is  present,  it  will  be  noticed  in  the  glass  placed  in  the 
tubing.  If  no  pus  is  found,  make  the  needle  penetrate  more  deeply  and  repeat 
the  suction.  After  every  change  in  the  position  of  the  needle  make  the  suction 
test  with  the  syringe.  When  the  piston  of  the  syringe  has  been  pulled  out  to  its 
full  extent,  clamp  the  rubber  tube,  detach  the  syringe,  push  the  piston  down, 
attach  the  syringe  to  the  tube,  remove  the  clamp,  and  proceed  as  before.  It 
may  be  necessary  to  push  the  needle  in  various  directions  before  the  pus  is  found. 
Having  found  the  abscess  by  the  above  means,  leavie  the  needle  in  situ  and  pro- 
ceed to  expose  the  abscess. 

Most  experienced  surgeons  are  afraid  of  infecting  the  pleura  if  they  use 
the  exploring  needle  in  the  above  manner.  Expose  the  aflfected  area  by  sub- 
periosteally  removing  a  segment  of  one  or  more  ribs,  palpate  the  uninjured 
pleura,  noting  if  motion  and  friction  are  absent  and  if  it  is  grayish-yellow 
in  color  or  infiltrated   (signs  of  adhesions).     McArthur  advises  that  a  fine 


PNEUMOTOMY  327 

exploring  needle  be  inserted  for  i  cm.  (%  inch)  or  less;  if  no  adhesions  are 
present  the  moving  lung  will  cause  the  needle  to  rock;  if  adhesions  are  present 
the  lung  cannot  slide  on  the  parietal  pleura,  hence  the  needle  will  not  rock. 
Note  that  this  needle  is  not  being  used  to  explore  for  pus,  but  for  adhesions. 
In  the  absence  of  adhesions  it  is  advised  never  to  use  the  needle  to  hunt  for  pus, 
because  of  the  danger  of  infecting  the  pleura.  If  adhesions  are  present  and 
palpation  shows  that  sohd — i.e.,  diseased — lung  is  opposite  the  wound,  either 
search  for  the  pus  with  an  aspirating  needle  (if  pus  is  found  leave  the  needle 
in  situ  until  a  free  opening  is  made  into  the  abscess)  or  at  once  penetrate  the 
diseased  area  with  a  closed  sinus  forceps  or  with  a  Paquelin  cautery  heated  to  a 
dull  red  color.  When  the  Paquelin  cautery  enters  the  cavity  not  only  will  pus 
flow,  but  smoke  will  be  inhaled  and  exhaled.  The  principal  advantage  gained 
from  the  use  of  the  cautery  is  that  the  walls  of  the  channel  made  by  it  are  sealed 
against  absorption  of  the  pus  coming  from  the  opened  abscess.  When  the 
cavity  has  been  penetrated,  pass  in  the  finger,  explore  and  open  secondary 
cavities,  gently  remove  with  the  finger  and  gauze  loose  sloughs  and  debris.  Do 
not  break  down  any  bands  felt  traversing  the  cavity,  such  may  be  blood-vessels. 
Do  not  douche  the  cavity;  douching  is  well  calculated  to  spread  infection  to  other 
parts  of  the  lung  or  to  drown  the  patient.  Do  not  use  peroxide  of  hydrogen, 
the  explosive  frothing  of  this  drug  has  all  the  evils  of  the  douche.  Intro- 
duce a  loose  gauze  pack.  If  iodoform  is  used  in  the  gauze  let  it  be  in  feeble 
quantity,  as  it  is  liable  to  be  rapidly  absorbed  and  cause  poisoning.  Instead 
of  gauze  a  split  rubber  tube — preferably  covered  with  gauze — may  be  used. 
The  tube  unless  soft  or  protected  may  cause  pressure,  necrosis  and  hemor- 
rhage.    A  roll  of  rubber  dam  is  probably  the  best  drain. 

If  when  the  pleura  is  exposed  the  adhesions  do  not  appear  so  strong  as 
to  be  above  suspicion,  reinforce  them  by  a  few  catgut  stitches  uniting  the  pa- 
rietal and  visceral  pleura  around  the  operative  area.  A  patient  of  L.  L.  Mc- 
Arthur  seemed  to  be  progressing  favorably  when  he  began  to  cough  severely, 
ruptured  the  pleural  adhesions,  infected  the  healthy  pleura  and  died  from  the 
infection.  It  is  a  good  plan  to  expose  the  pleura  (excising  the  necessary  seg- 
ments of  rib  and  also  of  intercostal  muscles)  under  local  anaesthesia.  If  the 
pleura  is  not  adherent,  the  patient  can  easily  force  his  lung  into  contact  with 
the  parietal  pleura  where  it  can  readily  be  fixed  by  a  few  catgut  sutures.  A 
layer  of  gauze  is  now  laid  into  the  wound  and  the  skin  wound  closed.  After 
a  few  days  the  wound  is  reopened,  the  gauze  removed  and  the  pus  sought. 

Adhesions  being  present,  "how  shall  we  look  for  the  disease  area  in  the 
lung  if  it  is  not  immediately  before  us?  Circumscribed  gangrene  in  the  lung  is 
always  surrounded  by  a  zone  of  infiltrated  inflammatory  tissue — nature's  bar- 
rier to  the  progress  of  the  disease — so  with  the  knife  and  finger  we  will  explore 
any  indurated  area  that  may  be  present.  If  this  fails  to  reveal  the  disease  we 
will  use  the  exploring  or  aspirating  needle,  and,  by  passing  it  in  various  directions 
in  the  lung,  judge  from  the  feeling  imparted  to  the  fingers  the  character  of  the 
tissue  the  point  is  traversing,  and  also  from  the  discharges  the  needle  may  bring 
away.  If  this  gives  us  negative  results  it  is  best  to  discontinue  any  further 
search,  and  complete  the  operation  by  leaving  a  drainage-tube  in  the  incision 
in  the  lung.     All  hope  of  evacuating  the  septic  material  need  not  yet  be  aban- 


328  OPERATIONS    ON   THE   CHEST 

doned,  for  several  cases  have  been  reported  where  the  pus  has  found  its  way 
to  the  drainage-tube  within  a  few  days,  and  the  patient  has  ultimately  made  a 
good  recovery." 

If,  after  subperiosteal  resection  of  the  ribs,  the  pleura  is  found  to  be  non- 
adherent, adhesions  must  be  provided,  otherwise  as  soon  as  the  pleural  cavity 
is  opened  a  dangerous  condition  of  pneumothorax  obtains.  The  formation 
of  adhesions  may  be  stimulated  by  the  application  of  irritants,  such  as  chlo- 
ride of  zinc,  to  the  outer  surface  of  the  unopened  parietal  pleura.  This  is 
rather  a  blind  method  of  reaching  the  goal.  Most  surgeons  proceed  some- 
what as  follows:  A  fully  curved  needle,  armed  with  a  thick  silk  or  catgut 
suture,  is  passed  through  the  unopened  pleura,  made  to  pick  up  as  large  a 
bite  of  the  lung  and  visceral  pleura  as  is  possible,  and  brought  out  again  through 
the  parietal  pleura.  Much  gentleness  must  be  exercised  in  tying  the  sutures  as 
the  pulmonary  tissue  is  friable.  From  two  to  four  sutures  will  generally  be 
found  ample  to  secure  apposition  of  the  two  pleural  layers.  The  parietal 
pleura  is  weak,  therefore  the  sutures  should  catch  other  tissues  as  well.  The 
sutures  may  be  made  to  penetrate  a  large  gauze  pad  (four  thicknesses)  laid  on 
the  outside  of  the  chest,  with  an  opening  in  the  centre  to  permit  of  subsequent 
operation.  The  subsequent  steps  of  the  operation  should  be  carried  out,  in  the 
manner  already  described,  after  the  lapse  of  a  week. 

Should  the  case  be  one  of  such  urgency  as  to  warrant  incurring  the  extra 
risk,  one  must  surround  the  diseased  area  by  a  row  of  interrupted  "back- 
stitch" or  interlocking  sutures  of  catgut,  uniting  the  parietes  to  the  visceral 
pleura  and  lung.  Do  not  take  too  deep  a  "bite"  of  lung  with  the  needle. 
If  pleural  suturing  is,  from  any  cause,  impossible,  pack  the  pleural  cavity 
as  it  is  opened  with  gauze,  as  in  the  case  of  appendicitis;  a  smaller  amount  of 
gauze  may  suffice  if  the  gauze  packing  is  sutured  with  catgut  into  the  pleural 
opening.  It  has  been  claimed  that  aseptic  silk  sutures  applied  to  the  non- 
infected  pleura  do  not  produce  enough  irritation  to  ensure  the  formation  of 
effective  adhesions.  Silk  sutures  soaked  in  turpentine  have  been  employed 
and  found  to  be  satisfactory. 

After  the  pus  has  been  evacuated,  provision  must  be  made  for  drainage. 
This  is  best  done  by  leaving  the  wound  wide  open  and  packing  with  sterile 
gauze  (iodoform  gauze  is  liable  to  lead  to  poisoning).  Rubber  tubes  may  be 
used  if  surrounded  by  gauze.  Tubes  unprotected  by  gauze  occasionally  cause 
erosion  of  blood-vessels.  Rubber  dam  is  safe  and  efficient.  When  there  is 
much  loss  of  lung  substance  and  there  is  not  sufficient  compensatory  distention 
of  the  remainder  to  fill  the  resulting  void  in  the  thorax,  the  treatment  must  be 
similar  to  that  of  old  empyema,  viz.,  resection  of  an  appropriate  amount  of 
thoracic  wall.  Lung  wounds  heal  slowly  and  form  but  few  granulations. 
Epidermization  progresses  from  the  skin  alone;  any  growth  of  epithelium  from 
divided  bronchi  leads  to  persistent  fistulae  being  formed.  As  soon  as  retraction 
or  dragging  inwards  of  the  external  soft  parts  ceases  to  progress  satisfactorily, 
recovery  may  be  hastened  by  the  use  of  skin-flaps  obtained  in  the  neighborhood. 
If  bronchial  fistulae  persist,  th^  may  be  closed  by  the  application  of  the  cautery. 
It  must  be  remembered,  however,  that  a  persistent  bronchial  fistula  may  be, 


PNEUMECTOMY  329 

in  reality,  beneficial  in  that,  it  gives  vent  to  discharges  which  would  otherwise 
be  retained  and  cause  serious  trouble. 

In  j)ulmonary  hydatids  C.  E.  Corlette  places  the  patient  in  the  semi-prone 
position  (see  p.  302)  and  excises  about  10  cm.  of  two  ribs  including  the  perios- 
teum. After  incising  the  adherent  pleura  and  exposing  the  adventitious  cap- 
sule of  the  hydatid  he  anchors  the  latter  by  stay  sutures  and  opens  it.  (In  the 
lung  the  cysts  are  simple,  i.e.,  have  no  daughter  cysts.)  After  evacuating  the 
contents  and  mopping  the  cavity  dry,  he  closes  the  opening  in  the  pleura  and 
capsule  with  sutures  and  closes  the  wound  without  drainage. 

Pneumectomy. — Th.  Gluck,  as  early  as  1882,  elaborated  the  following 
method  of  excising  one  lung  or  part  thereof.  After  opening  the  thorax  by  the 
removal  of  a  segment  from  one  or  more  ribs,  grasp  the  lung  with  a  clamp  and  pull 
a  cone  of  it  through  the  opening  in  the  thorax.  Apply  a  ligature  behind  the 
clamp,  pull  more  of  the  lung  through  the  wound  and  apply  another  clamp. 
Repeat  this  process  of  pulling  the  lung  outwards  with  a  clamp  and  ligating  until 
the  desired  amount  of  lung  is  herniated  or  until  the  pulmonary  root  is  reached. 
Cut  away  the  lung  distal  to  the  last  ligature,  leaving  about  one  inch  of  lung  tis- 
sue protruding  from  the  ligature.  Suture  the  cut  surface  of  the  stump  with 
interlocking  stitches  of  catgut. 

Gluck  ("Archiv  fiir  klin.  Chir.,"  Ixxxiii,  592)  reports  the  following  two  cases 
on  which  he  operated  using  the  clamp  and  ligature  method. 

R.  P.,  thirteen  years,  March  3,  1899.  Multiple,  fetid  bronchiectasis  of  left 
lung.  Resection  of  the  sixth  to  tenth  ribs.  Resection  of  the  upper  lobe  and 
total  pneumectomy  of  the  lower  lobe  of  the  left  lung.  Before  operation  an 
enormous  amount  of  gangrenous  material  was  discharged  each  day,  after  opera- 
tion the  discharge  was  not  worth  noticing  and  had  no  bad  smell.  The  patient 
felt  well,  ran  about  and  played  with  other  children.  In  October,  1899,  the 
thoracic  wound  was  not  completely  healed;  an  operation  was  undertaken  to 
close  the  wound  and  the  patient  died  from  unexpected  collapse  and  heart  failure 
(Herztod).  Autopsy  showed  chronic  interstitial  and  parenchymatous  myo- 
carditis. The  bronchiectatic  process  had  been  completely  removed  and  the 
limg  wound  had  healed.  Heidenhain  has  resected  the  lower  lobe  (left)  of  a 
lung — the  seat  of  bronchiectatic  cavities — with  success. 

Gliick's  second  case  is  most  important.  The  patient  suffered  in  1896  from 
lymphangitis  migrans  and  thrombo-phlebitis  of  the  left  and  subsequently  of  the 
right  lower  extremities.  In  May,  1897,  there  were  left-sided  pulmonary  in- 
farcts; the  left  pleura  was  twice  punctured  and  large  amounts  of  exudates 
removed.  Recovery  in  July,  1897.  In  April,  1899,  septic  phlegmon  extensor 
aspect  of  right  forearm,  which  was  nearly  healed  in  July,  when  there  was  a  chill 
with  41.5°  (Fh.  106.7)  of  fever.  Pyemia  developed  requiring  radical  opera- 
tion for  right  axillary  abscess  and  phlegmon  of  chest- wall  (twice);  evacuation 
abscess  on  sternum;  transverse  drainage,  right  ankle-joint;  operation,  left 
pleural  empyema  (twice).  In  spite  of  extensive  resection  of  ribs  and  evacua- 
tion of  pus  from  the  pleura  elastic  fibres  were  found  in  the  putrid  discharges. 
January  3,  1900,  there  were  bloody  sputum,  dyspnoea  and  extreme  weakness. 
The  thorax  was  opened  widely,  the  enormously  thickened  and  degenerated 
pleura  was  resected  and  the  whole  lower  lobe  of  the  left  lung  was  removed  with 


33'=>  OPERATIONS   ON   THE   CHEST 

the  aid  of  clamps  and  ligatures.  During  the  after-treatment  the  patient  could 
breathe  freely  and  comfortably  through  the  wound  when  his  mouth  and  nose 
were  closed.  Healing  was  completed  in  nine  months.  Nine  years  after  opera- 
tion the  scar  is  on  a  level  with  the  skin;  and  in  spite  of  the  extensive  resection  of 
ribs  there  is  neither  deformity  of  the  thorax  nor  spine.  The  diaphragm  has 
pushed  upwards  and  the  upper  lobe  of  the  lung  is  vicariously  expanded. 
In  pneumectomy  closure  of  the  divided  bronchi  is  always  a  difBculty.  Willy 
Meyer  has  overcome  this  difficulty  by  separating  the  peribronchial  vessels  from 
the  bronchi  and  ligating  them,  then  by  crushing  the  stiff  bronchi  with  an  angio- 
tribe  he  is  able  to  treat  it  by  ligature  and  inversion  sutures  like  the  stump  in 
appendectomy. 

Extrapleural  Resection  of  Lung  fTuffier,  International  Congress,  London, 
1913). — Suitable  in  cases  of  apical  tuberculosis.  • 

Open  the  thorax  widely  in  the  second  intercostal  space  but  do  not  incise 
the  pleura.     Separate  the  2nd  and  3rd  ribs  with  suitable  retractors  or  spreaders. 

With  the  finger  gently  separate  the  parietal  pleura  from  the  chest  wall  until 
the  whole  apex  of  the  lung  plus  the  corresponding  parietal  pleura,  is  freed. 

Ligate  the  lung  beyond  the  disease  and  cut  away  the  affected  apex.  Let 
the  stump  drop  back  into  the  thorax.     Close  the  chest  without  drainage. 

EXPOSURE   OF  THE  PERICARDIUM  AND   OF  THE  HEART 

Operations  on  the  Orifices  of  the  Heart. — The  investigations  of  Carrel  and 
his  disciples  have  achieved  so  much  that  no  great  boldness  is  required  to  proph- 
esy that  the  surgeon  will,  before  long,  aid  in  the  therapeutics  of  certain  lesions 
of  the  cardiac  orifices.  The  following  paragraphs  are  based  on  the  publications 
of  Carrel  and'Tufl&er  (Annals  Surg.,  July,  1914;  La  Presse  Med.  4,  March,  1914). 
The  lesions  which  ought  to  be  susceptible  to  surgical  aid  are: 

1.  Mitral  stenoses.  In  these  the  free  borders  of  the  valves  are  alone  affected, 
the  valves  themselves,  the  cardiac  muscle  and  the  peripheral  circulation  remain- 
ing for  a  long  time  in  good  condition. 

2.  Aortic  stenoses  may  occupy  three  positions,  viz.,  valvular,  supra-aortic 
and  infra-aortic;  of  these  only  the  valvular  are  likely  to  be  amenable  to  surgical 
intervention.  Valvular  lesions  are  characterized  by  adhesions,  thickenings  and 
deformations  of  the  borders  of  the  valves,  forming  a  simple  indurated  ring. 
Exceptionally  the  lesion  affects  the  fibrous  circle  at  the  base  of  the  valves. 

3.  Stenoses  of  the  pulmonary  artery  are  similar  to  those  of  the  aorta,  but  the 
artery  itself  is  dilated  above  the  stenosis,  this  being  due  to  a  loss  of  elasticity  in  its 
walls. 

4.  Congenital  tricuspid  stenoses  show  similar  characteristics  and  are  pecu- 
liarly suited  to  operative  treatment  because  of  the  integrity  of  the  heart. 

Although  an  orificial  lesion  is  anatomically  suitable  for  operation,  and 
although  the  cardiac  muscle  and  vessels  are  sufficiently  healthy  to  give  hope  of 
success,  yet  operation  is  not  justifiable  unless  the  disease  by  its  persistence  and 
progressiveness  inevitably  will  early  give  rise  to  grave  or  mortal  troubles.  Such 
indications  for  operative  treatment  are  rare. 

A  pure  mitral  stenosis  in  a  young  subject  with  a  healthy  heart,  in  which  the 
trouble  is  progressive  as  shown  by  functional  symptoms,  and  which  will  cer- 


OPERATIONS    ON   HEART  33 1 

tainly  be  fatal,  is  a  proper  case  for  operation.  Some  slowly  advancing  aortic 
stenoses  with  hypertrophy  of  the  left  ventricle  may  also  be  considered  mechani- 
cal lesions  susceptible  of  treatment  by  enlargement  of  the  orifice. 

Stenoses  of  the  pulmonary  artery  when  isolated  and  independent  of  any  other 
cardiac  malformation  are  almost  always  soon  fatal  from  pulmonary  tuberculosis. 
It  is  not  likely  that  lesions  causing  insufficiency  of  the  cardiac  orifices  will  be 
suitable  for  operation. 

Special  Dangers  in  Cardiac  Operations. — (o)  Injury  to  the  coronary  vessels. 

The  coronary  vein  may  be  tied  with  impunity  but  not  near  its  main  trunk. 

Injuries  to  the  peripheral  parts  of  the  coronary  arteries  are  well  borne. 
Near  the  origin  of  the  arteries  even  a  prick  with  the  finest  needle  gives  rise  to 
serious  symptoms.  Ligation  of  the  artery  proximal  to  its  bifurcation  is  always 
promptly  fatal. 

{h)  The  only  bleeding  which  is  difficult  to  arrest  is  that  from  the  left  auricle. 
This  is  due  to  the  thinness  and  friability  of  its  walls. 

(c)  The  entry  of  air  into  the  right  ventricle  with  consequent  pulmonary 
"air  embolism"  is  not  of  the  gravest  moment,  but  its  entry  into  the  left  ventri- 
cle leads  to  fatal  embolism  in  the  coronary  arteries.  Air  in  the  heart  is  removed 
by  aspiration.  ' 

{d)  The  danger  zones  of  the  heart  are: 

1.  The  coronary  vessels  between  their  origin  and  their  first  divisions  must 
not  be  touched. 

2.  The  inter-auricular  septum  is  so  sensitive  that  the  least  injury  to  it  causes 
arrest  of  the  heart  in  diastole. 

3.  Section  of  the  auriculo-ventricular  septum  causes  immediate  arrest  of  the 
left  ventricle  in  diastole.  In  the  auriculo-ventricular  region  near  the  left  border 
of  the  heart  there  is  a  sort  of  vital  node,  injury  to  which  is  dangerous  or  mortal, 
even  a  slight  pressure  here  excites  an  extrasystole. 

4.  At  the  junction  of  the  middle  and  upper  thirds  of  the  anterior  longitudinal 
groove  there  is  a  point  at  which  mechanical  irritation  can  cause  sudden  arrest  of 
the  heart. 

5.  The  motor  stimulus  of  the  heart  originates  at  the  base  of  the  right  auricle 
near  the  venous  orifices.     This  is  a  very  dangerous  zone. 

For  cardiac  operations,  anaesthesia  is  produced  with  ether  given  by  the 
Meltzer-Auer  method.  The  thoracic  cavity  is  opened,  the  operative  field  is 
walled  off  with  "oil  silk  and  cotton  knotted  compresses,"  the  pericardium  is 
opened  and  the  heart  exposed.  A  Doyen  forceps  (jaws  protected  by  rubber 
tubing)  is  used  to  compress  the  pedicle  of  the  heart.  The  heart  is  not  dislocated 
but  the  pericardial  wound  must  be  large  enough  to  give  free  access.  One  blade 
of  the  clamp  is  introduced  into  the  pericardium  under  the  pedicle  and  directed 
from  the  right  to  the  left  side  by  the  finger.  At  this  moment  (without  any 
compression)  over-ventilate  the  blood  by  the  Meltzer-Auer  method  and  then 
rapidly  close  the  clamp  and  without  a  moment's  delay  proceed  with  the 
operation.  The  pedicle  may  be  clamped  for  two  and  a  half  (2^)  or  three  (3) 
minutes  with  safety. 

Exposure  of  the  Aortic  and  Pulmonary  Orifices. — For  the  pulmonary  orifice 
make  the  incision  on  the  left  side  of  the  artery  at  the  junction  of  the  anterior  and 


332  OPERATIONS    ON    THE    CHEST 

left  sigmoid  valves.  The  incision  is  made  by  means  of  scissors  of  unequal 
blades,  the  longer  blade  being  pointed.  With  this  the  vessel  is  punctured  before 
the  cut  is  made.  Exposure  may  be  efifected  by  a  cut  in  the  artery  alone;  usually 
in  experiments  the  incision  was  about  4  cm.  long,  half  of  which  was  on  the  pul- 
monary artery  and  half  on  the  ventricle.  Here  the  branches  of  the  coronary 
artery  are  small  and  can  be  cut  without  danger. 

For  the  aortic  valves  make  the  incision  on  the  right  side  of  the  aorta  be- 
tween the  mouths  of  the  right  and  left  coronary  arteries,  generally  directly 
above  the  middle  of  the  right  valve. 

When  the  operation  has  been  completed,  suture  the  wound  with  a  continu- 
ous suture  of  No.  i  Chinese  silk  sterilized  in  vaseline.  Introduce  through  the 
line  of  suture  a  curved  cannula  connected  with  an  aspirator  and  suck  out  the 
air  from  the  heart.     Remove  the  pedicle  clamp. 

What  operations  may  be  performed  on  the  valves?  Carrel  has  cauterized 
the  valves  and  has  dilated  the  orifices  with  the  finger.  TuflSer  performed  this 
operation  on  a  patient  with  amelioration  of  symptoms.  Sir  Lauder  Brunton, 
Harvey  Cushing  and  others  have  divided  valves  by  special  long  delicate  teno- 
tome-like  instruments  introduced  at  a  distance.  Tuffier  remarks:  "if  one 
divides  the  valvular  diaphragm  without  resecting  a  portion  of  it,  it  is  necessary 
to  fix  one  of  the  lateral  valves  to  the  ventricular  wall  with  a  silk  suture  in  order 
to  prevent  coalescence  and  secondary  reunion  of  their  borders."  Such  opera- 
tions may  be  named  internal  valvulotomy.  External  valvulotomy  with  patch- 
ing of  the  vessel  is  being  done  very  successfully  in  animals  without  clamping  the 
pedicle  of  the  heart. 

Carrel  thus  describes  the  operation:  "A  piece  of  vena  cava  or  of  any  other 
vein,  preserved  in  cold  storage,  was  cut  into  the  shape  of  a  rectangular  flap  about 
2.5  by  2  cm.  This  flap  was  put  on  the  anterior  part  of  the  pulmonary  artery 
in  such  a  way  that  its  middle  corresponded  about  to  the  pulmonary  orifice,  the 
lower  part  being  on  the  surface  of  the  ventricular  wall.  Then  the  two  lateral 
sides  and  the  upper  side  were  fixed  to  the  surface  of  the  heart  and  the  pulmonary 
artery  by  means  of  a  continuous  suture.  The  longer  blade  of  the  scissors  was 
introduced  underneath  the  lower  side  of  the  flap  and  the  sharp  point  was  intro- 
duced into  the  lumen  of  the  pulmonary  orifice.  Then  the  wall  was  cut  and  dark 
blood  escaped  between  the  surface  of  the  heart  and  the  lower  part  of  the  flap, 
but  the  hemorrhage  was  immediately  controlled  by  the  index-finger  of  the  opera- 
tor which  compressed  the  flap  down  on  the  wound.  The  fourth  side  of  the  flap 
was  next  fixed  to  the  surface  of  the  heart  by  a  continuous  suture.  The  flap 
immediately  appeared  distended  by  dark  blood,  and  it  was  assumed  that  in  case 
of  stenosis  of  the  pulmonary  orifice  this  operation  would  permit  of  a  dilatation  of 
that  orifice.  The  operation  was  performed  without  stopping  the  circulation 
of  the  heart.  The  operation  would  be  rendered  easier  by  clamping  the  pedicle 
of  the  heart  for  a  very  short  time.  Although  this  is  a  more  dangerous  procedure, 
it  is  probable  that  it  would  simplify  the  operation."  In  their  experiments  on 
dogs  Carrel  and  Tuffier  opened  the  thorax  by  an  incision  from  the  sternum 
(internal  mammary  vessels  ligated  and  divided)  to  the  posterior  part  of  the 
axilla,  in  the  second  or  third  intercostal  space.  The  second  space  was  chosen 
when  access  to  the  great  vessels  was  desired. 


OPERATIONS    ON   HEART  333 

It  is  not  necessary  to  resect  any  ribs.  The  pleura  is  incised  and  the  ribs 
separated  by  a  mechanical  self-retaining  retractor.  Once  pneumothorax  is 
established  respiration  by  means  of  the  Meltzer-Auer  apparatus  is  easy.  The 
pleura  is  protected  by  compresses  of  fine  vaselinized  silk. 

H.  M.  W.  Gray  (Birkbeck  and  Lorimer,  Brit.  Med.  J.,  Oct.,  1915)  has 
removed  a  bullet  from  the  cavity  of  the  right  ventricle.  The  patient  died 
four  days  after  operation  from  multiple  pulmonary  infarction.  The  operation 
was  performed  under  morphine  and  local  anaesthesia  (eucaine  i  per  cent.;  potas- 
sium sulph.  3-^  per  cent.;  adrenalin).  The  pericardium  was  widely  exposed  by 
reflecting  a  large  flap  of  sternum  and  costal  cartilages.  The  right  pleura  was 
opened  and  the  lung  collapsed  causing  respiratory  trouble  and  anxiety  for 
about  one  minute.  The  pericardium  was  freely  opened.  During  palpation 
of  the  heart  a  beat  was  missed  occasionally  when  the  upper  and  back  part 
of  the  interventricular  septum  was  touched.  The  heart  was  held  forwards  by 
a  stitch  passed  through  the  muscle  of  the  right  ventricle.  Palpation  showing  the 
bullet  to  be  loose  in  the  ventricle  it  was  coaxed  away  from  the  neighborhood 
of  the  coronary  vessels  and  grasped  between  the  finger  and  thumb.  Two 
stitches  were  inserted  into  the  muscle  wall  over  the  bullet,  a  half  inch  incision 
made  and  the  bullet  extracted.  The  sutures  were  tied  and  an  extra  running 
stitch  applied.  The  pericardial  cavity  was  freed  of  blood  clot,  filled  with 
saline  solution  to  expel  air,  and  sutured.  The  right  pleural  cavity  was  filled 
with  saline  solution  and  the  pleural  wound  sutured.  While  the  wound  was 
being  closed  the  chest  was  aspirated. 

Scalene  (Ref.  Internat.  Abstract  of  Surg.,  June,  191 9,  471). — As  a  result  of 
experiments  comes  to  the  following  conclusions: 

"A  projectile  remaining  in  any  part  of  the  heart  affects  its  functioning  even 
if  the  patient  does  not  feel  any  disturbance. 

"Extraction  does  not  in  all  cases  lead  to  recovery  from  the  disturbances, 
especially  when  anatomic  alterations  have  taken  place. 

"From  the  operative  point  of  view  it  is  necessary  to  distinguish  projectiles 
embedded  in  the  myocardium  from  those  free  in  the  heart  cavities.  Projectiles 
in  the  myocardium  which  do  not  cause  disturbances  ought  to  be  left  alone. 
Operation  might  increase  the  anatomic  alterations  due  to  the  projectile,  the 
result  being  a  diffuse  myocarditis,  a  lesion  of  the  nerves  or  the  production  of 
adhesions. 

"Extraction  is  indicated  in  the  case  of  projectiles  in  the  myocardium  which 
cause  disturbances  not  referable  to  anatomic  alterations  but  to  severe  nerve 
lesions  not  otherwise  susceptible  to  treatment. 

"In  view  of  the  danger  of  embolus,  extraction  is  indicated  in  the  case  of 
projectiles  free  in  the  circulatory  system. 

"In  every  case  the  advantages  of  a  cardiotomy  ought  to  be  carefully  weighed 
against  the  dangers  and  results  to  be  derived  from  non-intervention." 

Statistics  of  16  cases  of  projectiles  in  the  heart  wall  treated  surgically  give 
14  recoveries  and  2  deaths  while  23  cases  in  which  no  operation  was  performed 
all  recovered.  In  spite  of  these  figures  Duval  considers  that  the  ultimate  dan- 
gers arising  from  the  presence  of  a  projectile  in  the  wall  of  the  heart  justifies  its 
removal  (Soc.  de  Chir.,  Paris,  1919). 


334  OPERATIONS    ON   THE   CHEST 

Pericardiocentesis. — This  operation  is  indicated  both  as  a  means  of  diag- 
nosis and  of  treatment.  For  diagnostic  purposes  we  may  use  an  exploring 
or  hypodermic  syringe  provided  with  a  long  needle;  for  purposes  of  treatment 
an  aspirator  is  required.  When  the  pericardial  effusion  is  non-infective,  a  cure 
may  be  obtained  by  simple  paracentesis.  In  performing  this  operation,  the 
fluid  must  be  withdrawn  slowly  and  the  suction  stopped,  temporarily,  whenever 
there  is  any  pulmonary  or  cardiac  distress.  It  is  unnecessary  and  imprudent 
completely  to  evacuate  the  fluid.  The  usual  site  for  introducing  the  aspirat- 
ing needle  is  in  the  fourth  or  fifth  intercostal  space,  one  inch  to  the  left  of  the 
sternum.  A  better  position  is  in  the  sixth  intercostal  space  immediately  to 
the  left  of  the  edge  of  the  sternum.  This  last  position  gives  the  greatest  se- 
curity against  injury  to  the  internal  mammary  artery,  to  the  pleura,  and  to 
the  heart  itself. 

G.  Blechman  (Internat.  Abstracts,  July,  1914)  disapproves  of  the  above 
methods  as  being  likely  to  puncture  the  heart  or  pleura.  He  recommends  Mar- 
fan's  method.  Introduce  a  lumbar  puncture  needle  in  the  middle  line  immedi- 
ately below  the  xiphoid  cartilage.  Pass  the  needle  obliquely  from  below  upward 
for  2  cm.  along  the  posterior  surface  of  the  sternum,  then  somewhat  obliquely 
backwards  passing  into  the  gap  in  the  sternal  insertion  of  the  diaphragm  so  as  to 
penetrate  the  pericardium  at  its  base.  Blechman  used  this  method  successfully 
seventeen  times  on  one  patient. 

In  cases  of  pericarditis  with  effusion,  even  suppurative,  Weil  and  Loiseleur 
(La  Pr.  Med.,  Dec.  28,  1916)  recommend  aspiration  of  the  fluid  and  injection, 
of  air  equal  in  amount  to  the  volume  of  fluid  withdrawn.  Repeated  aspirations 
and  injections  may  be  necessary,  and  may  be  aided  in  their  execution  by  the  use 
of  the  fluoroscope  to  detect  isolated  pockets  of  effusion.  When  producing 
pleural  pneumothorax,  one  can  well  introduce  the  air  at  the  same  time  that 
any  present  effusion  is  being  aspirated  but  in  producing  pericardial  pneumo- 
thorax one  is  compelled  to  aspirate  first  and  then  pump  the  air  in.  Weil  and 
Loiseleur  write  "one  injects  ordinary  atmospheric  air  without  any  special  fil- 
tration After  having  removed  the  liquid  with  Potain's  aspirator,  one  re- 
verses the  stop-cock  on  the  pump  and  so  can  inject  air.  ...  To  measure 
the  quantity  of  air  being  injected  one  counts  the  number  of  strokes  of  the  piston. 
(The  capacity  of  the  pump  is  about  30  c.c.)" 

When  there  is  an  infective  exudate  in  the  pericardium,  operation  is  clearly 
indicated.  The.  same  is  true  in  all  cases  of  wounds  in  the  cardiac  region  when 
there  is  marked  respiratory  distress  with  cyanosis  or  there  is  collapse  with 
anaemia  and  corresponding  changes  in  the  pulse,  accompanied  by  the  physical 
signs  of  pericardiac  effusion  (Kocher). 

Many  methods  have  been  devised  by  which  to  expose  the  pericardium  and 
heart:  of  these.  Ware  gives  an  excellent  account  in  the  "Annals  of  Surgery" 
(October,  1899),  but  almost  all  of  them,  e.g.,  those  of  Po^rez,  Niuni,  etc., 
assume  that  one  desires  to  expose  the  whole  pericardial  sac  in  every  case  and 
that  a  lesser  procedure  will  never  be  efl5cient.  Such  operations  consist  in  the 
formation  and  reflection  of  large  flaps  consisting  of  the  skin,  muscles,  costal 
cartilages,  and  sternum.  They  require  much  technical  skill  for  their  perform- 
ance.    Wounds  of  the  pericardium  and  heart  call  for  immediate  attention,  and 


PERICARDIOTOMY  335 

no  extremely  difficult  and  unnecessarily  complicated  method  should  be 
taught. 

Pericardiotomy.  Method  A. — (i)  Make  an  incision  down  to  the  bone  from 
the  middle  line  of  the  sternum  outwards  towards  the  left  side,  at  the  level  and 
following  the  line  of  the  sixth  costal  cartilage.  If  required,  the  incision  may 
extend  to  the  left  mammary  line.  (2)  Separate  the  perichondrium  and  all  the 
soft  parts  from  the  sixth  costal  cartilage  and  excise  the  cartilage.  This  exposes 
the  triangular  muscle  of  the  sternum  with  the  mammary  vessels,  which  are 
ligated  if  necessary.  Divide  the  tendinous  insertion  of  the  triangular  muscle 
into  the  sternum.  The  dense,  glistening  pericardium  now  lies  exposed,  and  if 
drainage  alone  is  required,  it  may  be  opened  and  the  operation  is  complete.  If 
more  room  is  required:  (3)  From  the  sternal  end  of  the  horizontal  incision  cut 
upwards  in  the  midsternal  line  to  the  desired  extent  (usually  to  the  level  of 
the  second  rib).  (4)  Separate  the  periosteum  and  soft  structures  from  the 
sternum  to  the  left  of  the  median  line.  Divide  the  fifth,  fourth,  and  third  left 
costal  cartilages  at  their  insertions  into  the  sternum.  (5)  Through  the  hori- 
zontal wound  push  the  exposed  margin  of  pleura  outwards.  Gradually  lift  up 
the  fifth  and  even  the  fourth  and  third  costal  cartilages,  slowly  and  gently  push- 
ing back  the  pleura  from  their  deep  surface.  (6)  After  separating  the  flap  from 
the  pleura,  fracture  or  divide  the  costal  cartilages  in  the  flap,  at  their  junction 
with  the  corresponding  ribs.  When  this  is  done,  the  flap  can  be  completely 
reflected.  (7)  Split  the  pericardium  along  the  sternal  margin  and  laterally 
along  the  fifth  interspace.  This  gives  access  to  the  heart  from  the  auricles  to 
the  apex  of  the  ventricles.  If  more  room  is  desired  (8)  excise  a  sufficient  por- 
tion of  the  sternum  by  means  of  ronguer  or  bone  forceps. 

The  pericardium  being  open,  wipe  away  blood-clots  which  may  be  present; 
search  for  and  suture  with  catgut  or  silk  any  cardiac  wounds.  Do  not  include 
in  the  suture  a  coronary  artery.  Close  the  pericardial  wound  with  or  without 
drainage.  Suture  or  drain  any  pleural  wounds  which  may  be  present.  Don't 
waste  time  by  trying  to  evacuate  thoroughly  blood  from  the  pleural  cavity; 
nature  may  generally  be  relied  upon  to  attend  to  that  better  than  can  the 
surgeon. 

Method  B.  Median  Thoraco-abdominal  Pericardiotomy . — Duval  and  Barasto 
(La  Pr.  Med.,  Aug.  29,  1919). 

^tep  I. — ^Make  a  median  incision  from  the  level  of  the  third  rib  to  a  point 
midway  between  the  ensiform  cartilage  and  the  umbilicus.  The  incision  pene- 
trates to  the  bone  and  to,  but  not  through  the  peritoneum,  in  the  linea  alba. 

Step  2. — With  a  knife  detach  the  recti-muscles  from  the  ensiform.  Divide 
the  attachments  of  the  diaphragm  to  the  posterior  surface  of  the  ensiform  ex- 
actly in  the  middle  line.  Push  two  fingers  upwards  behind  the  ensiform  keeping 
them  in  contact  with  the  posterior  surface  of  the  bone  until  the  level  of  the 
third  rib  is  reached.  This  separates  the  pericardium  from  the  sternum.  When 
pulling  the  fingers  out  separate  them  slightly  so  as  to  push  the  two  pleurae  from 
the  sternum  and  costal  cartilages. 

Step  3. — Divide  the  sternum  along  the  middle  line  with  strong  bone  forceps 
up  to  the  level  of  the  third  rib.  Opposite  the  third  rib  divide  the  sternum 
transversely.     Separate  the  two  parts  of  the  sternum  with  strong  hooks. 


336  OPERATIONS    ON   THE    CHEST 

Step  4. — Open  the  peritoneum  in  the  middle  Une.  Open  the  pericardium 
immediately  above  the  diaphragm  and  a  little  to  the  left  (the  pleurae  arc  well 
separated  here). 

Step.  5. — Note  the  diaphragm  forming  a  partition  between  the  peritoneum 
and  pericardium.  Divide  this  partition  up  to  the  coronar>'  ligament.  While 
doing  this  gently  support  the  inferior  border  of  the  heart.  With  the  hooks 
lift  up  the  two  segments  of  the  sternum.  This  is  like  opening  a  book  and  the 
ventricles,  auricles,  large  vessels  and  the  anterior  and  posterior  surfaces  of  the 
heart  are  widely  exposed  without  delivery  of  this  organ,  without  traction  or 
torsion  and  the  two  hands  of  the  operator  are  free  to  carry  out  any  necessary 
maneuvres  on  the  heart  under  guidance  of  the  eye. 

Step  6. — Suture  the  diaphragm  from  the  abdominal  side.  Close  the  ab- 
domen. Replace  the  sternal  flaps  unthout  bone  suture.  Suture  the  skin.  This 
operation  has  been  used  in  the  successful  extraction  of  a  bullet  from  the  peri- 
cardial segment  of  the  inferior  vena  cava.  Barbier  and  Goujon  (Ref.  Internat. 
Abst.  of  Surg.,  June,  191 9)  successfully  extracted  a  projectile  from  the  posterior 
wall  of  the  heart  midway  between  apex  and  base  by  the  thoraco-abdominal 
route. 

TuUy  Vaughan  ("Journ.  A.  M.  A.,"  Feb.  6,  1909)  has  collected  statistics 
of  150  patients  operated  on  for  wounds  of  the  heart  and  comes  to  the  following 
conclusions: 

"i.  There  is  no  longer  any  question  as  to  the  propriety  of  the  operation, 
since  35  per  cent,  of  the  patients  recover,  compared  with  15  per  cent,  (according 
to  Holmes  and  Fisher,  1881)  of  recoveries  after  non-operative  treatment — a 
gain  of  20  per  cent. 

"  2.  The  mortality  is  practically  the  same  that  it  was  twelve  years  ago,  when 
the  operation  was  first  introduced,  and  it  behooves  the  surgeon  to  study  the 
matter  and  find  a  means  of  improvement. 

"3.  The  two  great  causes  of  death  are  hemorrhage  and  inflammation  of  the 
pleura  or  pericardium.  Probably  little  more  can  be  done  than  has  been  done 
to  prevent  death  from  hemorrhage,  but  inasmuch  as  more  than  half  the  pa- 
tients who  survive  twenty  hours  have  infection. 

"4.  There  is  room  for  great  improvement  in  preventing  infection.  Besides 
the  observance  of  strict  asepsis  the  question  of  opening  the  pleura  and  of  drain- 
age of  pleura  or  pericardium  acting  as  predisposing  cause  of  infection  is  of  "the 
greatest  importance. 

"5.  As  a  rule,  therefore,  the  pericardium  and  pleura  should  not  be  drained." 
The  principles  of  operation  on  pericardiac  and  cardiac  wounds  may  be 
summarized  as  follows:  (i)  Cleanse.  (2)  Enlarge  the  external  wound.  (3) 
Freely  expose  the  injured  pericardium  by  excision  of  portions  of  the  ribs  and 
sternum  or  by  the  median  thoraco-abdominal  route.  (4)  Attend  to 
hemostasis.  (5)  Open  the  pericardium  and  remove  effused  blood.  (6)  Attend 
to  cardiac  wounds  if  present.  (7)  Close  the  wounds  in  pericardium  and  in 
pleura  if  such  be  ptesent.  (8)  Close  external  wound  with  or  preferably  without 
drainage. 

In  suppurative  pericarditis  Mintz's  operation  seems  very  practical  and  not 
difl5cult  ("Zent.  fur  Chir.,"  No.  30,  1912).     Make  an  incision  along  the  lower 


CARDIOLYSIS  337 

edge  of  the  seventh  costal  cartilage.  Separate  the  lower  edge  of  the  cartilage 
from  its  connections  but  do  not  open  the  peritoneum.  With  a  periosteal 
elevator  separate  the  cartilage  from  its  posterior  connections.  Divide  the 
cartilage  near  the  sternum  and  also  at  a  suitable  point  externally.  The  anterior 
surface  of  the  cartilage  is  not  denuded.  Reflect  upwards  the  flap  thus  formed 
and  so  expose  the  pericardium.  Blechman  recommends  Larrey's  method  of 
left  subchondral  incision  as  giving  easy  access  to  the  pericardium  through  the 
epigastrium  especially  in  children.  This  operation  seems  practically  the  same 
as  Mintz's. 

Cardiolysis  or  Pericardiolysis. — When  the  heart  becomes  adherent  firmly 
to  its  pericardial  pouch,  and  that  in  turn  to  the  sternum,  etc.,  a  distressing  and 
very  fatal  series  of  conditions  arise.  In  such  cases  the  heart  fails,  because  with 
every  systole  it  must  needs  pull  in  along  with  it  the  osseous  thoracic  wall.  No 
heart  can  long  stand  the  strain  of  such  excessive  overwork.  Two  methods  of 
operative  treatment  have  been  advised. 

Delorme's  Operation.— (A)  The  operation  is  particularly  indicated  (a)  when 
there  are  adhesions  of  rheumatic  origin  with  dilatation,  hypertrophy  and  ori- 
ficial  lesions  and  a  fortiori  without  such  lesions,  (b)  When  there  are  tuber- 
culous adhesions  specially  as  localized  lesions,  analogous  to  those  of  the  other 
serous  cavities,  joints,  etc.  (Delorme). 

The  Operation. — Expose  the  pericardium  by  excising  the  fifth  or  sixth  costal 
cartilage  from  the  sternal  insertion  outwards  for  from  6  to  8  cm.  If  the  adhe- 
sions correspond  to  the  origin  of  the  great  vessels,  excise  like  portions  of  the 
fourth  and  third  cartilages.  So  far  the  operation  is  exploratory.  If  the  ad- 
hesions are  solid,  extensive  but  separable,  reflect  a  flap  of  thoracic  wall  corre- 
sponding to  the  fourth,  fifth,  and  sixth  cartilages  and  having  its  base  external. 
Great  care  is  required  to  avoid  opening  the  pleura.  The  parietal  pericardium 
having  been  exposed  incise  it  through  the  whole  length  exposed.  Separate  the 
adhesions  with  the  fingers  or  blunt  pointed  scissors.  Do  any  cutting  necessary 
at  the  expense  of  the  pericardium  and  under  guidance  of  the  eye.  Leave  in- 
accessible and  very  resistant  adhesions  alone.  If  the  adhesions  are  too  intimate 
for  separation  be  content  with  section  of  the  pericardium  along  its  anterior 
diaphragmatic  attachments  from  the  left  sternal  border  to  the  apex  of  the 
heart  avoiding  in'ury  to  the  left  phrenic  nerve. 

(B)  Pericardiolysis. — Petersen  and  Simon  have  successfully  (three  cases) 
carried  out  an  operation  suggested  by  L.  Brauer.  The  object  of  the  operation 
is  not  to  free  the  heart  from  the  adhesions,  but  to  render  these  harmless.  It  is 
unnecessary  to  describe  the  steps  of  the  procedure,  which  consist  in  the  reflec- 
tion of  a  flap  of  skin  and  muscle,  the  exposure  of  those  ribs  and  that  part  of  the 
sternum  which  impede,  by  their  rigidity,  the  heart's  action,  and  the  excision  of 
these  bony  or  cartilaginous  structures  to  any  extent  required.  It  is  advised  to 
excise  the  periosteum  of  the  posterior  surface  of  the  sternum,  lest  new  bone  be 
formed.  This  is  the  most  difiicult  step  in  the  operation.  Very  careful  hemo- 
stasis  is  essential,  because,  when  operated  on,  the  patient  is  usually  very  weak, 
but  his  circulation  soon  regains  strength,  and  hence  hemorrhage  and  the  forma- 
tion of  a  hematoma  may  supervene.     Petersen  advises  that  we  should  begin 

22 


$$S  OPERATIONS    ON   THE   CHEST 

the  operation  by  excising  three  ribs,  and  then,  if  necessary,  remove  a  portion  of 
the  sternum  also. 

P.  Lecene  ("Archives  des  mal.  du  Coeur,  des  Vaisseaux  et  du  Sang.," 
Dec,  1909;  "La  Presse  Med.,"  April  23,  1910)  has  collected  twenty  cases 
of  pericardiolysis  performed  by  various  German  and  English  surgeons  where 
there  was  no  operative  mortality  and  the  results  were  notable  and  durable. 
After  operation  the  heart  became  regular,  dyspnoea  ceased  and  the  various 
forms  of  visceral  stasis  gradually  became  less,  suffering  disappeared  and  a 
relatively  active  life  became  possible. 

Alexander  Morison  ("Lancet,"  July  4,  1908  and  Nov.  20,  1909)  advised 
thoracostomy  (pericardiolysis)  in  a  case  of  excessive  cardiac  hypertrophy  in 
aortic  valvular  disease  associated  with  severe  and  frequent  attacks  of  pain  but 
with  >io  costo-pericardial  adhesions.  Mr.  Stabb  operated  for  Morison  and  the 
results  was  most  satisfactory.  The  reasoning  of  Morison  in  his  paper  is  most 
convincing.     (See  Douay's  remarks,  p.  322.) 

Milton's  Method  of  Exposing  the  Anterior  Mediastinum  (H.  Milton, 
Lancet,  ]March  27,  1897). — Make  a  median  incision  from  the  cricoid  to  the 
ensiform.  Expose  the  trachea.  Carefully  divide  all  the  attachments  to  the 
sternal  notch — while  doing  this  make  the  knife  absolutely  hug  the  bone.  If 
necessary  nick  the  sternal  attachments  of  the  sternomastoids.  Pass  the 
finger  gently  behind  the  sternum  from  above  downwards  as  far  as  possible. 
Either  beginning  at  the  sternal  notch  or  at  a  trephine  opening  made  through 
the  body  of  the  sternum  near  the  ensiform  cartilage  split  the  sternum  vertically 
with  chisel  or  saw  or  both.  Separate  the  ensiform  from  the  body  of  the  sternum. 
With  strong  sharp  hooks  separate  the  two  halves  of  the  sternum  for  about  i 
cm.  This  space  permits  the  division,  under  guidance  of  the  eye,  of  obstruc- 
tions to  a  further  separation  of  5  or  6  cm.  This  permits  free  exploration  of 
the  anterior  mediastinum  and  through  it  of  the  other  mediastina.  The  bone 
wound  is  easily  closed  by  wires  passed  through  holes  bored  in  the  bone. 

Lilienthal  (Surg.,  Gyn.  &  Obst.)  successfully  removed  a  mediastinal  thyroid 
by  Milton's  method. 

In  performing  Milton's  operation  it  is  not  always  necessary  or  proper  to 
divide  the  whole  of  the  sternum;  division  of  the  manubrium  is  often  sufficient. 

Milton's  method  will  prove  of  service  in  operations  upon  the  thymus. 
Kocher  exposes  the  upper  mediastinum  by  reflecting  outwards  a  trap  door 
flap  consisting  of  skin  and  manubrium  sterni. 

Exposure  of  cervico-mediastinal  space  may  be  necessary  in  the  treatment 
of  lesions  of  the  lower  neck  behind  the  clavicle  or  of  the  upper  anterior  medias- 
tinum. Such  lesions  include  aneurisms  of  the  great  vessels  arising  from  the 
arch  of  the  aorta. 

Le  Fort's  Method.  Anatomy. — The  clavicle  articulates  with  the  sternum 
and  first  rib.  The  sterno-hyoid  and  sternothyroid  muscles  are  inserted  into 
the  posterior  surface  of  the  clavicle,  sternum,  costo-clavicular  ligament,  cartilage 
of  the  first  and  even  of  the  second  rib.  Thus  there  is  a  thick  buttress  of  muscle 
and  aponeurosis  between  the  bones  and  the  vessels,  nerves  and  pleurae. 

The  Operation. — Place  patient  in  the  dorsal  decubitus  with  a  long  pillow 
between  the  scapulae  to  make  the  shoulders  fall  backwards. 


MEDIASTINUM  339 

Step  I. — From  the  level  of  the  first  intercostal  space  make  an  incision 
10-12  cm.  (4-4/^  in.)  long,  upwards  in  the  median  line.  This  incision  pene- 
trates to  the  bone  where  it  is  over  the  sternum,  and  through  the  skin  higher  up. 
From  the  lower  end  of  the  vertical  incision  make  a  cut  outwards  along  the 
middle  of  the  first  intercostal  space  until  the  deltoid  is  reached.  Split  the 
pectoralis  major  and  expose  the  intercostal  muscles. 

Step  2. — Expose  the  anterior  surface  of  the  sterno-mastoid.  With  finger 
or  closed  scissors  separate  the  posterior  surface  of  tjie  sterno-mastoid  from  the 
anterior  surface  of  the  sterno-hyoid  and  sterno-thyroid,  thus  exposing  the  in- 
sertion of  these  latter  muscles  into  the  posterior  surface  of  the  sternum  and 
sterno-costo-clavicular  articulation.  Hugging  the  bone  divide  these  insertions 
as  well  as  the  insertion  of  the  deep  cervical  fascia.  This  is  the  only  delicate 
step  in  the  operation  and  a  strongly  curved  rugine  is  a  great  aid  in  effecting  it. 
Continue  the  separation  of  the  soft  parts  downwards  and  outwards  from  the 
posterior  surfaces  of  the  sternum,  the  inner  end  of  the  clavicle  and  the  first 
costal  cartilage  until  the  finger  reaches  the  posterior  surface  of  the  first  inter- 
costal space. 

Step  3. — With  the  fingers  raise  the  tissues  in  the  supra-sternal  space  and 
divide  them.  This  means  division  of  the  anastomosis  of  the  anterior  jugular 
veins  which  is  of  little  importance  and  they  are  the  only  vessels  sacrificed  during 
the  operation. 

Divide  the  upper  part  of  the  manubrium  sterni  on  the  middle  line  down  to 
the  level  of  the  first  intercostal  space.  Bone  cutting  forceps  are  suitable  for 
this  purpose. 

Step  4. — ^Thoroughly  clear  the  inner  portion  of  the  first  intercostal  space 
both  on  its  anterior  and  posterior  surfaces.  With  a  rugine  or  elevator  free  the 
border  of  the  sternum  between  the  first  and  second  ribs  until  the  blade  of  a 
bone  cutting  forceps  can  be  insinuated  behind  the  sternum  without  injury  to 
the  internal  mammary  vessels.  Divide  the  sternum  horizontally  until  the 
vertical  line  of  section  is  met. 

Step  5. — Raise  the  mobilized  segment  of  sternum  along  with  the  clavicle 
and  first  rib  and  continue  the  separation  of  the  soft  parts  posteriorly.  As  the 
flap  is  raised  divide  the  muscles  of  the  first  intercostal  space  bit  by  bit  to  a 
point  near  the  axillary  vein. 

The  flap  can  now  be  retracted  or  reflected  upwards  and  outwards  without 
impeding  the  subclavian  or  axillary  vessels  and  without  injury  to  the  internal 
mammary  vessels. 

The  large  vessels  of  the  neck  and  the  mediastinal  organs  are  hidden  by  the 
infrahyoid  muscles,  the  cervical  fascia,  the  remnants  of  the  thymus,  much  con- 
nective tissue  and  the  pleura.  The  trunk  of  the  innominate  vein  is  recognizable. 
Further  exposure  of  vessels  and  organs  may  be  secured  through  the  cervical  or 
the  mediastinal  route  in  the  latter  with  or  without  opening  pleura. 

(a)  Cervical  Route. — Incise  the  deep  fascia  along  the  external  border  of  the 
sterno-hyoid.  This  gives  easy  access  to  the  deep  planes  and  vessels  of  the  neck. 
Remember  that  the  fascia  is  inserted  into  the  innominate  vein  and  avoid 
injuring  that  vessel. 

{h)  Extra-plenral  Mediastinal  Route. — Penetrate  the  connective  tissue  and 


340 


OPERATIONS    ON    THE    CHEST 


retract  the  pleura.  It  is  easy  to  expose  the  origin  of  the  carotids,  subclavians, 
innominates,  the  vagus,  convexity  of  the  arch  of  the  aorta,  the  recurrent  lar}Ti- 
geals,  trachea  and  oesophagus. 

(c)  Transpleural  Route. — Open  the  pleura  at  the  first  intercostal  space. 
Especially  on  the  left  side  it  is  very  easy  to  reach  the  origin  of  the  great  vessels 
which  are  clearly  visible  through  the  parietal  pleura.  This  route  has  the  ad- 
vantage of  avoiding  exposure  of  the  vagus,  cardiac  and  phrenic  nerves. 

Step  6. — Replace  the  flap.  Suture  of  the  bone  is  optional.  Suture  the 
intercostal  space,  the  pectoralis  major  and  the  fascia.     Close  the  wound. 

R.  Le  P'ort  (Rev.  de  Chir.,  LIII,  No.  5  and  6,  191 7)  has  studied  the  best 
methods  for  the  removal  of  foreign  bodies  in  the  mediastinum  and  finds  the 
anterior  transpleural  route  the  best  both  for  the  anterior  and  the  posterior 
mediastinum. 


Fig.  436. — (Schwartz.) 


If  the  foreign  body  is  deeply  situated  at  the  level  of  the  third  rib  posterior 
to  the  sternal  border,  maximal  excision  of  the  third  rib  with  maximal  retraction 
by  means  of  rib  spreaders  gives  a  wound  16  cm.  long  by  8  cm.  wide,  i.e.,  an  area 
of  85  cm.^  While  a  flap  containing  the  3-4-5  ribs  can  be  made  with  its  upper 
border  16  cm.  long,  lower  20  cm.,  inner  1 1  cm.,  i.e.,  an  area  of  198  cm.*  is  exposed. 

In  the  lower  chest  the  best  exposure  is  given  by  means  of  a  flap  (Delorme's). 
Wide  access  may  be  obtained  to  both  surfaces  of  the  heart,  to  the  aorta  (ascend- 
ing, transverse,  descending)  from  its  origin  to  the  diaphragm,  to  the  pulmonary 
vessels,  the  trachea  and  the  oesophagus,  in  a  word,  to  the  whole  mediastinum 
from  clavicle  to  diaphragm  and  from  the  sternum  to  the  spine,  between  the 
third  and  twelfth  dorsal  vertebrae. 

The  exposure  is  made  as  follows: 

Choose  the  appropriate  ribs  to  be  mobilized. 

At  the  points  A,  B,  C,  D  on  the  chosen  ribs  divide  the  bones  subperiosteally 
(Fig.  436)  (Chir.  du  Thorax,  Schwartz).  Trace  the  flap  XVZW.  Open  the 
pleura  along  the  lines  XY  and  WZ.     Divide  the  ribs,  intercostal  structyres 


MEDIASTINUM 


and  pleura  along  the  line  YZ.     Reflect  the  flap  outwards, 
thoracic  operation  is  finished,  replace  the  flap  and  suture. 


341 
When  the  intra- 


OPERATIONS  ON  THE  POSTERIOR  MEDIASTINUM* 

As  the  type  of  operations  on  the  posterior  mediastinum,  one  may  take 
that  of  Nassilov,  a  description  of  which  was  published  in  1888  and  in  1899  by 
Stoyanov.  The  following  description  closely  follows  that  of  Nassilov:  Place 
the  patient  in  the  ventral  or  semiventral  position.  Make  an  incision  at  least 
three  inches  in  length  along  a  line  parallel  to  the  vertebral  column,  and  four 
finger-breadths  from  it.  From  each  end  of  the  vertical  cut  make  a  horizontal 
incision  towards  the  spine.  Reflect  towards  the  spine  the  musculo-cutaneous 
flap  thus  delimited.  Resect  the  exposed  portions  of  ribs  subperiosteally.  This 
requires  great  care  because  of  the  danger  of  puncturing  the  pleura.     Should 


Fig.  437. — {Schwartz.) 

any  pleural  wound  be  inflicted,  suture  it  immediately.  The  ribs  should  be 
resected  close  to  the  spine,  as  this  gives  most  valuable  room.  The  superior 
portion  of  the  oesophagus  (above  the  arch  of  the  aorta— Bryant)  is  accessible 
after  excision  of  portions  of  the  third,  fourth,  fifth  and  sixth  ribs  on  the 
left  side;  the  inferior  portion  after  resection  of  three  or  more  of  the  lower  ribs  on 
the  right  side.  Attend  to  hemostasis.  Carefully  separate  with  the  fingers  the 
posterior  portion  of  the  pleura  from  the  remnants  of  the  excised  ribs  attached 
to  the  spine.  When  operating  on  the  left  side,  push  the  lung  forwards  with 
the  palm  of  the  hand  and  fingers;  this  exposes  the  thoracic  aorta,  to  the  right 
of  which  lies  the  oesophagus.  The  oesophagus  may  be  recognized  by  palpation, 
and  if  necessary  by  a  sound  being  passed  into  it  from  the  mouth.  By  blunt 
dissection  with  a  grooved  director  separate  the  loose  cellular  tissue  which  en- 
compasses the  aorta,  the  large  and  small  azygos  veins,  the  pneumogastric 
nerves,  and  the  thoracic  duct.  The  oesophagus  is  now  disengaged  from  its 
surroundings. 

The  accompanying  figure  437  shows  something  of  the  anatomical  diffi- 
*See  also  section  on  posterior  bronchotomy,  p.  1244,  and  Le  Fort's  method,  p.  340. 


342  OPERATIONS    ON    THE    CHEST 

culties  of  the  operation  if  the  first  rib  is  not  divided.     Resection  of  the  first 
rib  permits  much  greater  exposure  of  the  mediastinum. 

If  the  operation  is  for  the  removal  of  a  foreign  body  from  the  thoracic  gullet, 
the  oesophageal  wall  is  caught  with  two  forceps  and  divided  between  them 
over  the  body,  which  is  removed  with  forceps.  The  oesophageal  wound  may 
or  may  not  be  sutured;  certainly  free  drainage  of  the  wounded  posterior  medi- 
astinum is  a  necessity.  Small,  apparently  localized,  cancers  of  the  oesophagus 
may  possibly  be  excised  after  exposure  in  the  above  manner.  Inflammatory 
lesions  of  the  posterior  mediastinum  may  be  exposed  by  Nassilov's  operation 
and  subjected  to  proper  surgical  treatment. 


PART  III.-THE  ABDOMEN 


CHAPTER  XXXII 

LAPAROTOMY ;  CELIOTOMY ;  ABDOMINAL  SECTION 

POSITION  OF  PATIENT  DURING  OPERATION 

For  most  laparotomies  the  dorsal  decubitus  is  used.  When  a  patient  lies 
on  his  back  on  an  operating  table  there  is  always  a  strain  exercised  on  the  lumbo- 
sacral region,  which  strain  subsequently  manifests  itself  by  greater  or  less  pain 
in  the  back.  This  is  avoided  by  supporting  the  small  of  the  back  by  a  small 
pillow,  or  better  by  so  arranging  the  table  that  the  thighs  are  slightly  flexed  on  the 
pelvis  and  the  knees  moderately  bent.  This  latter  posture  is  particularly  valu- 
able in  that  it  relaxes  the  abdomen  and  decreases  intra-abdominal  pressure.  On 
a  properly  constructed  table  it  does  not  interfere  with  obtaining  the  Trendelen- 
burg posture  and,  according  to  Emmet  Rixford,  it  does  away  with  the  necessity 
of  adopting  the  Robson  position  in  operations  upon  the  biliary  passages. 
Rixford  has  devised  a  table  which  enables  the  upper  trunk  to  be  slightly  elevated 
thus  increasing  the  benefit  to  be  obtained  from  flexing  the  lower  extremities. 

During  operations  on  the  lower  abdomen  good  exposure  of  the  operative 
field  may  be  obtained  by  elevating  the  lower  end  of  the  table,  preferably  with 
simultaneous  slight  flexion  at  the  hips  and  knees  (Trendelenburg's  position). 
An  inclination  of  45°  may  be  used. 

When  Trendelenburg's  position  is  used  the  patient  should  be  prevented 
from  sliding  along  the  inclined  table  by  means  of  shoulder  braces  and  never 
by  letting  the  knees  be  flexed  over  the  foot  end  of  the  table,  which  increases 
intra-abdominal  pressure  objectionably. 

During  operations  in  the  region  of  the  gall-bladder  the  intestines  may  be 
kept  out  of  the  way  by  placing  a  sand-bag  about  five  inches  in  diameter  under 
the  back,  opposite  the  lower  dorsal  vertebrae.     (Robson's  position.) 

METHODS  OF  OPENING  THE  ABDOMEN 

The  patient,  anesthetized,  is  placed  on  the  operating  table.  The  limbs  and 
chest  are  well  protected  with  blankets.  The  operating-room  and  table  are  well 
heated.  The  field  of  operation  is  cleansed  and  surrounded  by  sterile  cloths 
or  towels.  A  good  incision  must  (a)  give  proper  access  to  the  disease  to  be 
investigated  and  treated  and  ought  to  be  capable  of  any  necessary  enlargement; 
(ft)  be  capable  of  easy  and  efficient  closure  with  the  least  possible  danger  of 
subsequent  hernia  or  paralysis. 

A  longitudinal  incision  in  the  linea  alba  is  classical,  is  easily  enlarged  and 
injures  no  important  vessels  and  nerves.     Unfortunately  hernia  is  a  frequent 

343 


344 


laparotomy;  celiotomy;  abdominal  section 


sequel  as  only  thin  layers  of  aponeurosis  can  be  coapted.  To  avoid  this 
objection  tlic  cut  is  usually  made  slightly  to  one  side  of  the  linea  alba,  the 
sheath  of  the  rectus  is  opened,  the  muscle  either  split  or  pulled  aside  and  the 
tissues  behind  are  cut.  A  longitudinal  cut  above  the  umbilicus  is  difficult  to 
close  because  of  tension.  The  fibres  of  the  transversalis  muscle  are  continued 
internal  to  the  outer  edge  of  the  rectus  and  acting  through  the  posterior  sheath 
of  the  rectus  makes  suture  of  this  structure  very  difficult  and  insecure. 


— _iir+ 

hypo^dstric 


Fig.  438. — {Fannctt.     By  permission  of  the  British  Journal  of  Surgery.) 


Vertical  incisions  through  the  rectus  or  at  its  outer  margin  destroy  its  nerve 
supply  to  a  greater  or  less  extent  and  ought  to  produce  an  objectionable  paral- 
ysis of  that  muscle.  Practically  one  finds  few  cases  of  serious  paralytic  lesions 
following  the  long  vertical  wounds  so  commonly  used  in  surgery  of  the  gall- 
bladder and  appendix,  but  when  they  do  occur  the  surgeon  wishes  he  had  spared 
the  nerves.  For  certain  pieces  of  intra-abdominal  work  incisions  like  that 
of  Mc Arthur  and  McBurney  for  appendectomy  are  ideal  as  in  them  the  different 


INCISIONS 


345 


layers  of  flat  muscles  and  aponeuroses  are  split  one  after  the  other  in  the  direc- 
tion of  their  fibres  and  the  nerves  are  not  cut. 

When  one  remembers  that  the  aponeuroses  of  the  abdominal  wall  are  the 
tendons  of  the  flat  muscles  (oblique  and  transverse),  and  that  these  are  inserted 
into  their  fellows  on  the  opposite  side,  one  must  realize  that  a  so-called  longi- 
tudinal incision  is  physiologically  transverse,  in  that  it  cuts  the  aponeuroses 
(tendons)  more  or  less  transversely.  This  applies  particularly  to  division  of 
the  rectus  sheath  but  not  to  that  of  the  recti  muscles.  Transverse  division 
of  the  rectus  muscle  particularly 
above  the  umbilicus  does  not  seem 
to  weaken  the  muscle  greatly,  it 
rather  merely  adds  a  new  inscriptio 
tendinecB.  The  so-called  transverse 
incisions  of  the  abdominal  wall  are 
usually  more  or  less  oblique  or  curved 
so  as  to  run  parallel  to  the  course  of 
the  nerves  (Fig.  438).  The  addi- 
tion of  a  short  vertical  cut  in  the 
middle  line  is  often  useful  and  does 
not  materially  add  to  the  difficulty 
of  closure. 

In  the  lower  abdomen  an  incision 
after  the  plan  of  Pfannenstiel  is  often 
very  useful  in  gaining  access  to  the 
pelvis.  A  curved  transverse  incision 
(convexity  downwards)  divides  the 
skin  and  aponeurosis;  the  aponeuro- 
sis is  dissected  from  the  recti  and 
retracted  upwards  and  downwards, 
the  recti  are  separated  and  the  peri- 
toneum is  opened.  Closure  is  easy 
and  very  secure.  (For  articles  on 
transverse  incisions,  see  Kocher 
Operationslehre;  Rockey,  N.  Y.  Med. 
Rec,  Nov.  4,  1905;  Maylard,  Brit.  Med.  J.,  ii,  1907;  Assmy.  Beitr.  z.  klin.  Chir., 
xxiii;  E.  Boeckmann,  St.  Paul  Med.  J.,  June,  1910;  Sprengel,  Archiv  f.  klin. 
Chir.,  xcii;  Fritz  Konig,  Zent.  F.  Chir.,  April  20,  1912;  Farr.,  Journ.  Lancet, 
Nov.  I,  1912;  C.  A.  Pannett,  Trans.  Surg.  Sect.  R.  Soc,  Med.,  Oct.  14,  1914.) 

(A)  Median  Incisions. — In  the  middle  line,  either  above  or  below  the 
umbilicus,  make  an  incision  through  the  skin  and  subcutaneous  tissues.  The 
length  of  the  incision  varies  according  to  circumstances,  but  to  begin  with  is 
usually  about  three  inches.  In  the  linea  alba  divide  the  firm  structures  con- 
stituting the  essential  belly- wall.  As  a  rule,  hemorrhage  will  be  trifling  and 
may  be  disregarded,  but  if  any  vessels  bleed  amazingly,  apply  clamps  or  liga- 
tures before  opening  the  peritoneum.  Pick  up  a  small  fold  of  peritoneum  in 
forceps  and  cautiously  make  a  very  small  incision  through  it.  When  satisfied 
that  the  peritoneum  is  opened,  catch  each  side  of  the  peritoneal  wound  in  a 


=^ 


SKIN 
.ANT.FASIA. 

RECTI. 
POST  FASCIA 
is-PERITONEUM. 


Fig.  441. 
Figs.    439,   440   and   441. — Chevrier's   incision. 


346  laparotomy;  celiotomy;  abdominal  section 

hemostat  and  by  crossing  the  forceps,  temporarily,  close  the  belly  until  the  hands 
can  be  once  more  rinsed,  first  in  an  antiseptic  solution  and  then  in  water  or 
salt  solution.  Enlarge  the  peritoneal  wound;  introduce  the  finger  to  explore. 
Enlarge  the  incision  with  scissors,  if  such  enlargement  be  necessary  to  permit 
of  further  operative  procedures. 

If  it  be  necessary  to  enlarge  the  incision  beyond  the  umbilicus,  cut  around 
that  structure  generally  to  its  left  side,  or  even  excise  it,  since  it  is  not  suitable 
for  suturing  and  it  is  impossible  thoroughly  to  cleanse  it. 

(B)  Chevrier's  Incision.— Incise  the  skin  in  the  middle  line  and  expose 
the  anterior  layer  of  the  rectus  sheath.  Reflect  the  skin  to  one  side  so  as  to 
lay  bare  the  fascia  for  distance  of  3-^  to  ^4:  inch  from  the  middle  line.  Incise 
the  fascia  about  3'^  inch  from  the  middle  line  and  reflect  the  fascial  flap  A, 
B,  C,  D,  the  pedicle  of  which  corresponds  to  the  middle  line  (Fig.  439). 
Reflect  the  flap  a  little  beyond  the  middle  line  so  as  to  expose  the  median 
border  and  a  little  of  the  opposite  rectus  muscle. 

Retract  the  rectus  so  as  to  expose  the  posterior  layer  of  the  rectus  sheath. 
Incise  the  sheath.  In  closing  the  wound  proceed  as  follows:  Suture  the  wound 
in  the  posterior  layer  of  the  sheath.  In  order  to  keep  this  line  of  suture  from 
sliding  towards  the  middle  line,  introduce  at  each  end  the  sutures  XX'  and 
YY'  which  penetrate  the  anterior  layer  of  tne  sheath,  the  rectus  muscle  and  the 
upper  and  lower  ends  of  the  sutured  wound.  Tie  sutures  XX'  and  Y Y'  only 
after  suture  of  the  anterior  layer  of  the  sheath. 

Suture  the  edge  (EF)  of  the  defect  in  the  anterior  fascia  to  the  base  (AD) 
of  the  flap  (A,  B,  C,  D,  Fig.  440).  Tie  the  sutures  XX'  and  YY'.  Suture 
the  edge  (BC)  of  the  flap  A,  B,  C,  D,  to  the  surface  of  the  fascia  along  the  line 
Z,  Z,  Z  (Fig.  440).     Close  the  skin  wound. 

The  result  of  the  procedure  is  shown  in   Fig.  441. 

(C)  Lennander's  Method. — (Kammerer;  Battle;  Jaboulay.)  Make  a  ver- 
tical incision  a  short  distance  to  the  right  or  left  of  the  median  line,  exposing  the 
anterior  surface  of  the  rectus.     Incise  the  anterior  layer  of  the  rectus  sheath. 

Retract  the  inner  edge  of  the  rectus  out- 
wards, exposing  the  posterior  layer  of  its 
sheath,  and  incise  that  layer.  Open  the  peri- 
toneum. Note  that  the  rectus  muscle  itself 
is  neither  incised  nor  split,  and  hence  its 
Fig.  442.— Rectus  incision.  nerve-supply  is  not  injured  in  the  slightest. 

In  closing  the  wound,  remember  to  suture 
each  layer  of  the  rectus  sheath  separately  (Fig.  442).  A  similiar  incision 
may  be  made  about  three-fourths  of  an  inch  internal  to  the  outer  edge  of  the 
rectus,  the  sheath  opened,  the  muscle  retracted  inwards,  and  the  abdomen 
penetrated.  This  outer  incision  is  very  commonly  used  for  exposing  the 
vermiform  appendix  but  it  of  course  may  injure  the  nerves. 

(Dj  Vertical  Incision  through  the  Rectus.^This  incision  is  excellent.  Make 
a  vertical  incision  to  one  side  of  the  median  line  down  to  and  through  the 
anterior  layer  of  the  rectus  sheath.  Split  the  rectus  muscle  by  blunt  dissection. 
Divide  the  posterior  layer  of  sheath  and  open  the  abdomen. 


CLOSURE    .U3DOMEN  347 

(E)  Vertical  Incision  at  the  Outer  Edge  of  the  Rectus. — This  requires  no 
special  description. 

(F)  Transverse  Incision. — As  has  already  been  stated  the  general  direction 
of  these  incisions  is  transverse,  but  as  a  rule  they  are  really  oblique,  curved  or 
even  angular.  The  direction  of  any  part  of  the  cut  depends  principally  on  the 
course  of  the  nerves.  In  the  region  of  the  gall-bladder  the  incision  usually 
runs  more  or  less  parallel  to  the  costal  margin,  though  when  dividing  the  rectus 
muscle  the  author  prefers  to  cut  at  right  angles  to  its  fibres.  In  exposing  the 
stomach  the  incison  may  be  curved  (convexity  upwards),  both  recti  being  di- 
vided, or  it  may  be  transverse,  one  or  both  recti  being  divided  in  whole  or  in 
part.  The  incisions  when  prolonged  beyond  the  recti  ought  always  to  split  the 
fibres  of  the  external  oblique  and  not  cut  them  transversely  to  their  course. 
Such  incisions  are  of  the  gridiron  type  like  the  McArthur-McBurney  incision. 
In  the  lower  abdomen  the  incisions  are  usually  curved  with  convexity 
downwards. 

As  an  example  of  transverse  incision  the  method  may  be  taken  by  which 
the  author  often  exposes  the  right  iliac  region  in  cases  of  chronic  appendicitis 
when  considerable  exploration  is  necessary.  Make  an  incision  in  the  inter- 
spinous  line  from  the  linea  alba  to  the  outer  edge  of  the  rectus  and  expose  the 
rectus  sheath.  Introduce  and  loosely  tie  two  lines  of  interrupted  catgut  stitches 
transversely  through  the  rectus  sheath  and  underlying  muscle.  Divide  the 
sheath  between  these  lines  of  sutures.  Cut  through  the  rectus  muscle  deliber- 
ately so  as  to  expose  the  deep  epigastric  vessels.  It  is  almost  always  necessary, 
to  ligate  and  divide  these  vessels.  Open  the  peritoneum.  If  it  is  necessary  to 
enlarge  the  wound  laterally,  this  is  easily  done  in  the  gridiron  fashion.  If 
median  enlargement  is  required,  the  other  rectus  muscle  may  be  divided  without 
ill  result.  Closure  of  the  above  wound  is  very  easy  and  secure.  The  method  is 
not  suitable  in  the  presence  of  acute  infective  lesions. 

It  is  specially  above  the  umbilicus  that  transverse  incisions  are  very  useful. 

(G)  Oblique  Incisions.— In  the  lower  half  of  the  abdominal  wall,  when  it 
is  desired  to  operate  remote  from  the  median  line,  incisions  are  recommended 
running  obliquely  from  above  downwards  and  inwards — i.e.,  in  the  direction 
of  the  fibres  of  the  external  oblique  muscle.  Such  avoid  division  of  important 
motor  nerves  and  permit  of  splitting  instead  of  dividing  the  external  oblique 
muscle.     (See  Chapter  on  "Appendicitis.") 

METHODS  OF  CLOSING  THE  ABDOMEN 

The  great  object  to  be  attained  in  closing  the  abdomen  is  the  prevention 
of  subsequent  hernia.  In  the  attempt  to  gain  this  end,  surgeons  have  adopted 
a  vast  number  of  methods  of  suture.  A  study  of  the  annexed  diagrams  (Figs. 
443  to  450)  will  explain  the  suture  methods  more  clearly  than  any  printed 
description.  The  buried  sutures  uniting  peritoneum  or  fascia  are  best  intro- 
duced with  full  curved  or  short  straight  needles,  and  may  be  catgut,  silk,  silk- 
worm-gut, or  silver  wire.  The  writer  prefers  some  form  of  catgut,  either 
mildly  chromicized  or  iodized.  Kocher  thinks  silk  the  only  proper  material. 
In  the  Johns  Hopkins  clinic  silver  wire  is  used.     Other  surgeons  prefer  silk- 


348 


laparotomy;  celiotomy;  abdominal  section 


worm-gut,  tendon,  aluminium-bronze  wire,  etc.  When  properly  used,  each 
material  does  good  work.  Some  surgeons,  e.g.,  Jonnesco,  object  to  the  use 
of  absorbable  sutures,  of  non-absorbable  buried  sutures,  and  yet  desire  to  close 
the  abdominal  wound  in  layers.     For  this  reason  thev  have  devised  more  or 


Fig.  445. 


Fig.  447. 


Fig.  444. 


Fig.  449. 


Fig.  450. 


Fig.  451. — Jonnesco's  method  (modified). 

less  complicated  means  of  suturing,  so  that  they  can  remove  the  stitches  when 
they  have  served  their  purpose  (Figs.  451,  452,  453,  454). 

In  not  extremely  rare  instances  a  wound  does  not  heal  by  the  time  catgut 
sutures  are  absorbed.     This  peculiarity   has   caused  a  number  of  disasters. 


AFTER    TREATMENT 


349 


It   is  wise  to  reinforce  the  catgut  sutures  by  two,  three  or  four  silkworm-gut 
relaxation  stitches. 

The  inexperienced  surgeon,  after  completing  a  prolonged  operation  on  an 
exhausted  individual,  sometimes  forgets  that  it  is  better  to  have  a  post-operative 
hernia  in  a  living  patient  than  a  perfectly  closed  wound  in  a  corpse.  Under 
some  circumstances  it  is  wise  to  put  in  as  few  stitches  as  possible,  and  these  in 
the  quickest  manner  possible. 


A.C43 


Fig.  453. — Davison's  method. 

A.  Slip-knot  to  prevent  suture  being  pulled  through 
the  tissues.  The  free  end  of  the  suture  is  left  projecting 
from  the  wound,  and  when  pulled  upon  unties  the  slip-knot 
and  so  permits  extraction  of  the  suture.  B.  Slip-knot 
tied  when  suture  is  in  place.     Untie  the  same  way  as  A. 


Fig.  454. 

Continuous   sutures   fixed   by 
pad  of  gauze  at  A. 


When  drainage  has  been  used,  it  is  good  practice  to  place  sutures  in  position 
for  the  closure  of  the  opening  left  by  the  removal  of  the  drain  and  tighten  and 
tie  these  subsequently. 

When  drainage  is  necessary  it  is  often  wise  to  establish  it  through  a  special 
incision  or  stab,  and  then  close  the  primary  wound  completely.  The  means 
used  to  provide  drainage  is  liable  to  cause  trouble  in  the  main  wound. 

DRESSINGS 

After  completion  Of  the  operation,  cover  the  wound  with  a  number  of  pads 
of-sterOe  absorbent  gauze;  over  these  place  a  liberal  quantity  of  sterile  ab- 
sorbent cotton.  Keep  the  dressings  in  place  with  a  binder,  or  preferably  by 
strips  of  adhesive  plaster.  Abundant  dressings,  snugly  applied,  support  the 
intra-abdominal  blood-vessels  and  prevent  the  patient  from  bleeding  into  his 
own  veins  after  large  tumors  have  been  removed.  Under  ordinary  circum- 
stances the  author  has  discarded  the  use  of  all  dressings  contenting  himself  with 
painting  the  wound  daily  with  alcohol  or  a  weak  solution  of  iodine.  A  sterile 
towel  may  be  throwm  over  the  abdomen,  it  rarely  remains  in  position. 

TREATMENT  AFTER  LAPAROTOMY 

Return  the  patient  to  bed.  A  small  pillow  may  be  placed  under  the  head, 
but  for  a  short  time  the  head  must  not  be  elevated.  If  there  is  much  pain  give 
an  efficient  dose  of  an  opiate,  as  suffering  and  restlessness  are  greater  evils 
than  are  the  noxious  effects  of  the  opiate  itself.  Rectal  instillations  of  salt 
solution  are  of  great  value  in  relieving  thirst  and  in  providing  the  patient  with 


350  laparotomy;  celiotomy;  abdominal  section 

needed  liquid.  An  enema  consisting  of  soda  bicarb,  o'lv  in  S^iii  of  water  is 
valuable  immediately  after  operation.  If  the  rectum  is  irritable,  hypodermocly- 
sis  is  often  valuable.  Washing  the  mouth  with  water  is  of  value  in  relieving 
thirst  and  is  very  grateful  to  the  patient.  A.  J.  Ochsner  stimulates  secretion 
of  saliva  by  letting  the  patient  use  chewing  gum  or  hold  some  object  like  the 
stone  of  a  plum  in  his  mouth.  The  increased  flow  of  saliva  lessens  thirst  and 
lessens  the  dangers  of  parotitis.  One  must  remember,  however,  that  a  too 
protracted  increased  flow  of  saliva  may  ultimately  increase  the  thirst.  As  soon 
as  nausea  passes  off,  begin  giving  small  doses  of  water,  preferably  hot,  by  the 
mouth.  If  this  is  well  borne  the  patient  may  soon  be  permitted  to  drink  two 
or  more  pints  per  day.  Orange  juice  is  greatly  appreciated  by  most  patients, 
and  to  it  a  little  egg  albumen  may  be  added  with  advantage.  In  most  cases 
liquid  nourishment  may  be  given  sparingly  in  12  or  24  hours  after  operation. 
The  author  in  recent  years  has  become  more  and  more  liberal  in  permitting 
food  to,  but  not  forcing  it  upon  his  patients  after  laparotomy. 

If  "gas  pains"  give  trouble  an  enema  of  soap  suds  gives  relief.  When  there 
is  difliculty  in  expelling  flatus  a  rectal  tube  should  be  introduced  and  left  in 
place.  Wetherill  long  ago  urged  that  post  operation  catharsis  be  discarded. 
The  writer  has  adopted  that  wise  man's  views  and  usually  leaves  the  bowels  at 
rest  for  some  days  unless  special  indications  calling  for  their  evacuation  arise. 
If  it  is  necessary  to  move  the  bowels  pituitrin  is  of  great  value. 

A  few  years  ago  many  surgeons  considered  it  essential  to  keep  patients  in 
the  dorsal  position  for  a  long  time  after  laparotomy.  This  is  cruel  and  in- 
jurious. Permit  the  patient  to  lie  in  whatever  position  is  comfortable  so  long 
as  it  does  not  exert  tension  on  the  wound.  After  certain  operations — e.g., 
those  on  the  stomach  and  those  for  peritonitis — the  above  rule  may  not  prevail. 
After  operations  on  the  upper  half  of  the  abdomen  it  is  permissible  to  allow  the 
patient  to  sit  up  early,  as  the  sitting  posture  does  not  increase  tension  on  the 
wound  to  any  great  extent.  After  operations  on  the  lower  half  of  the  belly, 
the  sitting  posture  means  increased  tension  on  the  wound  and  hence  increased 
risk  of  hernia,  therefore  the  author  usuallv  in  clean  cases  adheres  more  or  less 
closely  to  the  rules  formulated  for  the  after-treatment  of  hernia  operations. 
When  drainage  has  been  instituted  the  Fowler  position  may  be  imperative. 
The  tendency  of  surgeons  is  towards  letting  the  patients  sit  up  and  move 
about  at  an  early  date,  even  a  very  early  date,  after  operation,  but  to  the 
author  it  appears  risky  as  tension  on  a  wound  insuflaciently  solidified  is  well 
calculated  to  cause  hernia.  When  the  abdomen  has  been  opened  by  the  grid- 
iron method  of  McArthur  and  ]McBurney,  the  above  remarks  do  not  apply. 
The  avoidance  of  tympany  during  convalescence  is  of  great  importance  for 
the  same  reason,  viz.,  the  tension  it  exerts  on  the  wound. 

The  stomach  tube  is  of  enormous  value  after  laparotomy.  If  nausea  is  pro- 
longed the  stomach  ought  to  be  washed  out.  If  there  is  any  evidence  of 
beginning  acute  dilatation  of  the  stomach  lavage  is  imperative.  Half  an  hour 
before  passing  the  tube  in  a  nervous  patient  it  is  well  to  give  }'i  gr.  morph. 
hypodermatically  and  immediately  before  the  operation  the  fauces  should  be 
sprayed  or  swabbed  with  cocaine. 


GASTRO-INTESTINAL    OPERATIONS 


351 


*  GASTRO-INTESTINAL  OPERATIONS 

Before  describing  the  individual  operations  performed  on  the  gastro-in- 
testinal  canal  it  will  be  convenient  to  consider  the  means  at  our  disposal  for 
preventing  the  escape  of  its  contents  from  an  incised  gut  and  of  closing  in- 
testinal openings  by  means  of  sutures.  Some  special  means  of  suturing 
will  be  described  later,  along  with  the  operations 
for  which  they  were  devised. 

Preparation  of  a  Loop  of  Gut  for  Incision. — 
With  the  finger  and  thumb  express  the  contents 
of  the  selected  portion  of  gut  either  upwards  or 
downwards  so  as  to  leave  that  portion  empty. 
Prevent  the  return  of  the  contents  to  the  loop 
of  gut  by  appropriate  clamps,  applied  above 
and  below.  When  available,  the  best  clamps 
are  the  fingers  of  an  assistant  exercising  pressure 


Fig.  455. — Murphy's  clamp. 


Fig.  456. — Pean's  clamp. 


on  the  gut.  The  objections  to  this  are  that  the  fingers  are  liable  to  take  up  too 
much  room,  and  that  the  hands  of  the  assistant  become  so  fatigued  that  he 
can  give  but  little  assistance  during  the  rest  of  the  operation.  If  plenty 
of  help  is  at  hand,  of  course  the  latter  objection  loses  its  weight.     Murphy's  clamps 

(Fig.  455)  are  excellent.  It  is  entirely  unnecessary 
to  protect  the  blades  of  this  clamp  with  rubber 
tubing. 

Pean  has  suggested  a  most  convenient  intestinal 
clamp  (Fig.  456)  and  one  which  is  always  ready.  To 
the  proximal  side  of  the  catch  of  an  ordinary  hemo- 


FiG.  457. — Maylard's  clamp. 


Fig.  458. — Doyen's  clamp. 


Static  forceps  tie  the  end  of  a  soft-rubber  catheter  or  piece  of  drainage-tube. 
Pass  the  point  of  the  forceps  behind  the  gut  and  through  the  mesentery  close 
to  the  gut.  Open  the  forceps.  Place  the  free  end  of  the  rubber  tubing  over 
the  front  of  the  gut;  stretch  the  tubing  and  catch  it  in  the  jaws  of  the  forceps. 


352 


laparotomy;  celiotomy;  abdominal  section 


The  result  is  that  the  gut  is  clamped  by  the  rubber  in  front  pressing  towards 
the  forceps  behind. 

Passage  of  intestinal  contents  may  be  stopped  by  tying  around  the  gut  strips 
of  gauze  or  pieces  of  coarse  silk  or  catgut.  Of  course,  before  they  can  surround 
the  gut  they  must  perforate  the  mesentery.  Do  not  tie  such  materials  tightly 
as  little  pressure  is  necessary  and  much  is  injurious. 

Maylard  extemporizes  an  excellent  clamp  by  covering  the  blades  of  a 
dissecting  forceps  with  rubber  tubing.     When  the  blades  have  been  made  to 


Fig:  459.  Fig.  460. 

Figs.  459  and  460. — Lembert  suture. 

grasp  the  intestine,    their  points  are  kept  together  by  a  segment  of  tubing 
slipped  over  them  (Fig.  457). 

All  the  above  clamps  are  good  for  the  prevention  of  escape  of  intestinal 
contents,  but  certain  clamps  with  long  blades  (protected  by  rubber  tubing) 
not  only  serve  this  purpose  but  control  hemorrhage  and  may  be  employed  as 
handles  by  which  the  segments  of  gut  can  be  held  steadily  in  a  position  con- 
venient for  suturing,  etc.  Such  clamps  are:  Doyen's  (Fig.  458),  Hartmann's, 
Moynihan's,  Harrington's,  Scudder's,  etc.  A  clamp  good  for  gastro-enteros- 
tomv  is  good  for  most  intestinal  work. 


Fig.  461. — Lembert  suture. 

Intestinal  Suture. — The  most  common  material  for  intestinal  suture  is  fine 
twisted  silk — preferably  black.  The  disadvantage  of  silk  is  that  when  wet 
it  is  difficult  to  pass  through  the  eye  of  a  fine  needle.  To  avoid  this  difficulty 
a  sufficiency  of  needles  should  be  threaded  before  sterilization  is  begun.  The 
author  generally  uses  fine  waxed  silk  or  linen.  Fine  chromicized  or 
tanned  catgut  is  excellent.  The  best  needles  are  the  ordinary  seamstress' 
needles,  about  one  and  a  quarter  inches  in  length.  Various  curved  needles 
(without  any  cutting-edge)  are  useful  and  can  be  obtained  in  any  good 
instrument  store. 


LEMBERT   SUTURE 


353 


The  intestinal  wall  consists  of  the  following  tunics:  the  serosa,  the  musculosa, 
the  submucosa,  and  the  mucosa.     The   submucosa   is   the  firm,  thin  tunic 
which  is  used  in  making  sausages.    It  provides  the  most 
reliable  hold  for  a  suture. 

Lembert  Suture. — This  is  the  basis  of  almost  all  methods 
of  intestinal  suture.  Its  aim  is  to  close  an  intestinal  wound 
by  turning  the  cut  edges  inwards  and  bringing  the  serosa  of 
one  side  into  apposition  with  that  of  the  other  side. 
Halsted  has  shown  that  it  is  wise  to  include  tJie  submucosa 
in  the  stitch.  When  a  not  too  sharp  needle  is  introduced 
through  the  serosa  and  musculosa,  its  advance  is  easy,  but 
when  it  reaches  the  submucosa,  a  slightly  increased  resist- 
ance is  perceptible.  It  is  said  to  be  easy  to  pick  up  some 
of  the  submucosa  on  the  point  of  the  needle  without  pene- 
trating the  mucosa.  The  author  has  frequently  endeavored 
to  insert  Lembert  sutures  involving  the  serosa  and  mus- 
culosa alone,  but  they  always  tore  out;  the  picking  up  of 


Fig.  462. — Mattress 
suture.  {Monod  and 
Vanverts.) 


Fig.  463. — Alfred  H.  Gould's  mattress  stitch. 

Note  that  the  loop  is  reversed.     This  results  in  the  rolling  in  of  the  peritoneum  on  the  side 

of  the  loop — B  drawn  to  A. 

a  few  fibres  of  the  submucosa  without  letting  the 
needle  pass  into  the  mucosa  seems  to  be  an  ''iridescent 
dream."  The  blood-vessels  lie  in  the  submucosa,  and 
in  suturing  unless  the  thread  is  passed  under  the  vessels 
(i.e.,  nearer  the  mucosa)  the  stitches  will  exercise  no 
pressure  upon  them  and  thus  serious  hemorrhage  may, 
and  sometimes  does  occur.  In  inserting  sutures  the 
surgeon  should  see  to  it  that  each  stitch  embraces  firm 
tissue  and  will  not  cut  out,  and  that  each  stitch  goes  under 
any  visible  vessel  in  its  track.  If  these  two  rules  are 
observed  good  results  will  be  obtained  no  matter  if  the 
thread  does  pass  through  the  deeper  layers  of  the 
mucosa.  The  author  knows  of  one  or  more  cases  in 
which  the  operator  took  special  pains  to  insert  the 
sutures  through  the   serosa   and  musculosa   alone  and 

nearly  lost  the  patient  from  hemorrhage.      The  introduction  of  the  suture  is 

sufficiently  shown  in  Figs.  459,  460,  and  461. 

23 


Fig.  464. — Dupuy- 
tren's  suture.  {Esmarch 
and  Kowalzig.) 


354 


laparotomy;  celiotomy;  abdominal  section 


Halsted's  Quilted  Suture. — This  is  in  principle  identical  with  Lembert's. 
The  suture  is  introduced  after  the  U  fashion  (Fig.  4O2).  Gould's  mattress 
suture  with  reversed  loop  is  admirable  (Fig.  463). 

Dupuylren's  suture  (Fig.  464),  or  continuous  Lembert,  can  be  easily  and 
quickly  applied,  and  when  properly  used,  is  a  most  excellent  procedure. 
In  America  it  is  curious  to  notice  that  most  eastern  operators  use  the  inter- 
rupted suture,  while  the  Westerners  favor  the  continuous.  The  results 
seem    as  good   whichever  method  is' employed;  hence  the  continuous  being 


Fig.  465. 


Fig.  466. 


Fig.  467. 


Fig.  468. 


Fig.  469. 


Fig.  470. — Cushing's  suture. 


Fig.  471. — Gely's  suture. 

the  easier  to  apply,  it  seems  to  the  author  to  be  the  better.  It  is  important 
to  observe  the  blood-vessels  running  towards  the  wound  in  the  gut,  and  to 
pass  the  needle  under  such,  so  that  when  the  edges  of  the  sound  are  inverted 
by  the  tightening  of  the  sutures,  these  constrict  the  vessels  and  so  prevent 
hemorrhage.  If  one  fears  that  a  continuous  suture  will  act  as  a  purse-string 
and  cause  contraction,  one  may  obviate  this  danger  (if  danger  it  be)  by  occas- 
ionally interrupting  the  suture  by  fixing  it  with  a  knot  (interrupted  continuous 
suture). 


EXPLORATORY  GASTROTOMY  355 

Several  methods  of  closing  an  intestinal  wound  by  different  layers  of  suture 
have  been  devised.  Some  of  these  are  illustrated  in  Figs.  465,  466,  467,  468, 
and  469. 

Through-and-through  Sutures. — When  closing  a  wound  or  uniting  divided 
ends  of  gut  there  is  often  considerable  hemorrhage  and  some  danger  of  the  line 
of  Lembert  sutures  becoming  infected  by  intestinal  contents.  To  control 
hemorrhage  nothing  is  better  than  to  unite  the  edges  of  the  wound  with  a 
continuous  stitch  of  catgut  penetrating  all  the  thickness  of  the  gut-wall.  This 
line  of  suture  is  at  once  covered  and  hidden  by  a  row  of  Lembert  or  Dupuytren 
sutures,  and  serves  to  protect  the  latter  from  infection.  Cushing's  and  Gely's 
methods  of  suture  are  sufficiently  explained  by  Figs.  470  and  471. 


CHAPTER  XXXIII 
THE  STOMACH 

Exploratory  Operation  on  the  Stomach. — At  least  one  day  prior  to  opera- 
tion thoroughly  wash  out  the  stomach  with  warm  water.  Repeat  this  lavage 
immediately  before  the  operation.  Be  careful  to  empty  the  stomach  com- 
pletely. If  the  stomach  has  been  for  a  long  time  much  dilated,  do  not  empty 
it  during  the  first  lavage.  Under  these  circumstances  preparation  should 
consume  several  days.  If  the  organ  is  suddenly  or  rapidly  cleaned,  tetany 
is  very  liable  to  develop.  In  dehydrated  patients,  i.e.,  those  who  pass  not 
more  than  500  c.c.  of  urine  in  twenty-four  hours,  it  is  of  vital  importance  to 
supply  fluid  to  the  tissues.  This  may  be  accomplished  by  means  of  Murphy's 
proctoclysis  or  by  giving  hypodermically  from  40  to  60  ounces  of  saline  solution 
per  diem  for  several  days  before  operation. 

When  diseased,  the  stomach  almost  always  lies  at  a  lower  level  than  in 
health,  hence  the  incision  need  not  be  so  near  the  ensiform  cartilage  as  might 
be  imagined  from  a  study  of  normal  anatomy. 

Having  opened  the  abdominal  cavity,  introduce  the  finger  and  palpate 
the  stomach  and  its  surroundings.  This  is  often  sufficient  for  diagnosis. 
If  it  is  not  sufficient,  pull  the  stomach  into  the  abdominal  wound,  surround 
it  with  warm  pads,  and  inspect  the  anterior  gastric  wall.  If  a  pyloric  stenosis 
is  suspected,  invaginate  a  part  of  the  stomach-wall  with  the  finger  so  that 
the  finger  penetrates  and  palpates  the  pylorus.  Gentleness  must  be  employed. 
If  exploration  of  the  posterior  wall  is  necessary  it  may  be  exposed  through 
several  routes,  (i)  Gastro-hepatic  route.  Tear  a  hole  through  the  gastro- 
hepatic  omentum.  This  permits  finger  exploration  but  does  not  give  free 
access.  (2)  Trans-mesocolic  route.  This  is  the  same  route  as  used  in  posterior 
gastro-enterostomy  and  is  efficient.  (3)  Gastro-colic  route.  Make  an  incision 
parallel  to  the  greater  curvature  through  the  gastro-colic  omentum  being  careful 
to  avoid  injury  to  the  gastro-epiploic  vessels.  This  method  requires  the  liga- 
tion of  a  number  of  branches  of  the  gastro-epiploics  but  gives  excellent  access  to 
the  stomach.  Care  must  be  taken  lest  the  vessels  in  the  mesocolon  be  acci- 
centally  injured.  After  completing  the  active  operation  suture  the  wound  in 
the  omentum  or  stitch  the  divided  omentum  to  the  stomach.     (4)  Intercolo- 


356  THF    STOMACH 

epiploic  route.  Separate  the  great  omentum  from  the  transverse  colon  by  cut- 
ting an  opening  in  the  serous  membrane  of  the  transverse  colon  at  its  junction 
with  the  great  omentum  and  separate  the  omentum  from  the  colon  (see 
p.  404).  This  gives  good  exposure  of  the  stomach,  duodenum  and 
pancreas.  Pauchet  and  Sherwood  Dunn  strongly  advise  the  inter-colo- 
epiploic  route  in  the  treatment  of  posterior  gastric  and  duodenal  ulcers  and 
in  bullet  wounds  of  the  posterior  wall  of  the  stomach.  If  it  is  desirable 
to  explore  the  interior  of  the  stomach,  e.g.,  for  ulcers,  pack  the  abdominal 
cavity  around  the  stomach  with  warm  gauze  pads.  It  is  universally  ad- 
vised to  count  the  pads  before  beginning  the  operation.  This  is  a  good 
rule.  A  rather  better  precaution  against  losing  and  leaving  a  pad  in  the 
belly  cavity  is  to  have  6  inches  of  soft  tape  sewed  to  each  pad,  and  as  the 
pads  are  introduced  into  the  belly  to  let  the  tape  emerge  from  the  wound 
and  be  anchored  by  a  hemostat.  The  tapes  emerging  through  the  wound 
are  never  in  the  way.  The  pads  used  should  be  large.  Those  24  inches  long 
by  6  inches  wide  are  good.  The  writer  makes  it  a  rule  never  to  place  a  pad  in 
the  abdomen  without  an  anchor  affixed,  and  never  to  use  pieces  of  gauze  for 
sponging  inside  the  cavity  unless  they  are  held  in  sponge  forceps.  These 
rules  are  simple,  and  hence  efficient.  Masson  (Jour.  A.  M.  A.,  May  31,  1919) 
advises  that  a  metal  ring  be  placed  round  the  base  of  the  tape  and  firmly  stitched 
both  to  the  sponge  (gauze  pad)  and  to  the  tape.  If  any  doubt  regarding  the 
sponge  count  arises  a  roentgenogram  will  clear  it  up  at  once. 

Have  an  assistant  pick  up  a  fold  of  the  anterior  wall  of  the  stomach.  In- 
cise this  fold  in  a  direction  at  right  angles  to  the  long  axis  of  the  organ.  If 
there  is  fluid  in  the  stomach  and  its  walls  are  not  weakened  too  much  by 
disease,  introduce  a  blunt  tube  and  empty  the  viscus.  Introduce  the  finger 
into  and  palpate  the  stomach.  Retract  the  edges  of  the  wound  and  inspect 
the  interior.  In  doing  this  a  cylindrical  rectal  speculum  provided  with  a  dia- 
phragm and  2)-^  inches  long  by  i)-^  in  diameter  is  of  great  aid  and  permits 
inspection  of  the  duodenum  through  the  pylorus.  Close  the  gastric  wound 
by  sutures  of  catgut  involving  the  whole  thickness  of  the  wall;  this  row  of 
sutures  to  be  inverted  or  buried  by  a  series  of  Lembert  or  continuous  Lembert 
stitches  of  fine  chromic  gut.  Close  the  abdomen.  Return  the  patient  to  bed. 
Keep  him  warm. 

Thirst,  and  later  hunger,  may  be  relieved  by  warm  water  or  nutrient  ene- 

mata.     If  possible,  do  not  give  anything  by  the  mouth  for  at  least  twelve 

hours,  and  then  only  water.     Remember  that  the  danger  arising  from  giving 

drink  or  food  by  the  stomach  in  such  cases  is  really  not  from  its  leaking  through 

the  wound,  but  from  vomiting  being  set  up  by  its  presence,  and  also  from  its 

stimulating  effect  giving  rise  to  peristalsis,  etc.*     Hypodermoclysis  or  rectal 

instillation  of  salt  solution  is  of  inestimable  value  in  these  cases.     It  is  desirable 

that  the  stomach  rest  until  repair  is  advanced.      If  there  is  much  pain,  morphine 

in  an  efficient  dose  should  be  given.     If  possible  to  avoid  the  use  of  morphine 

without  cruelty,  do  so,  but  when  its  employment  is  decided  on,  administer  in 

one  dose  enough  to  insure  the  effects  desired. 

*  Possibly  too  much  weight  is  given  to  the  dangers  of  early  feeding.  Roux  is  extremely 
heterodox,  feeding  his  gastro-enterostomy  patients  with  almost  anything  they  desire  as  soon 
as  they  desire  it. 


GASTROSTOMY  357 

Exploratory  operations  are  strongly  indicated  "in  cases  of  rapidly  de- 
veloping cachexia  and  emaciation  with  the  symptoms  of  chronic  gastritis 
and  absence  of  HCl.  Tentative  treatment  should  not  be  prolonged  over 
three  weeks.  It  is  not  near  so  serious  a  fault  to  have  caused  the  opening 
of  a  stomach  and  found  nothing  operable,  as  to  permit  a  case  to  continue 
and  find  out  at  the  autopsy  only  that  it  was  a  circumscribed  carcinoma,  the 
removal  of  which  might  have  prolonged  life  for  years."  (Hemmeter,  "Dis. 
of  Stom.,"  p.  358.) 

Operating  for  Cardiospasm. — Mikulicz  observed  a  number  of  cases  in 
which  the  patients  suffered  severely  from  oesophageal  obstruction  due  to 
muscular  spasm  at  \^e  oesophageal-gastric  junction.  When  milder  means 
of  treatment  failed  he  obtained  complete  cure  by  opening  the  stomach,  pass- 
ing an  instrument  like  a  glove  stretcher  into  the  oesophagus  through  the 
stomach  and  thus  forcibly  stretching  the  muscle  at  fault.  Briinig  has  opened 
the  blades  of  the  Mikulicz's  forceps  as  much  as  2}^  inches  (6  cm.)  with  ex- 
cellent results. 

Dilatation  by  means  of  air  or  water  bags  introduced  through  the  mouth  has 
practically  entirely  displaced  the  Mikulicz  operation.  See  Plummer,  "Journ. 
A.  M.  A.,"  Aug.  15,  1908. 

Gastrostomy. — The  object  of  gastrostomy  is  to  make  a  convenient  fistula 
into  the  stomach  through  which  nourishment  can  be  administered.  (Esoph- 
ageal stenosis  is  the  indication  for  the  operation,  hence  we  have  usually  to 
do  with  emaciated  and  weak  patients.  The  simplest  method  of  operating 
is  the  worst.  It  consists  in  performing  an  exploratory  gastrotomy  and  sutur- 
ing the  stomach  wound  to  that  in  the  parietes.  The  objection  to  the  above 
method  is  that  it  permits  a  constant  escape  of  the  gastric  juices.  All  the 
other  methods  of  gastrostomy  are  attempts  to  avoid  the  above-mentioned  fault. 

(A)  Gastrostomy  with  Formation  of  Sphincter  (Hartmann ;  Terrier ;  Jaboulay , 
etc.). — By  percussion  and  palpation  define  the  lower  edge  of  the  liver  in  the 
epigastrium. 

Step  I. — Make  a  vertical  incision  i  to  i}'^  inches  to  the  left  of  the  median 
line,  beginning  at  the  lower  edge  of  the  liver  and  running  downwards  for  about 
2H  to  3  inches.  Divide  the  anterior  layer  of  the  muscular  sheath  and  split 
the  rectus  itself,  but  do  not  yet  divide  the  posterior  layer  of  the  sheath. 

Step  2. — Retract  the  wound  inwards  and  thus  expose  the  posterior  layer  of 
the  rectus  sheath  and  divide  it  along  with  the  peritoneum  near  the  median  line. 

Step  3. — Introduce  the  finger  and  pass  it  up  under  the  left  lobe  of  the  liver 

to  the  portal  fissure,  and  follow  the  gastro-hepatic  omentum  to  the  lesser 

curvature  of   the   stomach.     (Maylard,  "Surgery    

of    the    Alimentary    Canal.")        This    avoids    all    ^^^^^rr::^^^!^^^ 

danger  of  mistakmg  colon  for  stomach.      Pick  up    ^^-::^:^ir:^^^^^^^^g. 

the  anterior  wall  of  the  stomach  and  pull  a  cone  ^^^^^^^ 

of  it  through  the  wound.     Close  all  the  excess  of       ^       '        ^ 

,  ,  tiG.  472. — Gastrostomy, 

peritoneal  wound. 

Step  4. — -Remove  retractors  and  permit  the  rectus  muscle  to  resume  its 

normal  position  (Fig.  472). 

Step  5. — Close  all  excess  of  abdominal  wound  and  suture  the  protruding  cone 


358 


THE    STOMACH 


of  Stomach  to  the  skin.     Open  the  protruding  portion  of  stomach  and  intro- 
duce a  soft  catheter  into  it. 

Steps  I  and  2  may  be  varied  as  follows:  Divide  the  anterior  layer  of  rectus 
sheath  along  the  line  of  the  skin-incision;  retract  it  inwards,  i.e.,  to  the  right; 
retract  the  whole  rectus  muscle  outwards,  exposing  and  dividing  the  posterior 
layer  of  sheath  and  the  peritoneum  near  the  median  line;  pull  out  the  cone 
of  stomach;  split  the  rectus  muscle  along  the  line  of  the  skin-incision  and 
separate  the  internal  portion  from  its  posterior  layer  of  sheath;  pull  the  cone 
of  stomach  through  the  bridge  of  muscle  thus  formed  and  suture  to  the  skin 
(Figs.  473  and  474). 


Figs.   473  and  474. — Hartmann-Terrier-Jaboulay  gastrostomy.     (Monod  and   Vanverls.) 

(B)  Frank's  Operation. — Step  i. — Beginning  near  the  lower  edge  of  the 
liver,  make  an  incision  downwards  and  towards  the  left,  parallel  to  and  one 
inch  below  the  left  costal  cartilages.    Length  of  incision,  2  to  3  inches. 

Step  2. — Through  the  incision  pull  out  a  cone  of  stomach  from  as  near 
its  cardiac  end  as  is  possible  without  too  much  tension. 

Step  3. — Make  a  second  skin-incision,  about  1}^  inches  in  length,  parallel 
to  the  first  and  situated  over  the  left  costal  cartilages.  Undermine  the  skin 
between  the  two  incisions  and  pull  the  cone  of  stomach  through  the  tunnel 
thus  formed.     Suture  the  stomach  to  the  skin  at  the  second  incision. 

Step  4. — Close  the  first  wound  without  exerting  too  much  pressure  on  the 
cone  of  stomach  which  traverses  it.  Open  the  apex  of  the  stomach  cone. 
The  result  is  an  oblique  valvular  fistula. 

Frank's  operation  has  the  disadvantage  that,  the  stomach  being  small, 
the  peculiar  formation  of  the  fistula  causes  a  deformity  which  seriously  in- 
terferes with  the  carrying  on  of  the  normal  functions. 

(C)  WitzeVs  Operation. — The  object  of  this  operation  is  to  form  an  efficient 
fistula  between  the  stomach  and  the  skin  and  to  make  it  oblique,  so  as  to 
prevent  leakage  of  gastric  juices.  In  time  the  obliquity  is  lost,  but  yet  leakage 
does  not  take  place. 


GASTROSTOMY 


359 


The  Operation. — ^Open  the  abdomen  through  the  rectus  muscle  by  a  two- 
inch  vertical  incision  to  the  left  of  the  middle  line.  From  the  junction  of  the 
body  of  the  stomach  and  its  pyloric  portion  pull  into  the  wound  a  fold  of  the 
stomach  near  the  greater  curvature,  and  here  make  a  small  incision,  about  the 
calibre  of  a  lead-pencil,  through  the  serosa  and  musculosa.  Pick  up  the  mucosa 
with  forceps  and  open  the  stomach  cavity.  Take  a  soft-rubber  catheter,  about 
No.  25  Fr.;  close  one  end  of  the  catheter  or  tube  with  a  clamp  and  introduce 
the  other  end  into  the  stomach.     Cochem  writes  the  author  that  he  once  found 


Figs.  475  and  476.— Witzel's  gastrostomy. 

the  catheter  here  recommended  became  so  easily  clogged  with  food  that  the 
operation  was  a  failure  until  he  substituted  a  catheter  of  the  largest  size.  Fix 
the  tube  to  the  gastric  wound  with  one  or  more  catgut  structures.  Lay  the 
proximal  portion  of  the  tube  on  the  surface  of  the  stomach  and  bury  it  by  a  row 
of  Lembert  or  continuous  Lembert  sutures,  as  shown  in  Figs.  475  and  476. 
This  forms  a  canal  in  the  stomach- wall.  The  canal  should  be  i^  inches  in 
length  or  longer.     Unite,  with  sutures,  the  outer  opening  of  the  canal  to  the 


Figs.    477    and   478. — Stamm-Kader   gastrostomy. 

parietal  peritoneum.  Bring  the  free  portion  of  the  tube  out  through  the  ab- 
dominal wound.  Close  the  excess  of  abdominal  wound.  Over  the  portion  of 
the  tube  external  to  the  abdomen  slide  a  short  segment  of  a  larger  tube  fitting 
snuglv  to  the  main  tube.  This  outer  ring  of  tubing  is  pushed  up  to  beside  the 
skin,  and  through  it  is  passed  a  safety-pin  to  prevent  the  drain  from  penetrating 
too  far  into  the  stomach.  If  the  safety-pin  was  introduced  into  the  main  tube, 
stomach  contents  could  leak  out  alongside  of  it  and  irritate. 

(D)  Stamm-Kader  Operation. — Expose  and  open  the  stomach  as  in  the 
Witzel  operation.     Introduce  a  rubber  tube  and,  with  catgut,  suture  the  edge 


360 


THE    STOMACH 


of  the  gastric  wound  to  the  tul)e.  With  fine  chromicized  catgut  suture  the 
gastric  serosa,  about  }^  inch  distant  from  the  wound,  to  the  side  of  the  tube 
all  around  it  a  short  distance  from  the  wound  (Figs.  477  and  478).  Insert  a 
second  row  of  these  serous  sutures.  This  causes  an  inversion  or  invagina- 
tion of  the  stomach-wall,  which  serves  as  an  efficient  valve.  With  Lembert 
sutures  unite  the  stomach  around  the  tube  to  the  parietal  peritoneum.  Bring 
the  outer  portion  of  the  tube  through  the  abdominal  wound  at  a  convenient 
point.  Close  the  excess  of  abdominal  wound.  The  Stamm-Kader  operation 
is  the  only  one  applicable  when  the  stomach  is  much  diminished  in  size.  It 
is  an  excellent,  perhaps  the  best,  method  of  operating. 

An  easier  method  of  performing  the  operation  is  as  follows: 
Introduce  a  purse-string  suture  of  catgut  all  around  a  small  opening  in 
the  stomach-wall  exactly  as  when  a  Murphy  button  is  to  be  used.  Through 
the  opening  pass  the  bulb  of  a  Pezzer's  self-retaining  catheter  into  the  stomach. 
Pull  the  catgut  suture  snugly  round  the  shaft  of  the  catheter  and  tie  it.  In- 
troduce a  purse-string  suture  of  chromicized  catgut  in  the  stomach-wall  round 
and  about  J^  inch  distant  from  the  catheter.  As  this  suture  is  tightened  push 
the  catheter  inwards  and  invert  or  invaginate  the  stomach-wall.  Tie  the 
suture  but  leave  its  ends  long.  Using  the  catheter  as  a  handle  pull  the  stomach 
up  against  the  abdominal  wall.  With  a  needle  fix  the  long  ends  of  the  purse- 
string  suture  to  the  peritoneum  or  the  fascia  of  the  abdominal  wall.  If  de- 
sired introduce  one  or  two  sutures  to  unite  the  stomach,  near  the  gastrostomy 
opening,  to  the  peritoneum.  (This  is  usually  superfluous.)  Close  the  ab- 
dominal wound.  The  catheter  protrudes  through  the  abdominal  w-all  and 
aids  in  keeping  the  stomach  in  contact  with  it 

When  the  catheter  has  served  its  purpose  it  may  be  cut  off  flush  with 
the  skin  and  its  bulbous  end  permitted  to  drop  back  into  the  stomach. 

(E)  H.  H.  Janeway's  Gastrostomy  (Journ.  A.  M.  A.,  July  12,  1913). — 
Step  I. — Make  a  vertical  incision  through  the  inner  third  of  the  left  rectus 
muscle  beginning  at  a  point  about  i3^  inches  below  the  costal  margin.  Open 
the  abdomen.* 

Step  2. — Pull  out  of  the  wound  a  fold  of  the  anterior  wall  of  the  stomach 
slightly  to  the  right  of  the  abdominal  incision  and  anchor  it  with  forceps. 

Make  an  incision  into  the  stomach  about 
i^  inches  in  length  along  a  line  slightly 
oblique  from  above  and  the  left  to  the  right 
and  downwards.  This  incision  is  nearly 
transverse  to  the  long  axis  of  the  body. 
At  each  end  of  the  incision  make  a  cut  about 
^  inch  long  directed  towards  the  greater 
curvature. 

Step  3. — Make  traction  upwards  at  the 
point  X  (Fig.  479).     Unite  the  edges  X  A  C 
E  of  the  gastric  wound  to  the  edges  X  B  D  F. 
The  result  is  a  tube  about  2  inches  in  length  and  lined  with  gastric  mucosa. 

Step  4. — Method  A. — Suture  the  base  of  the  new  canal  to  the  margin  of  the 
rectus  sheath  and  its  tip  to  the  skin. 


Fig.  479. 


GASTROPEXY 


361 


Method  B. — Invert  the  base  of  the  canal  for  a  short  distance  into  the  stomach 
so  as  to  form  a  valve.     Treat  the  rest  of  the  tube  as  in  Method  A. 

The  canal  if  made  as  described  has  an  oblique  direction  toward  tshe  left 
and  is  therefore  in  itself  valvular.  It  is  completely  lined  by  mucosa  and  hence 
continuous  catheterization  is  not  necessary  in  order  to  keep  it  open. 

After-treatment. — It  is  better  to  administer  nourishment  per  rectum  for  a 
few  days  after  the  operation,  lest  vomiting  be  set  up.  If  the  patient  is  urgently 
in  need  of  nourishment,  it  may,  however,  be  at  once  introduced  by  the  catheter 
into  the  stomach.  For  weeks  after  operation  the  diet  should  be  liquid;  later 
solid  food  well  broken  up  or  chewed  by  the  patient  may  be  permitted. 

Gastroplication. — This  operation  is  occasionally  performed  in  cases  of 
gastric  dilatation.  It  is  exceedingly  simple  and  has  for  its  object  the  diminu- 
tion in  size  of  the  stomach. 

Step  I. — Open  the  abdomen  and  expose  the  stomach. 

Step  2. — Into  the  anterior  surface  of  the  stomach  introduce  several  rows 
of  exaggerated  Lembert  sutures  or  some  modification  thereof.  The  result 
is  an  invagination  of  segments  of  the  stomach-wall  and  consequent  decrease 
in  calibre  (Fig.  480). 

This  operation  is  not  curative,  in  that  the  cause  of  the  trouble  is  not  touched, 
and  relapse  is  the  rule. 


Fig.  480. — Gastroplication. 
{Monod  and  Vanverts.) 


Fig.  481. — Buret's  gastropexy. 
(Monod  and  Vanverts.) 


Gastropexy. — This  operation  has  been  performed  when,  on  account  of 
gastroptosis,  the  patient  has  become  a  chronic  invalid;  suffers  severely;  is 
much  emaciated,  and  none  of  these  conditions  is  satisfactorily  relieved  by 
the  ordinary  non-operative  methods  of  treatment.  The  object  of  the  opera- 
tion is  to  restore  the  stomach  to,  and  retain  it  in,  its  normal  position,  and 
thus  prevent  dragging  upon  the  gastro-hepatic  omentum  and  pressure  upon 
the  intestines  and  pelvic  organs,  as  well  as  obstruction  to  the  onward  passage 
of  food  from  the  stomach  offered  by  kinking  of  the  duodenum.  The  condition 
present  is  usually  one  of  general  visceral  ptosis,  hence  the  operation  is  commonly 
futile. 

Duret's  Operation. — Step  i. — Make  an  incision  in  the  median  line.     Open 


362  THE    STOMACH 

the  peritoneum  and  expose  the  stomach  in  the  lower  part  of  the  wound.     Ex- 
pose but  do  not  open  the  peritoneum  in  the  ujiper  part  of  the  wound. 

Step  2. — Insert  a  continuous  suture  on  the  modified  Lembert  plan,  so  as 
to  unite  the  stomach  and  upper  undivided  portion  of  peritoneum.     When  this 
suture  is  in  place,  make  both  ends  of  it  penetrate  the  fibromuscular  belly-wall 
and  tie  them  there  (Fig.  481). 
Step  3. — Close  the  wound. 

Rovsing^s  Operation. — Step  i. — Make  a  median  incision  from  the  ensiform 
cartilage  to  the  umbilicus. 

Step  2. — With  the  finger  pull  the  stomach  upwards  to  its  normal  level. 
Examine  the  pylorus  for  stenosis,  etc. 

Step  3. — Introduce  fairly  stout  silk  sutures  as  in  Fig.  482.  Do  not  tie 
them  until  the  surfaces  of  the  stomach  and  parietal  peritoneum  are  scarified 
where  they  are  to  be  apposed  and  the  belly-wall  is  sutured. 

Step  4.- — Close  the  abdominal  wound  and  place  on  it  a  pad  of  gauze  or 
a  plate  of  glass  covered  with  sterile  gauze  the  dimensions  of  which  are  a  little 
greater  than  the  stomach-surface  which  has  to  be  fixed.     Over  the  gauze  pad 

or  glass  plate  tie  the  sutures  suspending  the 
stomach.  These  sutures  are  left  in  situ  for  three 
or  four  weeks. 

The  operation  is  not  dangerous  and  has  given 

some  strikingly  brilliant  results.     ("Archiv  f.  klin. 

Chir.,"  Ix,  816.)     Rovsing   reports    the    following 

results:  Complete  cure,  63.2  per  cent.;  great  im- 

FiG.  482 — Rovsing's  provement,    12.8  per  cent.;   improvement,   7   per 

gas  ropexy.  cent.;  slight  improvement  or  no  change,  12.8  per 

cent.;  deaths,  4.6  per  cent.     None  of  the  deaths  could  be  fairly  attributed  to 

the  operation  (Trans.  Surg.  Section  A.  M.  A.,  191 2); 

Gastropexy  {Beyea's  operation)  has  been  accomplished  by  means  of  shorten- 
ing the  supports  of  the  stomach.  The  lesser  omentum  is  thrown  into  trans- 
verse folds,  which  are  rendered  permanent  by  a  few  sutures.  In  introducing 
the  sutures  be  careful  not  to  include  any  blood-vessels  in  their  bite.  Sir  Frederic 
Eve  ("Brit.  Med.  Journ.,"  May  7,  1910)  is  a  thorough  advocate  of  a  slight 
modification  of  Beyea's  operation.  The  Hver  is  well  raised  by  an  assistant 
and  the  lesser  omentum  fully  exposed.  The  stomach  is  suspended  by  four 
or  five  interrupted  silk  sutures  passed  above  through  the  upper  part  of  the 
gastro-hepatic  omentum  and  below  through  the  lesser  curvature  in  front 
of  the  vessels.  The  lesser  omentum  is  much  thicker  close  to  the  liver  than  it 
is  lower  down  but  if  the  whole  membrane  is  equally  thin  then  the  sutures 
are  passed  through  the  liver  substance  itself,  just  anterior  to  the  transverse 
fissure.  Of  seven  cases  operated  on  as  above  and  observed  for  a  sufficient  time 
afterwards,  six  were  cured. 

Grouse  ["Archives  of  Surg.,"  I,  550,  1920]  reinforces  the  plication  of  the 
gastro-hepatic  omentum  by  detaching  the  falsiform  and  round  ligaments  of 
the  liver  from  their  attachments  to  the  umbilicus  and  abdominal  wall,  leaving 
the  diaphragmatic  and  liver  fixation  points  intact  and  then  splitting  the  falci- 
form ligament  and  sewing  its  raw  surface  along  with  the  round  ligament  to  the 
plicated  gastrohepatic  omentum. 


in-CKR    STOMACH  363 

Operation  for  Ulceration  of  the  Stomach. — It  is  tempting  to  advise  opera- 
tion in  cases  of  acute  ulceration  where  there  is  a  copious  hemorrhage,  but 
recovery  generally  ensues  under  medical  treatment  and  operation  is  proper 
only  when  the  hemorrhage  is  not  merely  copious,  but  recurrent.  Ulcers  of  the 
stomach  not  producing  stenosis  ought  to  l)e  buried  by  invagination  with  sutures, 
or  better,  they  ought  to  be  excised.  Unless  the  invagination  or  the  excision 
gives  rise  to  stenosis,  gastro-enterostomy  ought  not  to  be  performed.  Every 
chronic  gastric  ulcer  with  hemorrhage  demands  operation.  For  those  who  be- 
lieve that  carcinoma  of  the  stomach  commonly  arises  on  the  basis  of  a  chronic 
ulcer  it  is  wise  to  excise  or  destroy  all  chronic  or  indurated  ulcers  whenever  this 
is  technically  feasible.  Balfour's  cauterization  is  excellent  for  this  purpose. 
Duodenal  ulcers  require  excision,  cauterization  or  invagination  to  produce  per- 
manent stasis,  plus  gastro-enterostomy,  otherwise  the  relief  afforded  by  the 
gastro-enterostomy  permits  partial  healing  of  the  ulcer,  a  return  of  the  pyloric 
function  and  a  return  of  the  symptoms.  This  rule  does  not  apply  when  nature 
has  herself  produced  the  stasis  by  contraction  of  scar  tissue  and  the  ulcer  has 
healed.  Excision  of  duodenal  ulcers  is  rarely  necessary  as  a  prophylactic 
against  malignancy  but  the  cautery  excision  is  of  great  value  in  preventing 
subsequent  hemorrhage. 

Donald  Balfour  (Sur.,  Gyn.,  Obst.,  xix,  528)  has  had  very  good  results  from 
the  use  of  the  cautery.  If  the  ulcer  is  on  the  lesser  curvature  he  carefully 
dissects  free  the  adjacent  lesser  omentum  and  then  burns  the  ulcer  completely 
with  a  Paquelin  cautery  kept  at  a  dull  heat.  This  of  course  perforates  the 
stomach.  The  wound  is  closed  by  a  few  through-and-through  chromicized  cat- 
gut stitches  and  these  are  buried  by  interrupted  sutures  of  chromicized  catgut. 
The  reflected  lesser  omentum  is  replaced  and  fixed  to  the  site  of  ulceration.  In 
suitable  cases  the  peritoneum  and  muscularis  may  be  reflected  as  a  flap  from 
over  the  ulcer;  the  ulcer  slowly  burned;  the  perforation  closed  with  catgut 
sutures  and  the  flap  replaced.     (Mayo,  Journ.  A.  M.  A.,  Sept.  25,  1915.) 

Moynihan  writes  (Brit.  Med.  Jour.,  July  12,  1919).— "Nowadays  I  perform, 
as  a  rule,  only  two  operations  for  cases  of  chronic  gastric  ulcer.  If  the  ulcer  is 
not  near  the  oesophagus,  and  is  of  average  or  small  size,  I  perform  partial 
gastrectomy.  If  the  ulcer  is  very  large,  burrowing  deeply  into  the  liver  or 
the  pancreas,  and  near  the  cardiac  end  of  the  stomach  I  perform  gastro-enter- 
ostomy in  Y,  and  into  the  proximal  limb  of  the  jejunum,  below  the  duodeno- 
jejunal flexure,  I  introduce  a  tube,  performing  jejunostomy.  Through  this 
tube  the  patient  is  exclusively  fed,  for  few  or  many  months,  until  an  X-ray 
examination  suggests  that  the  ulcer  is  healed." 

One  must  always  bear  in  mind  that  in  pure  neurasthenia  many  of  the 
symptoms  of  gastric  ulcer  may  be  present,  the  stomach  may  be  dilated,  etc., 
and  the  patient  may  be  in  such  a  frame  of  mind  as  to  tempt  the  surgeon  to 
perform  gastro-enterostomy.  If  the  abdomen  is  opened  and  no  scar  of  ulcer 
is  found  and  there  is  no  enlargement  of  the  gastric  lymph  nodes  indicating 
ulcer,  do  not  perform  gastro-enterostomy,  as  the  latter  state  of  such  a  patient 
is  very  liable  to  be  worse  than  the  first.  The  most  experienced  surgeons  are 
completely  skeptical  as  to  the  existence  of  the  so-called  "mucous  ulcers"  which 
cause  bleeding  but  cannot  be  seen  either  on  the  operating  or  postmortem  table. 


364  THE    STOMACH 

Whenever  there  is  acute  perforation  of  the  gastric  wall  from  ulceration, 
operation  is  imperative.  Excision  of  the  ulcer  is  unnecessary.  All  that  is 
necessary  is  to  close  the  ulcer  with  a  single  stitch  of  catgut  and  to  infold  the 
ulcer  and  a  portion  of  healthy  stomach  with  two  rows  of  continuous  Lembert 
sutures  (Moynihan)  or  to  use  Balfour's  operation.  If  there  has  been  much 
soiling,  flush  the  cavity;  "if  the  operation  is  done  within  ten  or  twelve  hours,  a 
gentle  wiping  of  the  surrounding  area  with  wet  swabs  will  suffice.  Drainage, 
as  a  rule,  is  not  necessary  except  in  the  late  cases.  When  adopted  it  should  be 
free,  a  split  tube  and  a  gauze  wick  being  placed  in  the  original  incision  and  in 
a  second  suprapubic  opening."  Do  not  be  content  with  finding  and  closing 
one  perforation:  look  for  more. 

When  operating  for  perforating  ulcer,  if  the  patient  is  in  very  poor  con- 
dition, it  is  often  wise  to  follow  W.  G.  Richardson's  advice  (Northumberland 
and  Durham  Med.  J.,  Nov.  12,  1903)  and  pass  a  rubber  tube  through  the 
perforation  into  the  stomach.  By  stitching  the  stomach  surrounding  the  tube 
to  the  parietes  a  fistula  is  established  through  which  the  stomach  may  be 
washed  and  food  administered.  After  a  few  days  the  tube  may  be  removed 
and  usually  the  opening  closes  spontaneously. 

In  the  preceding  remarks  no  account  has  been  taken  of  the  presence  of 
adhesions,  or  of  scars  and  stenoses  resulting  from  ulceration.  Adhesions 
are  Nature's  means  of  protecting  the  peritoneal  cavity  from  general  infection, 
but  while  immediately  life-saving,  they  are  very  liable  to  occasion  much  gastric 
disturbance,  and  certainly  make  operative  interference  much  more  difficult. 
The  mere  breaking-down  of  gastric  adhesions  (gastrolysis)  often  suffices  to 
cure  apparently  inveterate  cases  of  dyspepsia.  Mayo  Robson  ("Trans- 
actions Am.  Surg.  Association,"  xix)  has  carried  out  this  treatment  fifty-six  times 
with  complete  success.  Before  closing  any  perforation  or  before  uniting 
bowel  to  stomach,  if  adhesions  exist,  they  must  be  so  broken  down  or  divided 
that  the  parts  to  be  united  tend  to  lie  together,  and  the  sutures  when  inserted 
keep  the  parts  together  •without  any  tension.  Tension  on  sutures  is  fatal. 
The  technical  difficulties  occasioned  by  adhesions  may  dominate  the  choice 
of  operation  for  the  relief  of  ulcer  or  its  sequelae.  More 
than  90  per  cent,  of  gastric  ulcers  are  situated  along  the 
lesser  curvature,  often  constituting  the  so-called  saddle 
ulcer  where  the  disease  extends  on  to  both  the  anterior 
and  posterior  walls  of  the  stomach.  Ulcers  not  along  the 
lesser  curvature  are  more  frequent  on  the  posterior  than  the 
anterior  wall  of  the  stomach.  Less  than  6  per  cent,  of  the 
'  ^  ^'  ulcers  seen  are  multiple  (Mayo).     It  is  very  commonly 

accepted  that  chronic  gastric  ulcers  may  and  do  act  as  the  starting-point  of 
malignant  disease.  Influenced  by  the  above  consideration,  Rodman  has  sug- 
gested the  advisabihty  of  excising  the  pylorus  and  that  portion  of  the  stomach 
most  commonly  the  seat  of  ulceration.  The  lines  of  incision  advised  by  this 
surgeon  are  shown  in  Fig.  483.  Operations  for  the  excision  of  gastric  ulcers 
are  described  in  the  sections  devoted  to  partial  gastrectomy  and  to  pylorectomy . 
Gastro-enterostomy,  or  anastomosis  between  the  stomach  and  intestine, 
is  indicated  in  cases  of  pyloric  obstruction,  and  of  ulceration.     According  to 


ANTERIOR   GASTRO-ENTEROSTOMY 


365 


the  portion  of  intestine  selected  for  anastomosis,  the  name  "gastro-duodenos- 
tomy"  or  "gastro-jcjunostomy"  may  be  used. 

According  to  whether  the  gut  is  united  to  the  anterior  or  to  the  posterior 
wall  of  the  stomach,  the  operation  is  designated  "anterior"  or  "posterior 
gastro-enterostomy . " 

Woljler's  Operation. — Anterior  Gastro-enterostomy. — The  preparation  of  the 
patient  is  the  same  as  in  exploratory  gastrotomy. 

Step  I. — Open  the  abdomen  by  an  incision  in  or  near  the  middle  line,  be- 
tween the  umbilicus  and  the  ensiform  cartilage.  The  cut  is  about  four  inches 
long. 


Fig.  484. — Anterior  gastro-enterostomy.     (Mayo.) 

* 

Step  2. — Expose  the  small  intestine  by  pulling  the  omentum  upwards  and 
to  the  left.  Find  the  jejunum  by  the  method  described  on  page  366.  Empty 
the  loop  of  gut  and  apply  clamps  to  keep  it  empty. 

Step  3. — On  the  lowest  possible  point  of  the  anterior  wall  of  the  stomach 
select  a  spot  for  the  stomach  opening  (Fig.  484).  Pull  this  portion  of  stomach 
and  the  loop  of  jejunum  out  of  the  belly  and  protect  the  cavity  with  gauze  pads. 
Make  an  anastomosis  between  the  stomach  and  the  jejunum,  using  either 
sutures  or  the  Murphy  button.  The  method  of  making  the  anastomosis  is 
identical  with  that  employed  in  posterior  gastro-enterostomy,  page  368. 

Step  4. — Cleanse  the  field  of  operation.     Put  aside  all  instruments  which 


366 


THE    STOMACH 


have  touched  the  mucosa.  Inspect  the  line  of  union,  and  if  necessary  rein- 
force it  with  a  few  Lembcrt  sutures.  If  the  point  of  union  causes  the  intestine 
to  kink  sharply,  this  may  be  remedied  by  a  few  stitches  uniting  to  the  stomach 
a  little  more  of  the  afferent  or  efferent  portions  of  gut  or  of  both. 

Step  5. — Close  the  abdominal  wound.  The  after-treatment  is  the  same  as 
for  exploratory  gastrotomy.  Anterior  gastro-enterostomy  is  practically  obsolete. 
Occasionally  it  may  be  of  use  in  j)yloric  obstruction  when  the  patient  is  so  weak 
that  the  simplest  possible  method  must  be  chosen  and  under  such  circumstances 
possibly  a  jejunostomy  might  be  preferable. 

Posterior  Gastro-enterostomy.  Step  i. — Expose  the  stomach  through  an 
incision  'j'i  inch  to  the  right  of  the  median  line.  Examine  the  whole  anterior 
surface  of  the  stomach  and  duodenum.  No  matter  what  condition  is  apparent 
at  the  first  glance,  there  may  be  something  else  present,  e.g.,  a  trifid  stomach, 
which  it  is  necessary  to  recognize.  Remember  that  enlarged  lymph  nodes  may 
give  information  as  to  the  site  of  an  ulcer. 


Fig.   485. — Exposure   of  beginning   of  jejunum. 

Step  2. — -Lift  the  transverse  colon  out  of  the  abdomen  and  by  pulling  up- 
wards and  to  the  right,  bring  so  much  of  the  mesocolon  with  it  that  the  jejunum 
becomes  visible  (Fig.  485).  The  jejunum  from  its  point  of  origin  at  the  trans- 
verse mesocolon  passes  downwards,  to  the  left  and  backwards,  i.e.,  it  goes  into 
the  left  kidney  pouch  below  the  splenic  flexure  of  the  colon.  The  duodeno- 
jejunal junction  (the  origin  of  the  jejunum)  is  well  fixed  or  immobile,  lies  about 
i>^  to  2  inches  above  the  umbilicus  and  its  level  is  only  about  2  inches  lower 
than  that  of  the  pylorus.  To  avoid  kinking,  any  anastomosis  between  the 
stomach  and  jejunum  should  be  made  along  the  natural  line  of  relationship 
between  these  two  viscera,  i.e.,  along  a  line  on  the  posterior  gastric  wall  running 
from  above  downwards  and  towards  the  left.  The  origin  of  the  jejunum  being 
a  fixed  point,  if  the  anastomosis  is  made  at  too  high  a  level  the  jejunum  will 
pull  the  stomach  upwards  and  trouble  may  result.  If  the  anastomosis  is  too 
low  there  will  be  a  loop  of  jejunum  above  it  and  if,  as  has  often  happened,  this 
loop  becomes  filled  with  bile,  etc.,  the  weight  of  its  contents  can  pull  it  down  and 
cause  angulation  at  the  anastomosis.  This  is  the  principal  cause  of  the  'vicious 
circle'  which  was  the  chief  danger  in  the  early  days  of  gastro-enterostomy. 


POSTERIOR    GASTRO-ENTEROSTOMY 


367 


Pick  up  a  i)ropcr  loop  of  jejunum,  usually  about  three  inches  from  the  duo- 
deno-jejunal  junction.  Note  the  fold  of  peritoneum  passing  from  the  jejunal 
origin  to  the  transverse  meso-colon;  near  where  this  fold  joins  the  mesocolon 
is  the  best  place  to  tear  a  hole  in  the  mesocolon  and  expose  the  posterior  surface 
of  the  stomach  (Fig.  486).  Sometimes  this  fold  of  peritoneum  (ligament  of 
Trcitz)  extends  so  far  down  the  jejunum  that  an  anastomosis  between  the 
stomach  and  the  jejunum  distal  to  the  fold  leaves  sufficient  gut  above  the  anas- 
tomosis to  form  a  dangerous  loop.     When  such  is  the  case  divide  the  fold  of 


Fig.  4S6. — Colon  and  transverse  mesocolon  pulled  upwards  exposing  jejunum. 
Exposure  stomach  through  rent  in  mesocolon.     Limited  separation  of  gastro-colic  omentum  and  gastro- 
epiploic vessels  from  lowest  point  of  greater  curvature  of  stomach  permits  exposure  of  small  portion  of 
anterior  wall  stomach.     Fold  of  stomach  in  clamp  consists  of  a  small  portion  of  the  anterior  and  large  por- 
tion of  the  posterior  wall. 


peritoneum  as  the  avoidance  of  any  loop  of  gut  above  the  anastomosis  is  of 
prime  importance.  Division  of  the  fold  is  not  always  innocuous.  J.  H.  Nicoll 
(Brit.  Med.  Journ.,  Oct.  21,  1916)  found  in  one  case,  that  the  resultant  raw 
surface  on  the  intestine  became  adherent  to  the  under  surface  of  the  transverse 
meso-colon  causing  occlusion  of  the  loop  of  gut  leading  to  the  neostoma.  There 
was  reflux  of  duodenal  contents  through  the  pylorus  into  the  stomach  with 
inveterate  vomiting.  If  the  raw  surface  on  the  jejunum  is  utilized  in  the 
gastro-enterostomy,  i.e.,  if  the  opening  into  the  gut  is  made  in  this  area  then 
the  accident  reported  by  Nicoll  could  hardly  arise. 


368 


THE    STOMACH 


Step  3. — Tear  a  hole  through  a  non-vascular  area  of  mesocolon.  Pull  a 
portion  of  the  posterior  wall  of  the  stomach  through  this  hole.  By  separating 
the  gastro-colic  omentum,  and  with  it  the  gastro-epiploic  artery  from  the 
greater  curvature  of  the  stomach  for  a  short  distance  it  is  easy  to  pull  a  portion 
of  the  anterior  as  well  as  of  the  posterior  wall  of  the  stomach  through  the  rent 
in  the  mesocolon  (Fig.  486).  It  is  important  to  do  this  in  order  to  drain  the 
very  lowest  point  of  the  stomach.  Apply  a  gastro-enterostomy  clamp  to  a 
fold  of  stomach,  including  about  one  inch  of  the  anterior  wall.  The  direction 
of  the  clamp  and  of  the  contained  fold  must  be  from  right  to  left,  and  from 
above  downwards  (Fig.  486). 

Step  4. — Apply  a  similar  gastro-enterostomy  clamp  to  the  jejunum  along 
its  long  axis.  The  highest  point  of  the  gut  grasped  in  the  clamp  must  be  i3^ 
to  33-^  inches  from  the  duodeno-jejunal  junction  (Fig.  487). 


Fig.  487. — Posterior  gastro-enterostomy. 


Step  5.— Lay  the  two  clamps  side  by  side.  Place  a  narrow  gauze  pad  imme- 
diately behind  the  clamps,  between  the  stomach  and  the  jejunum.  With  other 
pads  placed  beneath  the  clamps  and  around  the  segregated  portions  of  stomach 
and  jejunum  thoroughly  shut  off  from  contamination  the  abdominal  cavity 
and  the  abdominal  wound. 

Sinclair  White  and  some  others  have  given  up  the  use  of  clamps  because  of 
fatal  hemorrhage  having  taken  place  from  the  suture  line  after  their  removal. 
If  the  following  method  is  used  there  is  little  if  any  danger  of  bleeding,  certainly 
the  danger  from  this  source  is  less  than  the  danger  to  be  apprehended  from 
soiling  of  the  field  of  operation  and  from  loss  of  blood  during  the  operation  in 
weak  patients  when  the  clamps  are  not  used.  When  hemorrhage  takes  place  it 
is  from  the  posterior  suture  line  of  the  gastro-jejunostomy. 

Unite  the  stomach  to  the  jejunum  for  a  distance  of  about  2^^  inches  by  a 
row  of  mattress  sutures  exactly  as  in  intestinal  lateral  anastomosis  (posterior 
serous  suture).  Make  an  incision  parallel  to  and  shorter  than  the  posterior 
serous  suture,  through  all  the  coats  of  the  stomach  except  the  mucosa.     The 


POSTERIOR   GASTRO-ENTEROSTOMY 


369 


mucosa  now  pouts  up  into  the  wound.  Make  a  corresponding  incision  in  the 
jejunum.  Introduce  a  button-hole  or  locking  continuous  suture  of  chro- 
micized  or  formalinized  catgut,  including  in  each  stitch  (a)  a  bite  of  the  unopened 
gastric  mucosa,  (b)  the  other  coats  of  the  stomach,  (c)  the  serous  and  muscular 
coats  of  the  jejunum,  (d)  a  bite  of  the  unopened  jejunal  mucosa.  This  line 
of  suture  unites  the  posterior  edges  of  the  stomach  wound  to  the  corresponding 
wound  in  the  jejunum   (Fig.  488).     Incise  the  mucosa  of  the  stomach    and 


Fig.  488. — Gastro-jejunostomy  made  with  three  lines  of  sutures  on  posterior  line  because 
of  occasional  hemorrhage  into  the  gastro-intestinal  tract  after  clamps  are  removed.  Drawing 
shows  catgut  button-hole  (second  line  of  sutures)  suture  applied  posteriorly  without  opening 
mucous  membrane.     (Mayo.) 


jejunum  and  with  the  same  needle  and  catgut  suture  used  in  the  preceding  line 
of  suture  unite  by  a  whip  stitch  the  mucous  coats  of  the  stomach  and  jejunum 
(Fig.  489).  With  the  same  suture  unite  the  anterior  edges  of  the  stomach 
and  intestinal  wounds  by  means  of  a  Connel  stitch  (through  all  the  coats  of  the 
organs)  or  of  a  through-and-through  buttonhole  (or  locking  stitch)  exactly  as 
in  lateral  anastomosis.  Remove  the  intestinal  clamps.  Complete  the  serous 
suture  as  in  lateral  anastomosis.  Discard  all  instruments  used  in  making  the 
anastomosis;  they  are  soiled.  Cleanse  the  operative  field.  Remove  the  gauze 
pads.  By  taking  hold  of  both  ends  of  the  narrow  gauze  pad  or  strip  placed  be- 
hind the  site  of  anastomosis  and  manipulating  it  properly  it  is  easy  to  bring 
into  view  the  whole  posterior  surface  of  the  anastomosis  for  inspection.     // 


370 


THE    STOMACH 


necessary  introduce  one  or  more  Lembert  or  Gould  sutures  to  assure  safe  union. 
The  gastro-enterostomy  is  complete. 

Step  6. — Unless  the  opening  in  the  gastro-colic  omentum  is  rendered  secure 
hernia  of  the  small  intestine  or  omentum  through  it  into  the  lesser  peritoneal 
cavity  can  take  place  and  cause  disaster. 

With  three  or  four  sutures  unite  the  lower  peritoneal  surface  of  the  meso- 
colon, a  quarter  of  an  inch  away  from  the  rent,  to  the  suture  line  and  tuck  in 
the  torn  edges  of  the  rent  so  as  to  avoid  adhesions.     If  the  mesocolon  is  fat 


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Fig.  489. — Gastro-jejunostomy  made  with  three  sutures  on  posterior  line  because  of 
occasional  hemorrhage  into  the  gastro-intestinal  tract  after  clamps  are  removed.  Drawing 
shows  mucous  membrane  opened.  Running  suture  of  catgut  to  bring  mucous  coats  of  stomach 
and  jejunum  together.     {Mayo.) 


attach  the  torn  margins  of  the  opening  to  the  stomach  (instead  of  to  the  suture 
line)  so  as  to  avoid  the  formation  of  a  coUar-Hke  band  at  the  anastomosis 
(Mayo). 

In  order  to  give  nourishment  early  after  gastro-enterostomy  and  to  avoid 
irritating  the  stomach  with  food,  A  Hammestahr  (Cent,  fiir  Chir.,  Jan.  6,  1903) 
uses  Rutkowsky's  method  of  combining  a  gastro-enterostomy  with  a  gastros- 
tomy. A  catheter  is  introduced  through  the  gastric  fistula  into  the  jejunum 
and  is  kept  in  place  until  the  stomach  is  in  condition  to  take  care  of  food. 
Feeding  is  carried  on  through  the  catheter.     On  removal  of  thf  catheter  the 


MAURY  S    OPERATION 


37^ 


fistula  quickly  closes.  The  method  seems  entirely  unnecessary  and  objection- 
able. 

Maury's  Method. — Maury's  operation  is  essentially  a  modification  of  Mc- 
Graw's,  but  is  accomplished  with  materials  always  at  hand  (strong  cord  in- 
stead of  elastic  ligatures). 

Steps  1,2,3  ^re  the  same  as  in  the  preceding  operation,  except  that  no  clamps 
are  used. 

Step  4. — Lay  the  chosen  segment  of  jejunum  against  the  lower  portion  of 
the  stomach.  Insert  a  row  of  Lembert  sutures,  90  degrees  distant  from  the 
mesentery,  and  so  unite  the  intestine,  to  the  stomach.  Leave  the  ends  of  this 
the  posterior  line  of  Lembert  sutures,  long. 


Fig.  490. — Maury's  method  of  gastro-enterostomy. 


Step  5. — Thread  a  straight,  round  needle  (darning-needle),  3  inches  long, 
with  very  strong  twine.  Introduce  the  needle  into  the  stomach  at  the  point 
A  (Fig.  490).  Be  sure  the  mucosa  is  penetrated.  The  point  A  should  be 
near  the  vessels  of  the  greater  curvature,  and  the  distance  between  A  and 
X  (the  mid-point  of  the  line  of  Lembert  sutures)  should  be  less  than  the  diameter 
of  the  gut.  Bring  the  needle  out  from  the  stomach  at  the  point  B,  ^  inch  from 
the  beginning  of  the  Lembert  suture.  Make  the  needle  traverse  the  intestine 
from  C  to  D  and  the  stomach  from  E  to  F.  The  points  D  and  E  must  be  3^ 
inch  from  the  ends  of  the  Lembert  suture. 

Make  the  same  needle  and  thread  traverse  the  gut  from  G  to  H,  the  stomach 
from  I  to  J,  and  lastly  the  gut  from  K  to  L. 

This  apparently  comphcated  but  really  simple  series  of  stitches  forms  two 
equal  triangles  the  apices  of  which  (A  F,  L  G)  are  equidistant  from  the  middle 
of  the  base  (X). 

Step  6. — Pull  firmly  on  the  ends  of  the  twine  (S,  S')  and  tie  very  tightly. 
This  is  of  great  importance,  as  necrosis  of  the  included  tissues  is  essential. 


372 


THE    STOMACH 


Step  7. — Continue  the  line  of  Lembert  sutures  already  in  place  completely 
around  the  site  of  the  twine.  The  tying  of  the  twine  will  have  thrown  the  sur- 
face of  the  gut  into  a  number  of  radiating  folds,  therefore  to  obliterate  these 
while  completing  the  Lembert  sutures  insert  the  stitches  as  much  as  possible  at 
the  bottom  of  these  sulci. 


Wire 


Edges  of  split  in  transverse 
mesocolon  sutured  to 
stomach. 

Gaslro-enter  ostomy . 


Entero-enterostomy . 


Fig.  491. 


Fig.  492. 


Roux's  Operation;  Operation  en  Y. — Steps  i,  2,  and  3,  as  in  posterior  gastro- 
enterostomy. 

Step  4. — Having  chosen  the  appropriate  portion  of  jejunum,  empty  it  of 
its  contents,  apply  two  clamps,  and  completely  divide  the  gut  between  them. 
Anastomose  w'ith  suture  or  button  the  open  end  of  the  lower  segment  of  gut 
to  the  posterior  wall  of  the  stomach  (Fig.  493).     Anastomose  the  open  end  of 

the  proximal  or  duodenal  segment  of  the  gut  to 
the  side  of  the  lower  segment  of  gut,  a  few 
inches  below  the  site  of  the  gastro-enterostomy. 
Many  surgeons,  to  avoid  the  possibility  of 
the  formation  of  a  "vicious  circle"  (page  375), 
complete  the  gastro-enterostomy  by  forming  an 
anastomosis  between  the  afferent  and  efferent 
loops  of  jejunum  at  a  point  6  inches  lower 
down  the  gut  (Fig.  491).  Fowler,  to  make 
assurance  doubly  sure,  encircled  the  afferent 
loop,  between  the  two  points  of  anastomosis, 
with  a  silver  wire  thread  to  obliterate  its 
lumen;  the  same  object  may  be  attained  by  a 
purse-string  suture  of  silk  around  the  gut  at 
the  same  place,  Fig.  492. 
Pyloric  Exclusion. — The  above  methods  endeavoring  to  obliterate  the  gut 
lumen  have  proven  unreliable,  at  least  in  the  case  of  the  pylorus,  as  the  sutures 
or  ligatures  become  extruded  into  the  gut  which  soon  assumes  its  former  size. 
Lambotte  finds  that  if  the  ligature  is  tied  tightly  enough  to  obstruct  but  not 
tightly  enough  to  strangulate  or  cause  pressure,  then  the  desired  occlusion  is 
attained  and  maintained.  Brewer  uses  strips  of  aluminum  instead  of  threads. 
For  the  same  purpose  and  also  to  prevent  the  passage  of  food  into  the 
duodenum  after  gastro-enterostomy  for  duodenal  ulcer  various  methods  of 


Fig.  493. 
tomv. 


— Roux's  gastro-enteros- 

{Monod  and  Vanverts.) 


PYLORIC    EXCLUSION 


373 


pyloric  exclusion  have  been  practised.  Operative  closure  of  the  stomach  or 
duodenum  above  the  ulcer  is  not  indicated  when  there  is  sufficient  stenosis  due 
to  the  ulceration. 

Bier  writes:  "pyloric  occlusion  ought  never  to  be  omitted  in  cases  of  gastro- 
jejunostomy when  well-marked  stenosis  is  absent  and  when  the  operation  has 
been  performed  for  very  painful  or  bleeding  ulcers  of  the  pylorus  or  particularly 
of  the  duodenum." 

1.  Doyen  and  v.  Eiselsberg's  Method. — -Choose  a  place  to  the  oral  side  of  the 
ulcer  and  in  healthy  tissue.  Make  an  opening,  close  to  the  lesser  curvature, 
through  the  lesser  omentum  and  a  corresponding  opening  close  to  the  greater 
curvature,  through  the  gastro-colic  omentum.  Apply  two  clamps  to  the  stom- 
ach. Place  a  strip  of  gauze  behind  the  clamped  portion  of  the  stomach. 
Divide  the  stomach  between  the  clamps  with  a  thermo-cautery.  Close  each 
stump  by  a  row  of  through-and-through  sutures  buried  by  a  row  of  serous 
sutures. 

2.  BartleWs  Method  (Journ.  A.  M.  A.,  Aug.  15,  1914). — Choose  a  place  on  the 
oral  side  of  the  ulcer  (whether  of  the  duodenum,  pylorus  or  pyloric  antrum). 
Make  an  opening  through  the  great  omentum  close  to  the  greater  curvature. 
Apply  two  crushing  clamps  to  two-thirds  of  the  diameter  of  the  stomach  and  cut 
between  them.  Close  the  wound  with  through-and-through  sutures.  Bury 
this  line  of  sutures  by  serous  sutures  (Fig.  494). 


Fig.  494. — Bartlett's  method. 


Fig.  495. — Bier's  method. 


3.  Bier's  Method. — Well  to  the  oral  side  of  the  ulcer  and  on  healthy  tissue 
apply  a  crushing  clamp,  e.g.,  Payr's,  to  the  stomach.  Remove  the  clamp  and 
replace  it  by  a  strong  ligature.  Bury  the  ligature  with  a  row  of  serous  sutures 
(Fig.  495). 

4.  Author^ s  Method. — ^Ligate  and  cut  away  a  sufficient  tag  of  great  omentum. 
Apply  this  tag  like  a  ligature  tightly  around  the  pylorus.  Bury  the  implant 
by  a  row  of  serous  sutures.  A  strip  of  fascia  may  be  used  in  the  same  fashion 
(Wilms). 

5.  C.  H.  Mayo's  Method. — Introduce  a  closed  hemostat  through  the  great 
omentum  close  to  the  greater  curvature,  pass  it  upwards  behind  the  stomach 
and  make  its  point  seize  the  lesser  omentum  some  distance  above  the  lesser 
curvature.     Pull  the  lesser  omentum  behind  the  stomach  out  through  the  per- 


;74 


THE    STOMACH 


forated  great  omentum  and  then  upwards  in  front  of  the  stomach  to  be  sutured 
to  the  rest  of  the  lesser  omentum. 

6.  Brewer  (Surg.,  Gyn.,  Obst.,  Feb.  1914). — Pass  a  band  of  aluminum  about 
5  cm.  long  by  i  cm.  wide  around  the  pylorus  and  compress  it  sufficiently  to 
obliterate  the  lumen  without  interfering  with  nutrition. 


Fig.  498. — {Porta,  J.  de  Chir.) 


Fig.  499. — {Porta,  J.  de  Chir.) 


Fig.  500. — {Porta,  J.  de  Chir.) 


Fig.  501. — {Porta,  J.  de  Chir.) 


7.  Biondi's  Method  (Figs.  496  to  501). — In  the  middle  of  the  anterior  sur- 
face of  the  antrum  pylori  make  an  incision  about  6-10  cm.  long  in  the  long  axis 
of  the  stomach  and  duodenum.  Most  of  this  incision  should  be  on  the  gas- 
tric side  of  the  pylorus.  Cut  through  the  peritoneum  and  the  muscular  and 
submucous  tunics  but  leave  the  mucosa  intact.     Shell  a  segment  of  the  mucosa 


JEJUNAL    ULCER  375 

as  a  tube  out  of  its  submucous  bed  and  doubly  ligate  and  divide  this  tube 
at  each  end.  Close  the  wound  in  the  serous  and  muscular  tunics.  Of  these 
methods,  section  of  the  pylorus  (Doyen,  v.  Eiselsberg,  Bartlett)  is  the  most 
efficacious  and  least  safe. 

Biondi's  operation  seems  good.  Probably  the  methods  devised  by  the 
author  and  Bier  are  the  simplest  and  least  efficacious. 

Instead  of  using  these  methods  of  pyloric  occlusion,  some  surgeons  having 
supplemented  the  gastro-enterostomy  by  making  a  lateral  anastomosis  be- 
tween the  afferent  and  efferent  loops  of  jejunum  completely  divide  the  afferent 
loop  between  the  two  points  of  anastomosis  and  close  the  open  ends  of  the  gut 
by  purse-string  sutures  (Fig.  491).  This  method  has  all  the  advantages  of 
Roux's  operation,  but  does  not  interfere  to  the  same  extent  with  the  mesentery. 
It  is  certain  that  in  the  hands  of  most  surgeons,  the  dangers  of  the  vicious 
circle  are  less  than  those  incident  to  the  complicated  methods  devised  for  its 
avoidance. 

Occlusion  of  the  duodenum  must  never  be  practised  if  the  McGraw  elastic 
ligature  or  Murphy's  triangular  string  method  have  been  employed  in  making  the 
gastro-enterostomy.  By  these  methods  it  takes  about  seventy-two  hours  to 
establish  gastric  drainage.  Maury's  experiments  ("Surg.,  Gyn.  and  Obstet- 
rics," May,  1906)  clearly  show  that  if,  in  dogs,  the  gut  is  divided  and  both  ends 
closed  at  any  point  nearer  to  the  pylorus  than  14  inches  (35  cm.)  and  the  distal 
segment  is  united  to  the  stomach  by  the  ligature  method,  the  dog  will  promptly 
die  with  symptoms  of  tetany.  The  death  in  these  cases  seems  to  be  from  some 
form  of  auto-intoxication  due  to  the  want  of  gastric  drainage,  because  when  a 
fistula  is  established  between  the  stomach  and  the  distal  portion  of  gut  at  the 
time  of  the  operation,  no  such  catastrophe  arises. 

The  Vicious  Circle.^ — When  the  afferent  portion  of  gut  is  so  placed  that 
stomach  contents  pass  into  it  instead  of  into  the  efferent  loop,  grave  conse- 
quences are  liable  to  ensue,  and  to  the  condition  the  name  "vicious  circle"  has 
been  given.  The  accident  seems  to  be  very  rare  after  posterior  gastro-enter- 
ostomy. Roux's  operation,  "en  Y,"  almost  precludes  its  possibility,  and  the 
various  methods  of  adding  an  enterostomy  to  the  gastro-enterostomy  give  safety 
in  regard  to  the  vicious  circle,  but  of  course  add  distinctly  to  the  gravity  of 
the  operative  procedure.  No  symptoms  of  the  vicious  circle  seem  to  have 
followed  the  performance  of  the  no-loop  operation. 

Peptic,  Gastro-jejunal  or  Jejunal  Ulcer.^ — Braun  and  Mikulicz  have  shown 
that  the  duodenum  and  upper  segments  of  the  jejunum  are  more  resistant  to 
the  corrosive  action  of  the  gastric  juices  than  are  the  lower  segments  of  gut. 
In  posterior  gastro-enterostomy  the  portion  of  gut  opened  is  9  inches  below 
the  duodeno-jejunal  fold,  while  in  the  anterior  operation  it  is  16  to  20  inches 
below  that  point.  Several  cases  of  fatal  peptic  ulcer  have  been  noted  after  the 
anterior  operation — hence  this  constitutes  an  argument  in  favor  of  the  posterior 
and  especially  of  the  no-loop  method.  The  ulcers  occur  at  the  point  of  anasto- 
mosis or  within  4  inches  of  it. 

Mayo  finds  that  the  employment  of  continuous  non-absorbable  sutures  (even 
in  the  serous  coats)  in  gastro-enterostomy  occasionally  causes  ulceration  at  the 
site  of  anastomosis. 


376 


THE    STOMACH 


If  jejunal  ulcer  is  diagnosed  some  time  after  the  operation  of  gastro-enter- 
ostomy  and  general  treatment  has  proved  useless  the  abdomen  must  be  opened 
again  and  the  anastomosis  and  neighboring  jejunum  examined. 

Mayo-Robson  ("Brit.  Med.  Journ.,"  Jan.  6,  191 2)  advises  as  follows: 

1.  There  is  ulceration  at  the  anastomosis  or  in  the  jejunum.  The  original 
pyloric  or  duodenal  ulcer  has  healed  (without  stenosis).  Detach  the  jejunum 
from  the  stomach.  Excise  the  ulcer.  Close  the  openings  in  the  stomach  and 
jejunum.  If  the  gastro- jejunal  ulcer  is  extensive  excise  that  segment  of  gut. 
Restore  the  continuity  of  the  gut  by  end-to-end  anastomosis.  Close  the  opening 
in  the  stomach. 

2.  The  pyloric  or  duodenal  ulcer  in  healing  has  caused  stenosis.  Either 
choose  a  new  site  for  posterior  anastomosis  or  perform  Roux's  gastro-enteros- 
tomy,  after  excising  the  ulcer  or  the  ulcerated  segment  of  jejunum. 

3.  The  anastomotic  opening  is  healthy;  the  jejunum  alone  is  affected. 
Excise  the  ulcer,  repair  the  bowel,  do  not  interfere  with  the  anastomosis. 

4.  If  the  patient  is  profoundly  ill  and  unable  to  bear  a  prolonged  operation 
perform  jejunostomy,  so  that  he  may  be  fed  and  the  ulcer,  whether  in  the  jeju- 
num, stomach  or  duodenum,  can  be  given  complete  rest  until  healing  is  effected. 

Choice  of  Method  by  Which  to  Efifect  the  Anastomosis. — Unless  under  very 
exceptional  circumstances  the  anastomosis  by  suture  is  the  method  of  choice. 
Where  haste  is  the  prime  consideration  Murphy's  button  has  its  place  of  useful- 
ness as  a  time  saver. 


Fig.  502. 


Fig.  503. 


Fig.  504. 


Fig.  505 


Fig.  506 


Fig.  507. 


0-  X  10.    «,uu  r 

Figs.  502  to  507. — Hour-glass  stomach.     (Moynihan.) 

Operation  for  "Hour-glass"  Stomach. — The  figures  (502  to  507*)  suffi- 
ciently explain  the  older  methods  of  operating  on  hour-glass  contraction  of  the 
stomach.  In  Fig.  502  an  anastomosis  is  made  between  the  two  gastric  pouches 
at  the  points  X  and  Y.  In  Fig.  505  the  cardiac  pouch,  being  large  and  depend- 
ent, is  united  to  the  jejunum.  In  Figs.  503  and  504  and  incision  is  made  through 
the  lowest  part  of  the  constriction  and  when  the  edges  of  the  cardiac  side  are 

*  Figs.  502  to  507  are  taken  from  Moynihan's  work,  but  Figs.  503  and  504  have  been 
modified. 


CONGENITAL   PYLORIC    STENOSIS  377 

united  to  those  of  the  pyloric  side,  the  normal  shape  of  the  stomach  is  more  or 
less  restored.  The  principle  of  this  operation  is  identical  with  that  of  Mikulicz's 
pyloroplasty. 

Note  that  pyloric  stenosis  may  accompany  hour-glass  stomach.  When  this 
is  so,  the  condition  must  be  corrected  or  a  gastro-enterostomy  established. 

Hour-glass  stomach  is  the  result  of  ulceration  and  as  carcinoma  is  often 
grafted  on  to  an  old  ulcer  it  is  wise  to  excise  the  affected  portion  of  the  stomach 
(see  Partial  Gastrectomy,  Segmental  Excision  of  Ulcer,  etc).  The  operations 
of  gastro-gastrostomy  (Fig.  502)  and  double  gastro-enterostomy  (Fig.  506) 
have  not  given  great  satisfaction. 

OPERATION  UPON  THE  PYLORUS. 

Congenital  Pyloric  Obstruction. — Cases  of  congenital  pyloric  obstruction 
which  do  not  promptly  yield  to  medical  treatment  must  be  subjected  to 
operation. 

Operation  may  either  avoid  or  remove  the  obstruction.  Gastro-enterostomy 
gives  excellent  ultimate  results,  but  in  this  class  of  case  it's  death  rate  is  high. 
(Scudder,  Annals  of  Surg.,lix,  257, 1914,  23.5  per  cent.  Downes,Surg.  Gyn.  and 
Obstetrics,"  xxii  251, 1916,  35  per  cent.)  The  Fredet-Rammstedt  operation  and 
it's  modification  by  A.  Strauss  seeks  to  remove  the  obstruction.  Downes  re- 
ported (Jour.  A.  M.  A.,  Ixxv,  228)  165  operations  by  the  Fredet-Rammstedt 
method  with  30  deaths  (17  per  cent.)  while  Strauss  (Surg.  Clinics  of  Chicago, 
ix,  93,  1920)  reported  103  operations  by  his  own  method  with  but  3  deaths. 

Fredet-Rammstedt  Operation. — From  beside  the  umbilicus  make  a  i)-^  inch 
incision  upwards  through  the  right  rectus  muscle.  Deliver  the  pylorus  and  ro- 
tate its  superior  surface  forwards.  Incise  the  tumor  longitudinally,  from  end  to 
to  end,  through  the  bloodless  area  above  the  limits  of  the  pyloric  vein.  Carry 
the  incision  down  to,  but  not  into,  the  submucosa  which  shows  a  white 
glistening  membrane.  With  blunt  scissors  separate  the  musculosa  from  the 
submucosa  for  about  3^  inch  on  each  side  of  the  wound.  Gas  now  escapes  from 
the  stomach  through  the  pylorus  to  the  duodenum  and  the  distended  stomach 
collapses.  (If  there  is  any  doubt  as  to  the  patency  of  the  pylorus  open  the 
stomach  and  pass  dilating  forceps  through  the  constriction.  Close  the  wound 
in  the  stomach.) 

Replace  the  pylorus  in  the  abdomen.  Do  not  suture  the  wound  in  the 
pylorus.     Close  the  abdomen. 

Strauss'  Operation. — Open  the  abdomen  and  deliver  the  tumor  as  in  the 
Fredet-Rammstedt  operation.  With  a  knife  make  an  incision  over  the  most 
bloodless  part  of  the  tumor  throughout  its  whole  extent.  Only  cut  the  super- 
ficial layers  of  the  musculosa.  With  the  handle  of  the  scalpel  split  the  rest  of 
the  musculosa  at  the  stomach  end  of  the  tumor,  until  the  submucosa  is 
reached.  From  this  point  continue  the  splitting  of  the  muscle  down  to  the 
duodenal  end  of  the  tumor.  Should  the  mucosa  be  accidentally  opened  close 
it's  wound  by  a  few  catgut  stitches.  Seize  the  edges  of  the  split  tumor  with 
fingers  and  thumb  and  spread  them  apart  like  opening  a  book  (Fig.  508). 
Be  sure  that  every  muscle  fiber  of  the  tumor  is  separated  down  to  the 
duodenum.  With  a  blunt  instrument  separate  the  mucosa  from  the  musculosa 
until  the  former  is  entirely  free.     Make  a  flap  of  musculosa  with  its  hinge  at 


378 


THE    STOMACH 


/ch'       r//f 


4 


(.\  JnHfi  ~;  °  f  '  ^^f  ^^''"u  stenosis.  The  abdomen  is  opened  by  a  right  rectus  incision 
(I)  and  the  pyloric  tumor  brought  out  by  means  of  a  blunt  hook  (2).  The  superficial  lavers  of 
pentoneum  and  muscle  are  incised  with  the  blade  of  the  knife  {t,  and  xa),  but  the  further  dis- 
section to  the  mucosa  is  made  with  the  handle.  The  flaps  of  muscle  are  turned  out  with  the 
hngers,  exposing  the  mucosa  (4)  and  the  mucosa  shelled  out.  {Aljrcd  A.  Shauss,  in  Surgical 
Clinics  of  Chicago,  I-ebruary,  1920.)  e    " 


CONGENITAL    PYLORIC    OBSTRUCTION 


379 


Buicrcn\i  mucosa 
heiddsiS'i.  Knife 
mukiri.--  i'Lfxp- 


Fig  qoQ  —Congenital  pyloric  stenosis.  A  flap  of  muscle  is  made  by  sphttmg  one  of  the 
leaves  of  the  incision  (5)  and  is  stitched  over  the  bulging  mucosa  (6);  this  m  turn  is  covered 
by  omentum  (7).  A  cross-section  of  the  condition  as  pictured  m  6  is  shown  in  b.  K^Alited 
A.  Straitss,  in  Surgical  Clinics  of  Chicago,  February,  1920.) 


38o 


THE    STOMACH 


the  edge  of  the  longitudinal  split  through  the  tumor.  Sew  this  flap  over  the 
bulging  muscosa.  Pull  a  piece  of  omentum  over  the  site  of  the  oi)eration  and 
fix  it  there  with  a  few  stitches  (Fig.  509).  Close  the  abdomen.  The  opera- 
tion is  not  difficult  and  has  been  very  successful.  The  author  has  used  both 
gastro-enterostomy  and  Strauss'  operation  with  satisfaction. 

Pylorodiosis. — When  pyloric  stenosis  is  due  to  spasm  or  hypertrophy  of 
the  sphincter  this  operation  may  be  indicated,  but  as  it  has  proved  to  be  by 
no  means  safe  and  recurrence  of  the  trouble  is  frequent  after  its  performance, 
and  as  other  methods  give  more  certain  results,  the  operation  is  not  much  in 
favor. 

Hahns  Method  of  Performing  Pylorodiosis. — Expose  the  stomach  by  an 
incision  to  the  right  of  the  middle  line.  With  the  finger  invaginate  a  portion 
of  the  anterior  wall  of  the  stomach  and  push  it,  along  with  the  finger,  through 
the  pylorus.  When  the  pylorus  is  sufiiciently  dilated,  close  the  abdominal 
wound. 

Loreta's  Method. — Expose  the  pylorus.  Incise  the  stomach  near  the  pylorus. 
Through  the  stomach-wound  pass  the  forefinger  of  each  hand  into  the  pylorus 
and  forcibly  dilate  it.     Instead  of  the  fingers  bougies  may  be  used. 


Fig.  icio. 


Fig.  511. 


Pyloroplasty.     Wrong  method. 


Fig.  512. — Pyloroplasty.     Correct  method. 

Pyloroplasty  (Heineke-Mikulicz  operation)  is  indicated  in  cases  of  spasmodic 
or  cicatricial  pyloric  stenosis. 

Step  I. — Expose  the  stomach  near  the  pylorus  by  a  vertical  incision.  Ex- 
plore the  whole  stomach  lest  coexistent  disease  be  overlooked.  Separate  ad- 
hesions which  may  exist  around  the  pylorus.  If  possible,  pull  the  pylorus  out 
of  the  abdomen.  Protect  the  peritoneal  cavity  with  gauze  pads.  Clamp  the 
stomach  and  duodenum  with  appropriate  instruments  {e.g.,  Doyen's  clamps). 


PYLOROPLASTY  38 I 

Step  2. — Make  a  small  opening  into  the  stomach  near  the  stenosis.  Pass  a 
finger  or  an  instrument  through  the  pylorus  as  a  guide.  If  is  generally  advised 
to  make  a  longitudinal  incision  through  the  anterior  wall  of  the  pylorus,  com- 
pletely dividing  the  stricture,  and  then  to  convert  the  longitudinal  into  a  trans- 
verse wound  and  close  it  by  sutures  (Figs.  510,  511).  But,  as  Mikulicz  re- 
marked "that  is  not  the  way  we  do  it."  According  to  him,  the  longitudinal 
incision  is  made  on  the  under  surface  of  the  stenosed  pylorus  (Fig.  512,  A,  B, 
C).  Having  made  this  inferior  incision,  unite  the  posterior  edges  of  the  wound 
first  by  a  continuous  or  interrupted  row  of  Lembert  sutures,  and  then  by  a  row 
of  sutures  embracing  the  whole  thickness  of  the  walls.  Continue  the  latter  row 
so  as  to  close  the  anterior  edges  of  the  wound,  and  complete  the  union  by  in- 
serting an  anterior  row  of  Lembert  sutures.  It  is  very  evident  that  this  method 
possesses  all  the  good  qualities  of  that  usually  described,  and  has  the  great 
advantage,  in  addition,  that  it  lowers  the  level  of  the  exit  of  the  stomach. 

Finney  s  Operation. — Finney's  operation  is  a  most  valuable  contribution  to 
surgery  and  in  many  cases  it  is  a  desirable  substitute  for  gastro-enterostomy. 
When  as  a  result  of  ulceration  there  is  a  spastic  condition  of  the  pylorus  the  rest 
secured  through  gastro-enterostomy  gives  a  very  brilliant  immediate  result, 
but  as  spasm  abates  food  once  more  resumes  its  normal  route  through  the  py- 
lorus, the  artificial  opening  is  liable  to  contract,  and  recurrence  of  the  trouble 
is  frequent.  In  such  cases  Finney's  method  is  of  great  service.  The  presence 
of  many  adhesions  is  stated  to  be  a  contra-indication  to  the  operation  but  it 
was  exactly  in  such  a  case,  where  adhesions  impeded  gastro-enterostomy, 
that  Finney  noticed  how  closely  and  conveniently  the  duodenum  and  stomach 
lay  together  and  at  once  proceeded  to  unite  them.  Many  variations  in  tech- 
nique have  been  devised  but  the  principles  of  all  are  the  same  and  the  author 
will  take  the  liberty  of  describing  the  operation  as  he  has  done  it  himself.* 
Clamps  may  or  may  not  be  used. 

The  Operation. — The  abdomen  having  been  opened  and  the  pylorus  with 
the  adjacent  portions  of  the  stomach  and  duodenum,  if  possible,  pulled  out  of 
the  abdominal  wound,  protect  the  peritoneum  thoroughly  with  gauze  packs. 

Step  I. — Unite  the  adjacent  surfaces  of  stomach  and  duodenum  by  a  con- 
tinuous Lembert  suture  (A,  B.  Fig.  514).     (Posterior  line  of  serous  suture.) 

Step  2. — Make  the  fl-shaped  incision  XYZ  (Figs.  513  and  514),  opening 
both  the  stomach  and  duodenum  and  dividing  the  pylorus. 

Step  3. — Unite  the  two  posterior  edges  of  the  fl  incision  by  means  of  Connell 
sutures  or  by  a  through-and-through  whipping-stitch  (Figs.  514  and  515). 
At  this  stage  scar  tissue  or  active  ulcers  present  in  the  anterior  wall  of  the 
stomach  or  duodenum  may  be  excised  through  the  incision.  Ulcers  in  the 
posterior  wall  may  have  their  overhanging  mucous  edges  trimmed  and  their 
dense  fibrous  base  incised,  care  being  taken  to  avoid  perforation  and  to  stop 
all  bleeding  by  ligature  or  suture.  With  the  same  suture  unite  the  two  anterior 
edges  of  the  fl  incision  (Fig.  515). 

Step  4. — Continue  the  Lembert  suture  introduced  in  Step  i,  around  the 
anterior  surface  of  the  anastomosis  (anterior  line  of  serous  suture)  and  bury 
from  sight  the  stitches  introduced  in  Step  3. 

*  This  account  of  the  operation  was  submitted  to  Finney  and  met  his  approval. 


382 


THE    STOMACH 


Fig.  516  shows  in  section  the  result  of  the  operation.  An  examination  of 
78  cases  seen  from  one  to  twelve  years  after  operation  showed  an  average  of 
93.8  per  cent,  satisfactory  results.     (Finney,  Surg.,  Gyn.,  Obst.,  March,  1914.) 

If  it  is  difficult  to  lay  the  duodenum  along  side  of  the  stomach  without 
tension  it  is  easy  to  make  a  vertical  incision  through  the  parietal  peritoneum 
two  finger-breadths  to  the  right  of  and  parallel  to  the  descending  portion  of 


Fig.  513.  Fig.  su- 

Figs.  513  and  514. — Finney's  operation. 


Fig.  515. 


Figs.  515  and  516. — Finney's  operation 


Stomach/. 


the  duodenum  (Kocher).  The  fingers  introduced  through  the  wound  in  the 
peritoneum  easily  separate  the  duodenum  (and  with  it,  if  necessary,  the  head 
of  the  pancreas)  from  the  vertebral  column,  vena  cava  and  aorta  and  so  mobilize 
the  gut  that  Finney's  operation  becomes  easy. 

How  extensive  ought  one  to  make  the  new  opening  between  the  stomach 
and  duodenum?     Finney  makes  a  very  extensive  opening  and  finds  it  satis- 


codmAiN's  operation  383 

factory.     The  Mayos  think  the  lower  end  of  the  new  opening  ought  not   to 
reach  as  low  as  the  ampulla  of  Vater. 

Excision  of  Gastric  Ulcers. — Codman  jwints  out  that  ulcers  of  the  stomach 
are  practically  always  confined  to  the  lesser  curvature;  when  they  are  ap- 
parently posterior,  it  is  because  adhesions  to  the  pancreas,  etc.,  so  twist  the 
stomach  as  to  make  the  lesser  curvature  appear  to  be  the  posterior  wall  of 
the  viscus.  Excision  of  the  ulcer-bearing  area,  when  done  in  the  classical 
fashion,  sacrifices  unnecessarily  the  greater  curvature,  renders  diflScult  the 
closure  of  the  gastric  wound  near  the  oesophagus  and  does  not  permit  of 
thorough  exploration  of  the  interior  of  the  stomach. 

Codman  operates  as  follows  (personal  communication) :  * 

Step  I. — Open  the  abdomen  and  explore. 

Step  2. — Divide  the  gastro-hepatic  omentum.  Divide  the  gastro-colic 
omentum  leaving  intact  the  left  gastro-epiploic  vessels.  Doubly  clamp  and 
divide  the  duodenum  near  the  pylorus.  Treat  the  duodenal  stump  secundum 
artem  and  let  it  drop  back  into  the  abdomen. 

Step  3. — At  this  point  the  jejunum  should  be  sought  and  pulled  upward 
through  a  slit  in  the  transverse  mesocolon.  A  clamp  is  applied  to  it  in  the 
usual  manner  and  it  is  left  ready  to  take  part  in  the  gastro-enterostomy. 

Step  4.— Pull  the  mobilized  stomach  out  of  the  abdomen.  Apply  an  in- 
testinal clamp  to  the  stomach  close  to  the  oesophagus  and  permit  the  clamp 
(well  protected  by  gauze)  to  go  inside 
the  abdomen.  This  clamp  should 
have  short  handles.  It  should  be 
applied  to  the  stomach  at  right 
angles  to  the  direction  in  which 
clamps  are  usually  placed — that  is, 
it  should  clamp  the  stomach  trans- 
versely. Cut  an  appropriate  slit  in 
a  large  sheet  of  rubber  dam.  Pull 
the  mobilized  stomach  through  this 
hole  and  spread  the  rubber  dam  as  a 

protection  over  the  whole  territory  P^^    . 

of  operation  so  that  no  stomach  con- 
tents can  soil  the  abdomen.     The  clamped  jejunum  can  be  palpated  through 
this  rubber  sheet  and  when  it  is  needed  the  rubber  can  be  incised. 

Step  5. — Make  a  free  cut  across  the  greater  curvature  at  a  point  chosen  so 
that  the  tip  of  the  greater  curvature  flap  will  easily  extend  to  the  point  of 
division  on  the  lesser  curvature  (Fig.  517).  The  gastro-epiploic  vessels  are  of 
course  ligated  at  the  point  of  section. 

It  is  the  fact  that  both  curvatures  are  sutured  transversely  that  makes 
them  so  much  easier  to  suture  and  turn  in  than  when  one  is  dealing  with  a 
corner  or  a  point.  By  this  method  the  corners  come  in  the  free  part  of  the 
stomach  where  there  is  no  tension. 

When  the  cut  in  the  greater  curvature  is  made,  the  latter  is  held  up  so 
that  when  it  is  divided  nothing  but  gas  will  escape.  Beginning  on  the  greater 
curvature  near  the  pylorus  cut  through  both  the  anterior  and  posterior  walls 


384 


THE    STOMACH 


on  a  line  directed  towards  the  oesophagus  and  so  excise  the  whole  lesser  curva- 
ture. At  this  point  all  of  the  stomach  can  be  carefully  cleaned  out  and  in- 
spected as  far  as  the  oesophageal  clamp.  If  necessary  the  clamp  can  also  be 
removed  and  still  more  of  the  lesser  curvature  excised.  If  the  two  main  vessels 
are  tied,  the  hemorrhage  from  the  free  edge  may  be  ignored  for  a  few  minutes. 
Before  completing  the  section  it  is  well  to  apply  forceps  or  a  stout  stitch  to  the 
stomach  near  the  oesophagus  and  proximal  to  the  line  of  section  in  order  to 
insure  against  the  stump  slipping  through  the  intestinal  clamp.  Ligate  the 
coronary  vessels. 

Step  6. — Incise  the  rubber  dam  and  secure  the  clamped  loop  of  jejunum. 
Lay  the  greater  curvature  of  the  stomach  at  a  suitable  place  over  it  having  made 
a  button  hole  in  the  posterior  wall.  Through  this  pull  the  loop  of  jejunum 
(the  clamp  remaining  outside  the  stomach).  Working  inside  the  stomach, 
open  the  loop  of  jejunum  and  complete  the  gastro-enterostomy  (exactly  as  in 
Maunsell's  end-to-end  enterorrhaphy)  in  the  simplest  possible  manner.  (Cod- 
man  says  that  any  method  of  suture  suffices  as  long  as  the  edges  of  the  sutured 
wound  project  into  the  stomach;  he  believes  that  a  single  row  of  ordinary 

close  sewing  is  enough.)  Remove  the 
clamp  from  the  jejunum.  If  there  is 
any  bleeding  from  the  gastro-enteros- 
tomy wound  it  is  easily  stopped  by  a 
stitch  or  two. 

Step  7. — The  greater  curvature  and 
adjacent  stomach  wall  form  a  large 
flap,  well  nourished  by  the  left  gastro- 
epiploic vessels.  With  a  mattress 
suture  unite  the  end  of  the  above  flap 
to  the  upper  end  of  the  stomach  wound 
in  such  a  fashion  that  the  coronary 
vessels  and  the  distal  divided  end  of 
the  left  gastro-epiploic  vessels  are  en- 
circled by  the  stitch  and  the  edges  of 
the  wound  are  everted  (Fig.  518).  Com- 
plete the  closure  of  the  stomach  by 
means  of  sutures  so  introduced  that  the 
wound  is  everted,  that  is,  mucosa  to 
mucosa.  Remove  the  clamp  controlling  the  gastric  circulation.  If  any  bleed- 
ing occurs  it  must  be  visible  and  so  easily  controlled  because  the  edge  of  the 
wound  is  slightly  everted.  The  preferable  suture  material  is  chromicized  catgut. 
Bury  the  everted  line  of  sutures  by  a  continuous  layer  of  chromicized  catgut 
sutures. 

Step  8. — Remove  the  rubber  dam  and  gauze  protection.  Restore  the  organs 
to  the  abdomen.  Close  the  abdomen. 

Codman  claims  for  this  operation  that  the  lesser  curvature  can  be  re- 
moved up  to  the  very  edge  of  the  oesophageal  opening.  By  the  use  of  a  double- 
headed  suture  the  flap  made  by  the  greater  curvature  is  readily  drawn  up. 
The  completion  of  the  gastro-enterostomy  has  been  made  with  ease  and  the 


,f 


Fig.  siS. 


GASTRECTOMY 


38s 


usual  difficulty  of  attaching  the  jejunum  to  the  stump  is  avoided.  But  the 
main  point  is  that  unsuspected  soft  ulcers  may  be  detected  when  the  stomach 
is  open. 

The  presence  of  ulcers  or  of  their  sequelae  is  the  most  common  occasion 
for  operations  on  the  stomach.  When  ulcers  are  present,  the  lymph  nodes 
corresponding  to  the  diseased  area  are  generally  enlarged  and  form  a  good 
guide  to  the  location  of  the  disease. 

Gastrectomy.  Partial  gastrectomy. — i.  It  is  imperative  to  bury  by  suture 
or  better  to  excise  by  knife  or  cautery  every  duodenal  ulcer  which  bleeds  easily 
or  threatens  to  perforate.  Hemorrhage  is  more  common  before  operation  in 
gastric  than  in  duodenal  ulcer,  but  hemorrhage  subsequent  to  operation  is  more 
common  in  the  case  of  duodenal  ulcer.  One  cause  of  this  pecuharity  is  undoubt- 
edly that  the  fear  of  malignancy  has  'led  more  frequently  to  excision  of  the 
gastric  ulcer  by  knife  or  cautery.  The  following  tables  from  the  Mayo  Clinic 
are  striking. 

TiVBLE    I. — HeMATEMESIS  IN  CaSES  OF  DuODENAL  UlCER  IN  WhICH  OPERATION  WAS  DONE 

Jan.  I,  1906,  to  Jan.  i,  1918 


Total  number 2,875 


Patients  having  hemorrhage  before  operation 583 

Patients  having  hemorrhage  before  operation  heard  from. . .  494 

Patients  reporting  hemorrhage  after  operation 63 

Patients  reporting  hemorrhage  after  operation   but  none 

before 20 


20+ 
86.0 
12. 7" 

0.9 


Operative 
mortality 

from  all 
causes, 

per  cent. 


1.6 

1  + 


*  Or  2  per  cent,  of  the  total  number. 

Table  2. — Hematemesis  in  Cases  of  Ulcer  of  the  Stomach  in  Which  Operation  was 

Done 


Cases.         Percent. 

Operative 
mortality 
from  all 
causes, 
per   cent. 

Total  number 

863 

222 

180 

IS 

2 

81  + 
8.0* 

0-3 

3  + 
4.8 

Patients  having  hemorrliage  before  operation 

Patients  having  hemorrhage  before  operation  heard  from. . . 

Patients  reporting  hemorrhage  after  operation 

Patients  reporting  hemorrhage  after  operation  but  none 
before 

Or  1+  per  cent,  of  the  total  number. 


2.  It  is  hardly  necessary  to  say  that  in  cases  of  well-limited  tumors  of  the 
stomach  wall  as  well  as  in  some  cases  of  ulcer  the  diseased  area  may  be  removed 
and  the  wound  closed  by  two  layers  of  suture. 

25 


386 


THE    STOMACH 


Balfour's  cautery  excision  of  duodenal  ulcer  is  sufficienlly  explained  by 
Figs.  51Q  and  520,  Journ.  A.  M.  A.,  Aug.  2;^,  1919).  The  line  of  suture  may 
be  reinforced  by  covering  it  by  adjacent  omenlum.  Of  course  this  operation 
must  be  combined  with  gastro-enterostomy. 

Excision  of  Saddle  Ulcer. — When  a  saddle-shaped  ulcer  or  any  disease 
situated  on  the  lesser  curvature  is  excised,  the  manner  of  closing  the  wound 
is  very  important.     If  the  resulting  wound  is  closed  in  the  long  axis  of  the 


Fig.  519. — {Balfour,  Jour.  A.  M.  A.) 

Stomach,  a  certain  amount  of  necessary  contraction  gives  rise  to  an  hour-glass 
stomach  (Fig.  521),  the  wound  must  be  closed  transversely.  A  good  way  to 
operate  is  as  follows: 

Step  I. — On  each  side  of  the  ulcer  apply  a  ligature  to  the  coronary  vessels. 
Make  a  longitudinal  slit  in  the  gastro-hepatic  omentum  above  the  ulcer. 
Through  this  slit  apply  a  volsella  to  the  posterior  wall  of  the  stomach  about 
^^  inch  beyond  the  posterior  limits  of  the  ulcer.  At  a  corresponding  point 
on  the  anterior  surface  of  the  stomach  apply  a  second  volsella.  By  lifting 
the  volsellae,  at  ransverse  fold  of  stomach  is  brought  forwards  (and  lies  anterior 
to  the  gastro-hepatic  omentum)  consisting  of  the  ulcer  and  portions  of  the 
anterior  and  posterior  gastric  walls. 

Step  2. — Apply  an  intestinal  clamp  to  the  fold.  The  blades  of  the  clamps 
are  at  right  angles  to  the  long  axis  of  the  stomach  (Fig.  522). 


BALFOUR  S    OPERATION 


387 


Ga.stroh.epatLc 
OTTven-taTTb 


Mattress  .■i\xturr 


Fig.  520. — {Baljour,  Jour.  A.  M.  A.) 


Fig.  521. — E.xcision  saddle  ulcer.     Wrong  method. 


388 


THE    STOMACH 


Step  3. — Excise  the  ulcer.  Payr  dries  the  mucosa  with  gauze  and  paints 
it  with  tincture  of  iodine  so  as  to  lessen  infection.  Close  the  wound  with 
catgut  sutures  applied  in  the  Connel  fashion.     Remove  the  clamps.     Apply  a 


Fig.  522. — Excision  saddle  ulcer. 


second  row  of  sutures  (fine  chromicized  catgut)  in  the  Lembert  fashion.     The 
wound  is  so  closed  that  its  scar  is  transverse  to  the  long  axis  of  the  stomach. 
Step  4. — Close  the  wound  in  the  gastro-hepatic  omentum. 
4.  Segmental  or  Slevee  Resection. — Instead  of  this  triangular  excision  of  the 

ulcer  a  segmental  or  "sleeve"  resection  of 
the  stomach  may  be  adopted  as  it  is  be- 
heved  to  give  a  better  result  as  regards 
gastric  motility.  (Stewart  and  Barber, 
Annals  of  Surg.,  Nov.,  191 6. 

Segmental  Resection.  Step  i. — Having 
exposed  the  stomach  and  the  ulcer  on  its 
lesser  curvature  Ugate  the  coronary  vessels 
on  each  side  of  the  ulcer  and  divide  the 
gastro-hepatic  omentum  close  to  the  ulcer. 
At  corresponding  points  on  the  greater  curva- 
ture ligate  the  gastro-epiploic  vessels  and 
divide  the  gastro-cohc  omentum  between 
those  points  close  to  the  stomach. 

Step  2. — Apply  intestinal  clamps  to  the 
stomach  on  each  side  of  the  segment  to  be  removed.  Cut  away  the  segment 
including  the  ulcer  (Fig.  523). 

Step  3. — Unite  the  proximal  and  distal  segments  of  stomach  as  in  any  end- 
to-end  anastomosis  using  fine  chromicized  catgut  sutures.     If  the  end  of  one 


Fig.  523. — Segmental  Resection. 


PYLORECTOMY 


389 


segment  is  longer  than  that  of  the  other,  place  the  sutures  farther  apart  in  the 
longer  than  in  the  shorter  segment.  Remove  the  clamps  and  repair  any  open- 
ings in  the  omenta. 

Transgastric  Partial  Gastrectomy. — If  an  ulcer  exists  on  the  posterior  wall 
of  the  stomach  and  is  adherent  to  the  pancreas  it  may  be  possible  to  gain  access 
to  it  by  penetrating  both  the  gastro-hepatic  omentum  and  the  transverse 
meso-colon  and  then  to  divide  the  adhesions,  excise  the  ulcer  and  close  the 
wound  in  the  stomach,  W.  J.  Mayo  has  found  it  much  easier  in  several  cases 
to  perform  a  transgastric  operation  as  follows:  Incise  the  anterior  wall  of  the 
stomach  by  a  vertical  incision;  note  the  extent  of  the  ulcer  and  its  adhesions; 
incise  the  posterior  wall  of  the  stomach  from  the  inside  around  and  close  to 
the  ulcer.  Remove  the  ulcer,  if  necessary  shaving  off  a  thin  surface  of  pan- 
creas. This  shaving  of  the  pancreas  is  not  so  formidable  as  might  be  im- 
agined, because  the  inflammation  which  has  made  it  adherent  to  the  stomach 


Fig.  524. — Transgastric  excision  of  ulcer  on  posterior  wall  of  stomach. 

has  converted  the  adherent  portion,  to  a  large  degree  at  least,  into  scar  tissue. 
Close  the  posterior  gastric  wound  by  a  row  of  serous  sutures,  then  by  a  row  of 
through-and- through  chromicized  catgut  sutures  (Fig.  524).  Close  the  anterior 
wound  in  the  stomach. 

Pylorectomy  and  partial  Gastrectomy. — Pylorectomy  is  almost  always 
supplemented  by  a  partial  gastrectomy.  The  indications  for  its  performance 
are  usually  malignant  disease  or  pyloric  ulcer  and  its  sequelae.  Before  opera- 
ting on  the  stomach  especially  for  cancer,  it  is  of  great  importance  to  have  a 
good  working  knowledge  of  the  anatomy  of  the  region,  a  knowledge  which  the 
standard  textbooks  on  anatomy  are  careful  not  to  give. 

The  gastro-hepatic  or  lesser  omentum  may  be  divided  into  three  parts: 
{a)  a  thick,  strong  portion  running  from  the  liver  to  the  cardiac  end  of  the 
lesser  curvature  and  part  of  the  oesophagus  (gastro-hepatic  ligament),  {b)  a 
central  or  thin,  often  translucent  portion,  and  (c)  a  thick,  strong  portion  at  and 
near  the  right  end  of  the  omentum  and  often  named  the  hepato-duodenal 
ligament  as  it  run's  from  the  liver  to  the  duodenum  (Fig.  525).     The  hepato- 


390 


THE    STOMACH 


duodenal  ligament  's  subject  to  variations  which  may  be  understood  by  the 
descriptive  names   given  to  it,  e.g.,  cystico-colic  ligament;  cystico-duodenal 


Fh... 


I.   ft  triangular  lig.  of  live 


Gall-bladder 


Hepa  to-duo- 
denal lig. 


Superior  portion 
of  duodenum 


Diaphragm 


Transverse  colon         I'ostirior  layer  of  great  omentum 

Fig.  525.     (Sohotta.) 


Right 
Gastro- Epiploic 
Vessels 


esentcric 
Vein 


Vfssels 

Fig.  ,26. 


ligament;  cystico-hepato-duodeno-colo-epiploic  ligament  (Tuffier  and  Jeanne, 
"Revue  de  Gyn.  et  Chir.  Abdom.,"  Jan.,  iQia).*  If  a  hole  is  torn  through  the 
thin  or  median  portion  of  the  gastro-hepatic  omentum,  the  lesser  peritoneal 


ANATOMY 


391 


cavity  (antrum  bursae  omentalis)  is  entered.  Behind  the  peritoneum  forming 
the  posterior  wall  of  the  lesser  cavity  lies  the  caliac  axis  which  divides  into 
three  branches  all  of  which  are,  to  begin  with,  retro-peritoneal  (Fig.  526).  These 
branches  are  (a)  the  splenic  which  passes  to  the  left  to  reach  the  spleen. 
During  much  of  its  course  the  splenic  artery  remains  retroperitoneal  lying  above 
and  behind  the  pancreas.  Before  reaching  the  spleen  the  vessel  gives  off  the  left 
gastro-epiploic  artery  which  runs  along  the  greater  curvature  of  the  stomach  in 
the  gastro-colic  or  great  omentum  to  anastomose  with  the  gastro-duodenal  artery. 
(b)  The  hepatic  artery  which  passes  retro-peritoneally  to  the  right  along  the 
upper  border  of  the  pancreas  for  a  short  distance  when  it  enters  a  fold  of  per- 
itoneum (hepatic  fold)  through  which  it  reaches  the  lesser  omentum  (hepato- 
duodenal ligament).     In  its  course  the  hepatic  artery  gives  off  (i)  the  pyloric 


Coronary  Art. 

IN    FalX     CORONARIA 


Gastro 
Duodenal 
Ar 


Coronary  Art. 
IN  Gastro-Hepatic 
Omentum 

Splenic  Art. 


Peritoneum  Removed 
ExposiNs  Pancreas 


Fig.  527. 


artery  which  enters  the  lesser  omentum  and  runs  to  the  left  along  the  lesser 
curvature  of  the  stomach  to  anastomose  with  the  coronary  artery,  (2)  the 
gastro-duodenal  which  runs  downwards  between  the  pancreas  and  the  duodenum 
and  after  giving  off  a  duodenal  branch,  passes  in  the  gastro-colic  omentum 
along  the  greater  curvature  of  the  stomach  to  anastomose  with  the  left 
gastro-epiploic.  ^^ 

(c)  The  coronary  or  gastric  artery  which  passes  into  the  falx  coronaria  or 
gastro-pancreatic  fold  (Fig.  527)  and  through  it  reaches  the  lesser  omentum 
near  the  cardiac  orifice  of  the  stomach  where,  after  sending  a  branch  towards  the 
oesophagus,  it  runs  along  the  lesser  curvature  of  the  stomach  to  anastomose  with 
the  pyloric  artery. 

The  folds  of  peritoneum  which  have  been  mentioned  (gastro-hepatic  fold, 
etc.)  bear  to  the  arteries  a  relation  more  or  less  similar  to  that  of  the  mesentery 
to  an  intestine. 

In  the  right  portion  of  the  lesser  omentum  i.hepa to-duodenal  ligament)  lie 
from  left  to  right  the  hepatic  artery,  the  portal  vein  and  the  bile  ducts.     If  an 


392  THE    STOMACH 

incision  is  made  through  the  anterior  layer  of  peritoneum  forming  the  lesser 
omentum  close  to  the  pylorus  it  is  easy  to  mobilize  the  pylorus  and  the  gastric 
end  of  the  duodenum  without  injuring  the  gastro-duodenal  vessels  or  the 
common  bile  duct. 

The  lymphatics  of  the  stomach  have  their  ultimate  roots  in  two  systems: 

1.  Under  the  epithelium  and  surrounding  the  gland  tubules  there  is  a  very 
rich  plexus  of  lymphatic  capillaries.  From  this  plexus  short  vessels  penetrate 
the  muscularis  mucosae  and  join  another  rich  plexus  in  the  submucosa.  In  turn, 
the  submucosal  plexus  drains  through  vessels  penetrating  perpendicularly  the 
muscular  tunics,  into  the  subserous  plexus. 

2.  Among  the  fibres  of  the  musculature  of  the  stomach  another  set  of 
lymphatics  arises  and  drains  into  the  subserous  plexus.  There  is  free  anasto- 
mosis between  the  lymphatics  perforating  the  musculosa  and  those  originating 
in  the  musculosa.  The  lymphatics  of  the  mucosa  and  submucosa  are  truly 
capillaries — i.e.,  they  are  endothelial  tubes,  are  innocent  of  fibrous  and  muscular 
tunics  and  are  not  provided  with  valves.  It  is  only  in  the  large  collectors  of 
the  subserous  plexus  that  valves  make  their  appearance. 

The  richness  of  the  submucosal  lymphatic  plexus  and  its  freedom  from  valves 
make  it  easy  for  infective  or  cancerous  material  to  spread  along  the  submucosal 
plane.  There  is  such  free  communication  between  the  lymphatics  (submucosal 
and  subserosal)  of  all  areas  of  the  stomach  that,  given  obstruction  to  the  flow 
through  one  set  of  collecting  vessels,  material  injected  into  the  subserous  or 
submucous  plexuses  can  readily  travel  in  any  direction  from  which  the  outflow 
is  easiest.  Thus,  if  the  primary  lymph  nodes,  through  which  a  certain  cancerous 
area  of  the  stomach  usually  drains,  become  diseased  and  obstruct  drainage 
then  the  drainage  will  take  place  by  another  route  and  the  original  disease 
spread  in  the  submucosa.  While  the  duodenal  submucosa  is  very  similar  to 
that  of  the  stomach,  viz.,  a  layer  of  loose  connective  tissue  rich  in  lymphatics 
and  blood-vessels,  yet  at  the  pylorus  itself  the  connective  tissue  constituting  it 
becomes  condensed  and  poor  in  lymphatics,  thus  there  is  comparatively  little 
direct  lymphatic  communication  between  the  stomach  and  duodenum.  The 
duodenal  and  gastric  lymphatics,  however,  drain  into  the  same  lymph  nodes 
and  on  their  way  to  these  nodes  may  anastomose,  and  so  there  may,  on  occasion, 
take  place  a  retrograde  flow  of  lymph  from  the  gastric  into  the  duodenal  vessels. 
While  this  exchange  of  lymph  may  not  be  extensive  yet  it  rnust  be  remembered. 
Clinically  we  know  that  cancer  can  spread  from  the  stomach  to  the  duodenum, 
but  that  this  spread  is  not  usually  extensive  and  may  be  explained  in  part  at 
least  by  the  above  anatomic  facts. 

From  a  practical  point  of  view  the  surgeon  is  interested  in  knowing,  first, 
how  and  in  what  directions  gastric  cancer  spreads  in  the  stomach  walls  so  that 
he  may  make  his  lines  of  incision  beyond  those  regions  which  may  be  reasonably 
considered  affected,  although  no  macroscopic  evidence  of  disease  may  be  present; 
second,  in  what  directions  the  disease  may  have  spread  through  the  lymphatics 
so  that  he  may  excise  all  those  lymphatic  territories  which  may  reasonably 
be  considered  involved. 

The  first  of  these  questions  has  been  fairly  answered  by  the  remarks  already 
made  regarding  the  lymphatic  plexuses  of  the  stomach  and  duodenum.     For- 


LYMPHATICS 


393 


tunately  the  drainage  from  the  pyloric  and  pre-pyloric  portions  of  the  stomach 
is  so  free  that  it  is  comparatively  rare  to  find  obstruction  to  it  sufficiently 
extensive  to  dam  back  the  infected  lymph  into  the  cardiac  area,  and  it  is  cancer 
of  the  pyloric  portion  of  the  stomach  which  is  of  particular  interest  to  the 
surgeon. 


Mesenteric 


Fig.  528. 


Fig.  529. — Lymphatic  drainage  areas  of  stomach.     (Cuneo.) 

The  second  practical  question  is  much  more  difficult  to  answer.  Practically 
all  of  the  stomach  drains  ultimately  into  the  glands  near  the  celiac  axis.  The 
areas  adjacent  to  the  lesser  curvature  drain  directly  into  glands  along  the 
coronary  artery;  the  areas  adjacent  to  the  greater  curvature  drain  into  the  gastro- 
colic glands  which  in  turn  pass  into  the  subpyloric  glands.  The  pylorus  itself 
drains  both  upwards  to  the  suprapyloric  and  downwards  to  the  subpyloric 


^94  THE    STOMACH 

glands  (Figs.  528,  520  and  530).  Thus  the  subpyloric  glands  (Jamieson  and 
Dobson,  "Lancet,"  April  20,  1907)  are  a  secondary  group  for  the  prepyloric 
region,  but  primary  for  the  pylorus  and  duodenum.  One  or  two  vessels  form 
the  suprapyloric  group  pass  behind  the  duodenum  to  low-situated  nodes  on 
the  biliary  chain. 

The  subpyloric  group  drain  in  two  directions,  (i)  along  the  gastro-duodenal 
artery  anterior  to  the  pancreas  to  the  middle  superior  pancreatic  glands  which 
accompany  the  hepatic  artery  before  its  division;  (2)  downwards  in  front  of  the 
pancreas  to  glands  lying  beside  the  superior  mesenteric  artery. 


GanJIion 

Pneumoga5iric  fti^i 

Coronary  Artery  _ 
Coronary  Vein  _ 

Ganglion 


Fig.  530.— (J/ajyo,  after  Cuneo.) 


Remember  that  the  celiac  axis  is  retroperitoneal,  that  the  coronary  artery 
in  its  course  along  the  lesser  curvature  of  the  stomach  lies  in  the  gastro-hepatic 
or  lesser  omentum,  but  that  that  portion  of  the  coronary  artery  between  its 
origin  in  the  celiac  axis  and  its  inclusion  in  the  lesser  omentum  lies  in  the  falx 
coronaria  or  gastro-pancreatic  fold  of  peritoneum.  A  number  of  glands  are 
present  in  this  fold  and  through  them  drains  the  lymph  from  the  glands  in  the 
lesser  omentum.  It  must  be  remembered  that  certain  of  the  lymph  vessels  aris- 
ing near  or  at  the  pylorus  pass  along  the  lesser  omentum,  dodge  the  glands  there 
present  and  pass  directly  into  those  of  the  falx  coronaria.  In  operating  for 
gastric  cancer  it  is  usuaUy  easy  enough  to  remove  with  the  disease  the  suspected 
lymphatics  in  the  greater  and  lesser  omenta  and  the  subpyloric  group,  but  the 
relation  of  the  subpyloric  vessels  to  the  superior  mesenteric  group,  the  supra- 


PYLORECTOMY 


395 


pyloric  to  the  retro-duodenal  biliary  group  and  the  direct  route  of  drainage  from 
the  pyloric  region  to  the  glands  in  the  falx  coronaria  are  all  elements  threatening 
success  in  the  radical  operation  for  gastric  cancer. 

Malignant  disease  of  the  pylorus  usually  spreads  towards  the  cardiac  end 
of  the  stomach,  especially  along  the  lesser  curvature;  hence  in  operating  in 
malignancy  it  is  wise  to  excise  along  with  the  pylorus  the  whole  lesser  curva- 
ture of  the  stomach  and  all  suspected  lymph-glands.  "In  cutting  across  the 
stomach  the  incisions  should  be  i}4  to  2  inches  wide  of  the  disease  at  least" 
(Mayo  Robson).  As  malignant  disease  does  not,  as  a  rule,  iniiltrate  towards 
the  duodenum,  the  division  of  the  duodenum  may  be  made  at  a  point  about 
^^  to  I  inch  away  from   the  disease.     "In  excising  glands  from   the   great 


Fig.  531. — Lj^mphatics  of  stomach. 


omentum  there  is  great  danger  of  wounding  the  middle  colic  artery  and  thereby 
causing  gangrene  of  the  transverse  colon.  The  glands  along  the  greater  curva- 
ture are  most  numerous  near  the  pylorus."  (Mayo  Robson,  "Surg.  Treatment 
Diseases  of  the  Stomach.")  This  danger  is  avoided  in  the  method  described 
below. 

In  view  of  the  facts  stated  in  the  preceding  paragraphs,  it  follows  that  the 
original  operations  of  pylorectomy  were  defective  in  extent.  When  a  sufficiency 
of  the  viscus  is  removed,  it  will  rarely,  if  ever,  be  possible  to  unite  the  open  end 
of  the  duodenum  to  the  open  end  of  the  stomach  (partially  closed  by  sutvures), 
and  when  possible  it  will  be  much  more  difficult,  time-consuming,  and  risky 
than  the  methods  to  be  described. 

Pylorectomy  or  Partial  Gastrectomy. — Step-  i. — Open  the  abdomen, 
usually  by  a  longitudinal  incision  between  the  ensiform  cartilage  and  the 
umbiHcus.     Explore  the  abdomen. 

Step  2. — Tear  a  hole  in  the  thin  portion  of  the  lesser  omentum  and  through 
this  hole  feel  the  coronary  artery  as  it  passes  in  the  falx  coronaria  (gastro- 


396 


THE    STOMACH 


pancreatic  fold)  into  the  lesser  omentum  near  the  oesophageal  end  of  the 
lesser  curvature  of  the  stomach.  With  a  full  curved  needle  pass  two  ligatures 
round  the  coronary  vessels  (Fig.  532)  and  divide  the  vessels  between  them. 
Divide  the  lesser  omentum  except  that  thick  portion  of  it  called  the  hepato- 
duodenal ligament  in  which  He  the  bile  ducts,  the  portal  vein,  etc.  (N.B. 
The  lesser  omentum  is  usually  sufficiently  divided  by  the  tear  made  in  it 
during  exposure  of  the  coronary  vessels.  The  portion  of  the  omentum  torn  is 
avascular  and  innocent  of  lymph  nodes.) 


%«li 


\. 


y 
J/ 


r^ 


Fig.  532. — Ligation  of  coronary  vessels  in  the  falx  coronaria.     (Guibt.) 

Step  3. — Divide  the  anterior  layer  of  peritoneum  forming  the  hepato- 
duodenal Hgament  and  pass  the  finger  round  the  duodenum  from  above  down- 
wards between  the  gut  and  the  portal  vein,  bile  ducts,  pancreas,  etc.  Expose 
and  tie  the  pyloric  artery. 

Step  4. — Pass  the  left  hand  from  above  downwards  behind  the  pylorus 
and  stomach  and  lift  the  great  omentum  forward.  Ligate  the  right  gastro- 
epiploic vessels.  Ligate,  in  three  or  four  segments,  the  great  omentum.  The 
hand  behind  the  omentum  protects  the  vessels  of  the  transverse  mesocolon 
from  being  included  accidentally  in  the  ligatures.  Should  this  accident  happen 
the  devascularized  transverse  colon  must  of  course  be  removed  (enterectomy). 
Ligate  the  left  gastro-epiploic  artery  well  to  the  left  of  the  disease  and  of  the 
last  of  the  glands  in  the  great  omentum  if  the  disease  is  cancer.  Divide  the 
great  omentum  leaving  attached  to  the  stomach  that  portion  containing  lymph 


PYLORECTOMY 


397 


nodes.  As  the  gastro-colic  omentum  is  being  divided  "it  will  sometimes  be 
found  that  the  avascular  area  which  lies  in  the  circle  of  the  middle  colic  vessels 
and  the  posterior  layer  of  the  mesocolic  peritoneum  is  attached  to  the  growth. 
If  this  is  the  case  the  attached  peritoneum  can  be  cut  out  and  removed  with 
the  growth.  The  opening  thus  made  in  the  transverse  mesocolon  can  be 
used  later  through  which  to  make  the  gastro-jejunostomy"  (Mayo). 

Step  5. — Continue  the  division  of  the  gastro-colic  omentum  towards  the 
right  so  as  to  get  below  and  to  the  right  of  the  inferior  gastro-duodenal  lymph 
nodes  situated  below  and  to  the  right  of  the  pylorus  about  the  head  of  the 
pancreas  (Figs.  527,  528,  531).    Lift  up  the  fat  and  glands  from  over  the  head  of 


Fig.  533. — Blood  vessels  tied,  glands  separated,  crushing  forceps  in  place,  and  also  clamps 
to  prevent  leakage  from  part  to  bt  removed.  Upper  left  drawing  shows  stump  of  duodenum 
in  crushing  clamp  with  suture  placed  for  closing.     {Mayc.) 

the  pancreas  separating  them  from  the  curve  of  the  duodenum  but  leaving  them 
attached  to  the  stomach  and  pylorus.  During  the  above  dissection  the  vessels 
anastomosing  with  the  branches  of  the  superior  pancreato-duodenal  artery  are 
exposed  and  tied.  Continue  the  dissection  until  at  least  2  inches  of  the  in- 
ferior border  of  the  duodenum  is  cleared  and  the  gastro-duodenal  artery  is 
exposed  in  the  groove  between  the  head  of  the  pancreas  and  the  duodenum. 
Ligate  and  divide  the  gastro-duodenal  vessels.  This  permits  thorough  re- 
moval of  the  glands. 

Step  6. — If  the  gastric  growth  is  adherent  to  the  pancreas,  shave  oflF  a 
portion  of  the  pancreas  leaving  the  shaved-oflF  portion  attached  to  the  stomach. 


398 


THE    STOMACH 


If  the  involvement  of  the  pancreas  is  extensive  "it  is  better  to  leave  this  part 
of  the  operation  until  the  stomach  is  either  cut  across  and  separated  from 
the  (luodinuiii  or  stomach  section  on  the  cardiac  side  is  llnished  and  the 
stomach  turned  over  in  order  that  this  portion  of  the  dissection  may  be 
completed  under  inspection.  If  such  injuries  to  the  pancreas  are  properly 
cared  for,  we  have  not  found  that  they  give  rise  to  serious  consequences.  .  .  . 
The  best  manner  of  treating  such  an  injury  to  the  pancreas  is  to  cover  it  as 
far  as  practicable  with  the  sheath  and  posterior  peritoneum,  and  after  com- 
pletely closing  the  end  of  the  duodenum,  if  possible  the  stump  of  the  duodenum 
should  be  buried  in  the  injured  surface  of  the  pancreas"  (Mayo). 


KiG.  534. — Crush  clamp  on  stomach.  Cautery  used  to  sterilize  and  prevent  carcinomatous 
implantation.  Stump  of  duodenum  closed.  Sutures  placed  to  turn  the  duodenal  stump 
into  the  denuded  head  of  the  pancreas.     (Mayo.) 

Apply  two  clamps  to  the  duodenum  distal  to  the  disease  and  about  3^ 
inch  apart.  The  distal  clamp  should  be  a  very  powerful  crushing  one  like 
Payr's;  for  the  proximal  segment  of  gut  any  efficient  clamp,  such  as  Ochsner's, 
will  serve.  Cut  between  the  clamps  with  a  cautery  and  burn  the  stumps 
protruding  from  the  clamps  even  to  such  an  extent  that  the  Payr's  clamp  is 
heated  sufficiently  to  char  the  tissues  crushed  between  its  jaws.  Insert  a 
continuous  fine  chromic  catgut  suture,  in  the  Gushing  fashion,  the  bites  being 
alternately  on  each  side  of  the  clamp  and  the  threads  crossing  it  (Fig.  533). 

Remove  the  Payr's  clamp,  pulling  its  blades  out  from  under  the  threads. 
The  divided  duodenum  is  so  crushed  and  charred  that  it  remains  closed.     Pull 


PYLORECTOMY 


399 


on  the  ends  of  the  suture.  As  tension  is  put  on  the  suture  the  wound  becomes 
inverted  as  by  a  continuous  Lembert  suture.  Fasten  the  ends  of  the  suture. 
Put  in  an  extra  line  of  mattress  sutures  to  reinforce  the  closure.  Suture  the 
duodenal  stump  to  the  area  of  pancreas  denuded  during  the  mobilization  of 
the  duodenum  or  to  the  edge  of  the  fascia  which  covered  the  pancreas. 


a. 


Fif"'  535- —  Thierry  de  Mattel's  Clamp. 

Thierry  de  Martel  (La  Pr.  Med.,  July  7,  1910)  uses  a  powerful  clamp  which 
crushes  evenly.  Figs.  535  and  536  sufficiently  explain  it.  Two  of  the  clamps 
are  applied  to  the  duodenum  and  two  to  the  stomach,  section  of  the  viscera 
being  made  between  each  pair  of  instruments;  de  Martel  applies  an  ordinary 
intestinal  clamp  to  the  intestine  before  removing  the  crushing  clamp  and  closes 
the  viscus  with  two  lavers  of  suture.* 


Fig.  536. — Forceps  for  closing  de  Mattel's  clamp. 

Step  7. — Choose  the  line  of  section  on  the  stomach  to  the  left  of  the  lym- 
phatic glands  into  which  the  diseased  area  drains  (Figs.  529,  530,  531).  To 
the  cardiac  side  of  this  line  apply  Payr's  large  crushing  clamp;  to  the  pyloric 
side  apply  any  efficient  clamp.  Divide  the  stomach  between  the  forceps 
with  the  cautery  and  remove  the  diseased  segment.  Insert  a  chromicized 
catgut  suture  in  the  stomach  stump  exactly  as  was  done  in  the  duodenal  stump, 
tightening  the  suture  as  the  Payr's  clamp  is  removed.  Reinforce  the  line  of 
suture  by  a  few  mattress  or  Gould  sutures  of  chromicized  catgut  and  bury  these 
by  a  line  of  interrupted  sutures. 

Step  8. — Perform  a  posterior  gastro-jejunostomy. 

If  the  portion  of  the  stomach  left  after  excision  of  the  disease  is  very  small 

*  Since  this  was  written  de  Martel  has  devised  a  double  clamp  which  seems  convenient 
though  not  essential.     (L.  Pr.  Med.,  June  30,  1920.) 


400 


THE    STOMACH 


it  might  be  technically  difficult  to  perform  gastro-jejunostomy  and  the  second 
operation  might  well  jeopardize  the  nutrition  of  the  gastric  stump.  To  avoid 
these  evils  the  latter  part  of  Step  7  may  be  modified  by  using  a  method  of 
anastomosis  credited  by  Mayo  to  Polya  and  by  Bier  to  Kronlein.  Instead  of 
closing  the  gastric  stump  as  described  above,  anastomose  it  to  the  side  of  the 
jejunum  as  follows:  Make  an  opening  in  an  avascular  portion  of  the  transverse 


Fig.  537. — Upper  jejunum,  6  to  12  inches  from  origin,  brought  through  an  opening  which 
has  been  made  in  the  transverse  mesocolon  and  united  by  outer  row  of  sero-muscular 
chromicized  catgut  sutures  to  posterior  wall  of  stomach.     (Mayo.) 


mesocolon;  pull  the  upper  jejunum  through  this  opening  and  lay  it  along  side 
the  stomach  stump  without  tension.  Balfour  (Surg.,  Gyn.  Obst.,  Nov.,  1917) 
prefers  to  select  a  loop  of  jejunum  14  to  18  inches  below  the  duodenojejunal 
junction  and  bring  this  loop  anterior  to  the  transverse  colon  so  as  to  reach  the 
stomach  stump  without  perforating  the  mesocolon.  Apply  an  intestinal  clamp 
to  the  loop  of  jejunum  exactly  as  in  gastro-jejunostomy.  Unite  the  jejunum 
to  the  posterior  wall  of  the  stomach  behind  the  Payr's  clamp  by  a  row  of 
chromicized  catgut  sutures  (Lembert  or  Gould  sutures)  (Fig.  537). 

Apply  an  intestinal  clamp  to  the  stomach  proximal  to  the  line  of  serous 
sutures.     Remove  the  Payr's  clamp.     Unite  the  open  end  of  the  stomach  to  a 


PYLORECTOMY 


401 


corresponding  opening  now  made  in  the  jejunum,  by  a  row  of  through-and- 
through  sutures  of  chromicized  catgut,  exactly  as  in  gastro-jejunostomy  (Figs. 
538  and  539).  Remove  the  intestinal  clamps  and  introduce  the  anterior  row  of 
chromocized  catgut  Lembert  sutures.     Draw  the  entire  anastomosed  end  of  the 


l^:in'i><.,ctch 


^^■J' 


'0 ' 


Fig.  538. 


-Crushing  clamp  removed  from  the  stomach  and  holding  clamps  applied  to  jejunum 
and  stomach  to  prevent  soiling.     (Mayo.) 


Stomach  down  through  the  opening  in  the  transverse  mesocolon.  Unite  the 
edges  of  the  opening  in  the  mesocolon  to  the  stomach  wall  (Fig.  540).  Some- 
times it  is  not  easy  to  pull  the  jejunum  up  to  the  upper  end  of  the  opening  in  the 
stomach  or  to  keep  it  there  without  tension.  Under  these  circumstances  it  is 
easy  to  apply  an  intestinal  clamp  well  back  of  the  Payr's  clamp  and  after  re- 

26 


402 


THE    STOMACH 


moving  the  latter  to  close  the  upper  end  of  thr  gastric  opening  by  two  rows  of 
suture  and  then  to  anastomose  the  side  of  the  jejunum  to  the  low  part  of  the 
stomach  opening.     When  this  is  done  it  is  well  to  suture  the  jejunum  to  the 


JF!y*T^ 


Fig.  539. — Inner  row  of  catgut  through-and-through  sutures  applied  to  the  posterior 
walls,  uniting  jejunum  to  cut  end  of  the  stomach  and  continuing  part  way  down  the  anterior 
wall.     {Mayo.) 


stomach  for  a  short  distance  alcove  the  site  of  anastomosis  so  that'the  unopened 
jejunum  acts  as  a  patch  applied  to  a  part  of  the  line  of  suture  closing  the 
stomach  (Fig.  541). 


PYLORECTOMY 


403 


Moynihan's  Technic. — The  sequence  of  steps  in  the  operation  as  per- 
formed by  Moynihan  is  as  follows: 

The  belly  having  been  opened  and  parts  exposed. 

(a)  Divide  the  duodenum  between  crushing  clamps.  Catch  and  ligate 
vessels  individually.  Find  and  remove  the  subpyloric  (subduodenal)  lymph 
nodes  which  lie  near  the  second  part  of  the  duodenum. 


Fig.  540. — Anastomosis  completed  by  an  anterior  row  of  scro-muscular  sutures.  Anas- 
tomosed end  brought  through  the  opening  in  transverse  mesocolon,  and  margins  of  opening 
sutured  to  the  stomach.     (Mayo.) 


(b)  Divide,  between  ligatures,  the  gastro-colic  omentum. 

(c)  Divide,  between  ligatures,  the  gastro-hepatic  omentum  as  high  up  as 
possible.  Ligate  the  coronary  artery  late;  this  permits  access  to  it  at  a  high 
level  and  gives  access  to  some  high  lymph  nodes  into  which  lymphatics  drain 
directly  from  the  pyloric  region.     Remove  the  nodes. 

(rf)  Tear  a  hole  in  the  mesocolon  and  pull  a  loop  of  jejunum  through  it. 
Perform  posterior  gastro-enterostomy  using  the  cardiac  portion  of  the  stomach. 


404  THE    STOMACH 

The  anastomosis  is  more  easily  performed  before  rather  than  after  excising  the 
portion  of  stomach  to  be  removed. 

■(e)  Choose  the  line  of  section  on  stomach.  Put  in  a  stay  or  traction  suture 
on  the  lesser  curvature  well  proximal  to  the  line  of  section.  Apply  a  clamp  to 
the  stomach  ^4  inch  proximal  to  the  line  of  section  and  distal  to  the  stay  suture 
which  forms  a  great  safety  if  the  clamp  slips. 

(/)  Divide  the  stomach  with  the  cautery. 

(g)  Suture  the  mucosa  with  catgut.  Apply  two  layers  of  continuous 
Lembert  (Gushing)  sutures,  after  removing  the  clamp. 

(h)  Fix  the  cut  edge  of  the  gastro-colic  omentum  to  the  lower  end  of  the 
stomach. 


v^ilk 


• 


Fig.  541. — The  stomach  has  been  closed  from  the  lesser  curvature  to  the  point  A.  A.B.  is 
the  site  of  anastomosis.  A.C.,  a  portion  of  jejunum  acting  as  a  patch  over  Billroth's  fatal 
angle. 

[i)  Attend  to  the  duodenal  stump  in  the  usual  fashion  and  then  attach  it 
by  a  stitch  to  the  anterior  surface  of  the  pancreas. 

(/)  Pull  the  great  omentum  up  in  front  of  the  transverse  colon  and  tuck  it 
into  the  cavity  now  existing  above  the  colon. 

Pauchet's  Gastrectomy. — Pauchet  (La  Pr.  Med.,  Oct.,  9,  19 16  Sherwood 
Dunn,  Am.  J.  of  Surg.,  Oct.,  1916)  is  a  great  advocate  of  the  intercoloepiploic 
route  for  exploring  the  posterior  gastric  and  duodenal  walls,  for  operating  upon 
lesions  of  these  walls  as  well  as  upon  ulcers  of  the  lesser  curvature. 

Step  I. — Open  the  abdomen.  Pull  the  great  omentum  and  the  transverse 
colon  out  of  the  abdomen  and  reflect  them  upwards.  If  slight  traction  is 
made  upwards  on  the  omentum  and  downwards  on  the  colon  numerous  delicate 
peritoneal  folds  will  be  seen  passing  from  omentum  to  colon.  Divide  some  of 
these  folds  carefully  close  to  the  gut  and  begin  separating  the  omentum  from 
the  colon  by  scissors  guided  by  the  finger  introduced  through  the  original  cut. 
As  soon  as  possible  enter  the  lesser  peritoneal  cavity.  Turn  the  stomach  with 
the  attached  omentum  upwards,  thus  exposing  the  whole  posterior  surface  of 
the  stomach  and  doudenum  as  well  as  the  pancreas  (Fig.  542,  543,  544,  545). 

In  case  of  a  bullet  wound  of  the  stomach  the  anterior  wound  may  be  sutured,  the  posterior 
wound  found  by  inter-colo-epiploic  separation  and  sutured.  The  great  omentum  may  now 
be  packed  into  the  lesser  peritoneal  cavity  and  the. inferior  border  of  the  stomach  sutured 
directly  to  the  colon  along  the  line  of  its  separation  from  the  great  omentum. 


PAUCHET  S    GASTRECTOMY 


405 


Step  2. — (There  is  extensive  ulcer"  of  the  lesser  curvature,  or  hour  glass 
stomach  is  present.)  Ligate  the  coronary  and  gastro-epiploic  vessels  proxi- 
mally  and  distally  to  the  segment  of  stomach  to  be  removed. 

Step  3. — Choose  the  lines  of  section  necessary  for  removal  of  the  affected 
portion  of  the  stomach.  Apply  a  crushing  clamp  to  the  stomach  on  each  side 
of  the  distal  line  of  section  and  divide  the  stomach  between  them  with  the  cau- 


FiG.  542. — Separation  of  omentum  from  transverse  colon.     {Lardennois,  Journ.  de  Chir.) 


tery.  Burn  the  pyloric  stump  protruding  from  the  clamp  until  the  clamp  is 
heated  sufficiently  to  char  the  tissues  crushed  between  its  jaws  (p.  398).  Insert 
a  continuous  fine  chromic  gut  suture  in  the  Gushing  fashion,  the  bites  being 
alternately  on  each  side  of  the  clamp  and  the  threads  crossing  it.  Remove  the 
clamp.  Pull  on  the  ends  of  the  suture  until  the  wound  becomes  neatly  inverted 
as  by  a  continuous  Lembert  suture.  Fasten  the  ends  of  the  suture  and  rein- 
force by  a  number  of  mattress  sutures.  Similarly  apply  crushing  clamps  to 
each  side  of  the  proximal  line  of  section  and  proceed  exactly  as  described  on 
page  399,  steps  7  and  8.     If  the  disease  is  cancer,  after  carrying  out  step  i 


4o6 


THE    STOMACH 


m0''y'''^' 


Fig.  543. — {Paiichet  of  Dunn.) 


Fig.  544. — {Pauchei  &  Dunn.) 


GASTRECTOMY 


407 


proceed  as  follows:  Working  from  below  upwards  by  sharp  dissection,  separate 
the  cancerous  pylorus  from  the  ])ancreas  and  mesocolon  (Fig.  544).  'There 
may  or  may  not  be  oozing  of  blood  during  this  step  but  there  will  not  be  real 
hemorrhage.' 

Slcp  3. — Mobilize  the  duodenum  down  to  the  pancreas.  Ligate  the  vessels 
following  the  u])])er  and  lower  borders  of  the  duodenum.  Crush,  divide  and 
close  the  duodenum  as  described  on  ]).  398.  As  a  precaution  cover  the  duodenal 
stump  with  a  cap  made  from  remnants  of  the  gastro-hepatic  omentum  or  of 
great  omentum.  This  may  be  done  at  a  later  stage  of  the  operation  but  should 
not  be  omitted. 

Step  4. — ^Complete  the  operation  as  described  on  p.  399. 


Fig.  545. — {Pauchel  er  Dunn.) 

After-treatment.- — ^The  special  rules  for  the  after-treatment  of  stomach  opera- 
tions are,  shortly,  as  follows: 

(a)  If  the  patient  is  much  dehydrated,  give  intravenous  or  subcutaneous 
infusions  of  saline  solutions.  These  may  be  repeated  during  a  few  days  if 
necessary.  If  not  dehydrated  and  if  stimulation  is  necessary,  administer  sub- 
cutaneously  a  20  per  cent,  solution  of  camphor  in  sterile  olive  oil.  As  the 
patient  leaves  the  operating-table  8  ounces  of  warm  coffee  should  be  given 
per  rectum.  Murphy's  proctoclysis  is  excellent.  Transfusion  of  blood  is 
often  of  life-saving  value.  Morphine  in  an  efficient  dose  may  be  administered 
if  required. 

{b)  As  soon  as  the  effects  of  the  anesthetic  wear  off  (within  a.few  hours) 
raise  the  patient  into  a  sitting  or  rather  semi-sitting  posture.  This  tends  to 
obviate  pulmonary  disturbances  and  is  important. 


408  THE    STOMACH 

(c)  Small  doses  of  hot  water  or  tea  may  be  given  as  soon  as  nausea  is  over- 
come.    Water,  if  well  born  by  the  stomach,  is  of  great  value. 

(d)  It  is  usually  safe  to  give  liquid  food  twelve  hours  after  operation.  If 
the  stomach  is  troublesome  rectal  feeding  must  be  practiced. 

(e)  These  rules  are  possibly  too  conservative.  Roux  permits  his  patients 
to  eat  almost  anything  they  desire  as  soon  as  they  desire  after  gastroenterostomy. 

Ultimate  results  of  resection  of  the  stomach  for  cancer. 

Out  of  ninety-four  cases  which  survived  three  years  or  longer  and  which 
were  without  recurrence  at  the  beginning  of  the  third  year  only  five  suffered 
from  later  recurrence.  Of  the  remaining  eighty-nine  cases  the  cures  had 
persisted  sixteen  years  in  one,  ten  years  in  five,  and  from  five  to  ten  years  in 
thirty-four.  The  hope  of  permanent  cure,  according  to  Leriche's  figures, 
is  about  20  per  cent.  [Leriche,  "Rev.  de.  Med.,"  Feb.,  1906.  Ref.  "Zentral- 
blatt  flir  Chir.,"  1907,  No.  29.] 

The  Mayos'  statistics  of  partial  gastrectomies  and  pylorectomies  per- 
formed between  April,  1897,  and  January,  19 10,  are  as  follows: 

Number  of  operations  266  with  thirty-four  deaths  (12.4  per  cent.).  Forty- 
two  of  the  operations  were  nofior  cancer.  During  1909  there  were  forty-six 
operations  w-ith  four  deaths  (8.6  per  cent.). 

Operations  for  carcinoma  involving  the  pyloric  end  of  the  stomach: 
Total  number,  224.     Average  age,  53. 

Patients  operated  on  over  five  years  ago:  Total  number,  50.  Present  con- 
dition known,  39.  Alive  and  well:  one  8  years,  2^^  months;  one  8  years; 
one  7  years  2  months  (has  since  died  of  recurrence);  one  6  years;  one  6 
years,  11  months;  one  5  years,  3)^  months;  one  5  years.     Total,  8. 

Patients  operated  on  over  four  years  ago:  Total  number,  85.  Present  con- 
dition known,  64.     Alive  and  well,  13. 

Patients  operated  on  over  three  years  ago:  Total  number,  117.  Present 
condition  known,  88.     Alive  and  well,  18. 

Patients  operated  on  less  than  three  years  ago:    Total  number,  107. 

In  one  case  of  gastric  carcinoma  operated  on  by  the  author  the  stomach  was 
inseparably  adherent  to  the  abdominal  wall  at  the  umbilicus  and  also  adherent 
to  the  pancreas.  The  umbilicus  was  excised  along  with  most  of  the  stomach. 
Three  years  after  the  operation  the  patient  was  well. 

(B)  Complete  gastrectomy  is  indicated  when  the  whole  stomach  is  affected 
by  malignant  disease;  or  if  only  one  part  is  evidently  affected,  the  rest  is  in 
a  suspicious  condition.  It  is  useless  to  attempt  a  complete  gastrectomy  if 
neighboring  structures  are  involved.  Connor  first  performed  this  opera- 
tion in  1889.  The  patient  lived  forty-eight  hours.  Schlatter  subsequently 
and  independently  operated;  his  patient  died  one  year  afterwards  from 
recurrence. 

The  Operation. — Open  the  belly  in  the  middle  line  by  an  incision  extending 
from  near  the  ensiform  cartilage  to  the  umbilicus.  Divide  the  greater  and 
lesser  omenta  after  securing  their  vessels  by  chain  ligatures.  The  stomach 
remains  attached  to  the  body  by  the  oesophagus  and  duodenum.  Pull  the 
oesophagus  downwards  as  far  as  possible  and  apply  a  clamp  to  it  at  as  high 
a  point  as  can  be  reached;     Clamp  the  cardiac  orifice  of  the  stomach.     Divide 


DUODENUM  409 

the  oesophagus  between  the  clamps.  Apply  two  clamps  to  the  pyloric  end 
of  the  stomach  or  to  the  duodenum  and  divide  between  them.  Remove  the 
stomach.  Close  the  open  end  of  the  duodenum  by  a  continuous  through- 
and-through  suture  covered  by  a  row  of  Lembert  sutures,  interrupted  or  con- 
tinuous. Approximate  a  loop  of  jejunum  to  the  open  end  of  the  oesophagus. 
Anastomose  the  oesophagus  and  the  portion  of  gut  selected  by  suture  or  by 
the  Murphy  button.  Of  course,  if  the  open  end  of  the  duodenum  can  be 
approximated  to  the  oesophagus  without  undue  tension,  then  these  structures 
ought  to  be  united.     (Harvie,  "Annals  of  Surg.,"  1900,  p.  344.) 

Excision  of  Cardia  and  Abdominal  (Esophagus. — H.  Boit  (Zent.  fiir  Chir.,  xvi,  May, 
1914)  has  frequently  successfully  operated  on  dogs  and  once  unsuccessfully  on  man,  in  the 
following  manner: 

Anesthesia  by  the  Sauerbruch  or  Meltzer-Auer  method. 

"Left  dorsal  flap  incision  with  base  near  spine.  Temporary  division  of  the  ribs  from 
the  eighth  to  twelfth  near  the  longitudinal  muscles  of  the  back.  Longitudinal  opening  of 
the  pleura  and  peritoneum.  Intercostal  incision  in  the  seventh  interspace  with  retraction 
of  the  wound  in  chest.  Division  of  the  tendinous  diaphragm  up  to  the  cardia.  Separation 
of  the  cardiac  end  of  the  stomach  and  of  the  affected  oesophagus.  -Division  of  both  vagi 
immediately  above  the  diaphragm.  ■  The  stomach  and  oesophagus  can  now  be  pulled  out 
of  the  wound  and  the  operation  carried  on  outside  of  the  body.  Completely  protect  the 
chest  cavity,  mediastinum  and  abdomen  with  pads.  Resect  a  segment  of  stomach  and 
oesophagus.  To  avoid  subsequent  stenosis  divide  the  oesophagus  obliquely.  Close  the  wound 
in  the  stomach.  Make  an  anastomosis  between  the  fundus  of  the  stomach  and  the  stump 
of  the  oesophagus  using  two  rows  of  interrupted  sutures.  Suture  both  halves  of  the  divided 
diaphragm  over  the  line  of  anastomosis  in  such  a  way  as  to  provide  the  latter  with  a  per- 
itoneal covering.  Close  the  diaphragmatic  and  mediastinal  wounds.  Close  the  chest  under 
hj'perpressure."  The  great  danger  apart  from  shock  consists  in  suture  insufficiency.  This 
is  prevented  by  avoidance  of  too  great  dissection  of  the  oesophagus,  avoidance  of  tearing  and 
crushing  of  the  oesophageal  stump  and  in  avoidance  of  tension  on  the  sutures.  Usually  the 
operation  must  be  preceded  by  jejunostomy  to  permit  of  nourishment  being  given.  During 
the  laparotomy  the  abdomen  must  be  explored  to  determine  if  the  major  operation  is  justifiable. 


CHAPTER  XXXIV 

OPERATIONS   ON  THE  INTESTINES 

Apart  from  operations  which  are  essentially  directed  against  the  biliary 
passages,  or  from  the  operation  of  gastro-duodenostomy,  the  only  lesion 
commonly  calling  for  interference  with  the  duodenum  is  ulceration.  Duo- 
denal ulceration  is  much  more  common  than  is  usually  supposed  and  has  been 
largely  dealt  wdth  in  the  chapter  on  ulceration  of  the  stomach.  The  opera- 
tive treatment  depends  on  the  presence  or  absence  of  perforation. 

Perforation  of  the  Duodenum. — The  ulcer  is  almost  invariably  situated 
in  the  first  23>^  inches  of  the  gut,  and  is,  therefore,  accessible. 

Step  I. — Open  the  abdomen  by  the  right  rectus  incision.  Guided  by 
evidences  of  inflammation  and  by  anatomical  knowledge,  expose  the  disease. 

Step  2. — Cleanse  the  affected  area.  Protect  the  rest  of  the  belly  with 
gauze.     If  possible,  close   the  perforations  by  Lembert  sutures.     Reinforce 


4IO  OPERATIONS    ON    THE    INTESTINES 

the  suture  by  an  omental  graft.  If  possible  make  the  line  of  suture  trans- 
verse to  the  long  axis  of  the  bowel;  this  to  avoid  stricture.  In  one  case  H.  S. 
Clogg  ("Brit.  Med.  Jour.,"  Jan.  2,  1905),  unable  to  close  the  perforation  by 
sutures,  brought  up  the  free  edge  of  the  omentum  and  stitched  it  around 
the  perforation  with  excellent  effect.  One  must  remember,  however,  that  this 
procedure  might  form  the  excuse  for  the  occurrence  of  an  internal  hernia.  A 
free,  i.e.,  non-pedunculated  omental  graft  is  entirely  preferable.  Murphy 
writes:  "Where  the  intestinal  wall  is  indurated  and  adherent  to  neighboring 
tissues  it  must  be  sufficiently  liberated  and  freed  to  admit  of  an  easy  apposition 
of  its  convex  surfaces  with  two  rows  of  suture.  The  failure  to  free  the  intestine 
from  neighboring  structures  is  the  most  common  cause  of  failure  of  union." 

Step  3. — Provide  for  drainage  through  the  primary  incision;  through  a  special 
opening  made  in  the  right  loin  just  below  the  last  rib,  or  when  there  is  much 
peritonitis,  provide  pelvic  drainage  through  an  anterior  wound  and  keep  the 
patient  in  the  Fowler  position. 

When  the  patient's  general  condition  is  good,  it  might  be  wise  to  follow 
Step  3  by  performing  a  gastro-enterostomy  so  as  to  give  rest  to  the  duodenum 
and  permit  healing"  of  the  ulcer. 

Corner  has  treated  duodenal  and  gastric  perforations  by  mere  plugging 
with  a  strip  of  gauze.  This  seems  a  very  risky  procedure  as  a  duodenal  fistula 
does  not  tend  to  close  spontaneously  and  unclosed  is  invariably  fatal. 

A.  A.  Berg  recommends  treatment  of  duodenal  fistulae  by  means  of  gastro- 
enterostomy plus  pyloric  occlusion.  This  is  thoroughly  logical.  Pannett 
(Lancet,  April  18,  1914)  in  a  case  of  duodenal  fistula  when  the  patient  was  in 
extremis  from  starvation,  established  a  jejunostomy  after  the  Witzel  method, 
at  the  same  time  anastomosing  the  loop  of  jejunum  going  to,  with  that  coming 
from  the  jejunostomy  opening.  Pannett  claims  the  following  advantages  for 
jejunostomy:  "it  is  technically  a  simpler  operation,  because  there  are  few  or  no 
adhesions  to  be  dealt  with;  a  septic  area  of  the  abdomen  has  not  to  be  opened 
up;  the  normal  functioning  of  the  pancreas  is  not  interfered  with  by  hindering 
the  formation  of  the  hormone  of  the  pancreas  (secretin),  which  occluding  the 
pylorus  does. 

The  disadvantage  lies  in  the  fact  that  a  subsequent  gastro- jejunostomy, 
should  it  become  necessary,  would  be  a  very  difficult  and  complicated  pro- 
cedure. Nevertheless,  I  think  this  operation  will  become  the  method  of  choice, 
and  Mayo  has  found  that  \ery  few  perforated  duodenal  ulcers  subsequently 
need  a  gastro-jejunostomy." 

Duodenal  Ulceration  without  Perforation. — The  treatment  of  ulceration 
and  its  sequel,  stenosis,  has  been  dealt  with  in  the  chapter  on  gaetric  ulcers. 

Duodeno-jejunostomy. — Chronic  obstruction  due  to  trouble  at  the  duodeno- 
jejunal angle  may  call  for  an  anastomosis  between  the  duodenum  and  the 
jejunum.  The  distal  portions  of  the  duodenum  are  normally  immobile  and 
thus  unless  mobilized  are  inconvenient  of  access.  Kummer  ("Bui.  et.  Mem. 
Soc.  de  Chir.  de  Paris,"  xlvi,  1161,  Oct.,  1920)  advises  mobilization  of  the 
last  (fourth  or  ascending)  portion  of  the  duodenum  through  Clairmont's  inci- 
sion ("Beitr.  2  Klin.  Chir.,"  Ixxi,  509).  Pull  the  transverse  colon  upwards; 
retract  the  small  intestines  upwards  and  towards  the  right.     This  e.xposes 


ENTEROTOMY 


411 


the  duodeno-jejunal  junction.  Beginning  al  the  inferior  duodeno-jejunal  fold 
make  a  vertical  incision  downwards  through  the  posterior  parietal  peritoneum 
and  through  this  mobilize  the  gut.  The  rest  of  the  operation  requires  no  special 
description. 

Enterotomy  and  Closure  of  Intestinal  Perforations. — Enterotomy  is  the 
operation  performed  for  the  extraction  of  foreign  bodies  or  for  the  evacuation 
of  intestinal  contents  in  certain  cases  of  ob- 
struction where  enterostomy  is  not  indicated. 
As  the  closure  of  the  gut  after  incision  is  simi- 
lar to  the  procedure  required  in  perforation, 
the  two  subjects  may  be  treated  together. 

Step  I. — Expose  the  intestine  by  an  inci- 
sion in  or  near  the  median  line.  Exception- 
ally some  other  incision  is  preferable. 

Step  2.— Find  and  pull  out  of  the  belly 
the  loop  of  gut  to  be  attacked.  (If  the  case 
is  one  of  perforation,  empty  the  loop  by  strip- 
ping it  wdth  the  fingers  and  apply  clamps  or 
their  equivalent.)  Protect  the  belly  cavity 
with  pads. 

Step  3. — Make  a  longitudinal  incision 
through  the  intestinal  wall  on  the  side  opposite  to  the  mesenteric  attachment. 
Extract  the  foreign  body.  Undoubtedly  a  longitudinal  incision  when  closed 
narrows  the  gut  lumen  more  than  does  a  transverse,  but  the  amount  and 
danger  of  this  narrowing  have  been  much  exaggerated  and  the  longitudinal 
cut  is  the  more  convenient  and  practical. 

Step  4. — Closure  of  the  intestinal  wound. 

(A)  If  the  opening  is  very  small,  one  or  two  points  of  Lembert  sutures  will 
suffice,  or  a  purse-string  suture  may  be  better  (Fig.  546). 


Fig.  546. — Purse-string  suture. 
{Monod  and  Vanverls.) 


Fig.  547. — Intestinal  perforation.     {Monod  and  Vanverts. 


(B)  If  the  opening,  while  longer,  is  linear,  insert  a  row  of  continuous  through- 
and-through  sutures  for  hemostasis  and  occlusion  (Connell's  Structure  is 
good),  and  cover  these  by  a  line  of  Lembert  sutures,  either  continuous  or 
interrupted.  Some  surgeons  do  not  use  the  deep  row  of  sutures,  but  it  is  both 
a  convenient  and  a  safe  procedure. 

(C)  If  the  opening  is  large,  or  so  contused  or  diseased  that  sutures  close 
to  it  will  not  hold,  direct  closure,  whether  transverse  or  longitudinal,  leads 
to  serious  obstruction  (Fig.  547).  The  effects  of  the  resulting  stenosis  may 
be  discounted   by  making  an  anastomosis  between  the  loop  of  gut  leading 


412  OPERATIONS    ON    THE    INTESTINES 

to  and  that  going  from  the  stenosis,  or  the  injured  segment  of  intestine  may 
be  excised. 

Step  5. — Cleanse  the  exposed  gut.  Review  the  line  of  suture  reinforcing 
it,  where  necessary,  by  points  of  Lembert  sutures.  Remove  the  protective 
pads.     Replace  the  intestines  in  the  belly. 

Step  6. — Close  the  belly. 

If  there  is  any  fear  that  the  intestinal  sutures  will  fail  to  do  their  duty, 
many,  probably  most,  surgeons  apply  a  wick  of  gauze  or  cigarette  drain  to 
the  wounded  gut,  bringing  the  free  end  of  the  drain  out  through  the  parietal 
wound.  To  the  writer  it  appears  that  such  a  precaution  is  liable  to  lead 
to  the  very  state  of  affairs  it  is  meant  to  prevent;  that  the  foreign  body  or  drain 
close  to  the  line  of  suture  may  possibly  interfere  with  the  process  of  repair. 

Lateral  Anastomosis  by  Means  of  Suture. — The  following  operation  is  in 
all  essentials  that  described  by  Abbe: 

Step  I. — Bring  outside  the  abdominal  cavity,  which  is  protected  by  gauze 
pads,  the  loops  of  gut  to  be  united.  Place  the  loops  together  in  such  a  manner 
that  about  five  inches  lie  in  contact.  Squeeze  the  contents  out  of  the  loops  and 
apply  suitable  clamps  to  keep  them  empty. 

Step  2. — Unite  the  two  loops  of  gut  for  about  four  inches  by  a  row  of  con- 
tinuous suture  (continuous  Lembert),  parallel  to  and  not  far  from  the  mes- 
enteric border.  The  stitches  involve  the  serous,  muscular,  and  fibrous  or 
sub-mucous  tunics.  Fasten  the  suture  with  a  knot  (Fig.  548).  The  objection 
to  continuous  non-absorbable  sutures  when  used  in  gastro-enterostomy  does 
not  apply  in  the  case  of  the  intestine  where  if  the  suture  causes  any  irritation 
it  is  promptly  sloughed  into  the  gut  and  no  harm  results. 

Step  3. — At  a  safe  distance  from  the  line  of  suture  A,  B,  make  the  opening 
X,  Y,  in  one  of  the  loops.  The  opening  must  be  about  one  inch  shorter  than 
the  line  of  suture  A,  B.  A  portion  of  intestinal  wall  about  one-half  inch  in 
width  may  be  excised  along  the  line  of  the  opening  X,  Y.  This,  however, 
is  optional.  Seize  any  bleeding  points  with  forceps.  Payr  ("Zent,  fiir  Chir,," 
March  23,  191 2)  wipes  the  mucosa  dry  and  paints  it  with  tincture  of  iodine. 
This  sterilization  of  the  mucosa  he  finds  to  be  very  useful.  Repeat  Step  3  on 
the  other  loop  of  gut. 

Step  4. — With  a  continuous  catgut  suture  unite  the  corresponding  edges 
of  the  openings  in  the  two  loops  of  gut  (Fig.  t;49).  This  continuous  suture 
involves  all  the  coats  of  the  intestine  and  shuts  off  the  intestinal  cavity  from 
the  line  of  Lembert  sutures;  at  the  same  time  it  prevents  loss  of  blood.  The 
suture  may  be  applied  in  the  Connell  fashion,  v.  Schmieden  ("Zent.  f.  Chir.," 
April  15,  1911,  No.  15,)  advises  using  the  old-fashioned  postmortem 
suture  for  the  anterior  mucosa  suture  (Fig.  550).  This  inverts  all  the  coats  of 
the  gut.     Rovsing  uses  a  similar  stitch. 

Step  5. — Continue  the  line  of  suture  A,  B  (posterior  row  of  Lembert  suture) 
completely  around  the  site  of  the  anastomosis  (Fig.  549,  L,  L,  L),  thus 
entirely  burying  from  view  the  occlusion  or  hemostatic  sutures  introduced 
in  Step  4.  Fig.  551  shows  the  last  of  these  sutures  being  introduced  in  the 
interrupted  fashion.  The  continuous  suture  is  as  good  as,  or  really  better 
than,  the  interrupted. 


LATERAL   ANASTOMOSIS 


413 


Fig.  548.  Fig.  549. 

Figs.  548  and  549. — Abbe's  operation. 


^^ 

^^^B^H 

''  :^'  i^ 

M 

Fig.  550. — {Schmieden. 


414 


OPERATIONS    ON    THE    INTESTINES 


Step  6. — Review  the  line  of  suture  and  if  necessary  reinforce  it  by  a  few 
extra  stitches.     Fig.  552  shows  a  sectional  view  of  the  anastomosis. 

Step  7. — Remove  the  intestinal  clamps.  Clean  the  wound.  Remove 
gauze  pads.     Return  the  intestines.     Close  the  abdominal  wound. 


Fig.  551. — Abbe's  operation. 

Dr.  Charles  T.  Parkes  recommended  a  smaller  opening  in  the  gut  than 
that   described   above.     After   making   a   longitudinal    incision  through   the 


Fig.  552. — Lateral  anastomosis. 

intestinal  wall  at  a  point  opposite  the  mesenteric  attachment,  he  made  a  short 
transverse  incision  at  either  end  of  it  and  so  formed  two  flaps  of  gut-wall 
which  he  turned  inwards,  fastening  them  in  this  position  by  a  few  sutures 


MURPHY  BUTTON 


415 


The  turning-in  of  the  flaps  prevented  contraction  of  the  anastomotic  openings. 
After  making  the  openings  in  the  opposing  loops  of  gut,  Parkes  completed  the 
union  by  a  single  row  of  continuous  Lembert  sutures,  each  stitch  involving 
one-third  inch  of  intestinal  wall,  the  stitches  being  one-eighth  of  an  inch  apart. 

"It  makes  no  difference  whatever  what  kind  of  suture  is  used,  so  that 
the  principle  of  positively  securing  the  application  of  two  broad  surfaces  of 
peritoneum  in  contact  with  each  other  is  certainly  carried  out."     (Parkes.) 

Fig.  553  shows  how  the  Abbe  operation  may  be  more  conveniently  per- 
formed with  the  aid  of  two  gastro-enterostomy  clamps.  The  clamps  used  as 
in  the  diagram  simplify  the  operation  amaz- 
ingly, hold  the  segments  of  gut  in  convenient 
position,  prevent  bleeding  and  prevent  escape 
of  intestinal  contents. 

Lateral  Anastomosis  by  Means  of  the 
Murphy  Button. — Step  i. — Having  opened 
the  belly,  pull  the  two  loops  of  gut  which 
it  is  desired  to  unite  out  from  the  abdominal 
cavity  and  protect  the  latter  with  gauze 
pads.  Empty  the  segments  of  intestine  and 
keep  them  empty  by  means  of  clamps. 

Step  2. — Introduce  a  purse-string  suture 
of  fairly  stout  silk  or  catgut  into  the  gut 
opposite  its  mesenteric  attachment.  The 
suture  pierces  all  the  coats  of  the  gut. 
Make  a  longitudinal  opening  into  the  gut, 
large  enough  to  permit  the  introduction  of  a 
Murphy  button  of  appropriate  size.  This 
cut  is  in  the  area  surrounded  by  the  purse- 
string  suture  (Fig.  554). 

Step  3. — Seize  one-half  of  the  Murphy 
button  with  hemostatic  forceps  and  introduce 
its  head  into  the  gut.  Weir  has  found  that 
the  forceps  may  so  injure  the  button  as  to 
render  it  unsafe.  Dawbarn  plugs  the  two 
segments  of  the  button  with  corks,  thus  pro- 
viding handles  and  at  the  same  time  preventing  escape  of  intestinal  contents. 
Cordier  has  devised  ingenious  metal  handles  to  plug  the  button  and  take 
the  place  of  the  corks. 

Pull  the  purse-string  tight  and  tie  it  in  such  a  manner  that  the  opening 
in  the  gut  is  snugly  fastened  around  the  neck  of  the  button  (Fig.  555).     With 
scissors  or  knife  remove  any  excess  of  tissue  distal  to  the  suture  which  might 
interfere  with  the  proper  approximation  of  the  two  halves  of  the  button. 
Repeat  Steps  2  and  3  on  the  other  loop  of  gut. 

Step  4. — Remove  the  hemostatic  forceps  or  corks  from  the  two  halves  of 
the  button.  Insert  the  neck  of  the  male  half  of  the  button  into  that  of  the 
female  half  and  push  them  together  firmly  (Figs.  556  and  557).  A  few  points 
of  Lembert  suture  may  be  used  to  reinforce  the  union. 


Fig.  553. — Lateral  anastomosis. 

Clamps  in  place.  Posterior  row  serous 
sutures  in  place.  Gut  incised;  through- 
and-through  or  Connell  suture  begun. 
When  the  through-and-through  suture  is 
in  place  completely  around  the  anastomotic 
opening,  remove  the  clamps  and  then 
insert  the  anterior  row  of  serous  sutures. 
In  this  diagram  it  is  assumed  that  a  por- 
tion of  gut  has  been  excised;  that  both 
afferent  and  efferent  loops  have  been  closed. 
M.  S.  indicates  the  line  of  union  of  the 
mesentery  of  the  two  loops  of  the  gut.  No 
holes  must  be  left  in  the  mesentery. 


4i6 


OPERATIONS    ON    THE    INTESTINES 


In  Step  2  the  incision  may  be  made  into  the  gut  before  the  purse-string 
suture  is  introduced.     A  good  method  of  applying  the  stitch  is  shown  in  Fig.  558. 


Fig.  554. 


Fig.  555 


Figs.  554  and  555. — Use  of  Murphy's  button.     {Monod  and  Vanverts.) 


.  ,^;v-?<'' fT-'j 


Fig.  556.  Fig.  557. 

Figs.  556  and  557. — Use  of  Murphy's  button.     {Monod  and  Vanverts.) 


Fig.  558. — Use  of  Murphy's  button. 


Anastomosis  by  Means  of  McGraw's  Elastic  Ligature. — Steps  i  and  2 
are  identical  with  the  operation  by  means  of  suture. 

Step  3. — Thread  a  piece  of  well-rounded  elastic-cord,  about  3  mm.  in 
diameter,  in  a  straight  Hagedorn  needle.     (The  end  of  the  cord  is  tapered 


CIRCULAR   ENTERORRHAPHY  417 

with  a  knife  to  permit  of  threading.)  Pass  the  needle  into  the  lumen  of 
the  gut  and  out  again  at  a  point  about  2)'^  inches  distant.  The  track  of 
the  needle  corresponds  to  the  incision  made  into  the  gut  in  the  suture 
operation.  With  a  sharp  jerk  pull  the  needle  and  with  it  the  elastic  cord 
through  the  intestinal  walls.  The  assistant  keeps  the  cord  on  the  stretch 
during  this  manoeuvre.  Repeat  this  in  the  opposite  direction  on  the  other 
loop  of  gut.  Tighten  the  ligature  as  much  as  possible;  cross  its  ends  and 
secure  them  by  a  stout  silk  thread  passed  underneath  and  tied  on  top. 

Step  4. — Complete  the  line  of  continuous  Lembert  suture  around  the  site 
of  anastomosis  thus  entirely  hiding  the  elastic  ligature.  This  finishes  the 
intestinal  part  of  the  operation. 

The  elastic  cord  or  ligature  establishes  a  communication  between  the  two 
loops  of  gut  in  from  three  to  four  days.  By  its  use  dangers  of  soiling  the 
peritoneum  by  visceral  contents  escaping  during  the  operation  are  eliminated. 
In  the  hands  of  McGraw,  Willy  Meyer,  and  others  the  method  has  proved 
very  satisfactory. 

End-to-end  Anastomosis ;  Circular  Enterorrhaphy.— In  making  an  end- 
to-end  anastomosis,  whether  by  means  of  suture  or  the  Murphy  button,  it 
is  of  prime  importance  to  understand  the  anatomy  of  the  mesenteric  insertion. 
When  the  mesentery  approaches  the  gut,  its  two  peritoneal  surfaces  separate 
to  surround  the  intestine  and  leave  a  A-shaped  space  loosely  filled  with  fat 
and  containing  the  vessels  going  to  or  from  the  gut.  Opposite  this  space  the 
muscular  tunics  lie  uncovered  by  peritoneum.  The  most  important  stitch 
in  circular  enterorrhaphy  is  that  which  closes  this  space.  The  author  has 
frequently  operated  with  satisfaction  in  the  following  manner: 


Fig.  559.  Fig.  560. 

Figs.  559  and  560. — Circular  enterorrhaphy. 

Step  I. — Bring  the  divided  ends  of  the  two  segments  of  gut  together  out- 
side the  belly  cavity.  Unite  them  by  a  stitch  of  silk  or  catgut  at  a  point  be- 
side the  mesenteric  attachment,  at  a  point  on  the  free  edge,  and  at  a  point 
midway  between  these  two  (Fig.  559).  These  three  stitches  insure  uniformity 
in  suturing.  The  same  end  may  be  attained  by  the  use  of  miniature  volsellae. 
With  a  continuous  suture,  involving  all  the  coats  of  the  gut,  complete  the 
union  of  the  two  segments  (Fig.  560).  This  suture  stops  bleeding  and  prevents 
contamination  of  the  next  or  essential  row  of  sutures  by  the  intestinal  contents. 

Step  2. — At  the  mesenteric  attachment  introduce  a  Mitchell-Hunner  mes- 
enteric mattress  suture  (Fig.  561),  involving  the  serous,  muscular,  and  sub- 
mucous tunics.  To  secure  serous  apposition  at  the  mesenteric  space  there  is 
no  suture  comparable  to  the  above.  The  suture  shown  in  Fig.  562  is  less 
desirable. 

27 


4i8 


OPERATIONS    ON    THE    INTESTINES 


Step  3. — Introduce  a  Lembert  suture  at  the  free  margin  of  the  gut  opposite 
the  mesenteric  attachment.  Introduce  a  continuous  Lembert  suture  all 
around  the  gut.  Each  stitch  should  pick  up  about  3.3  inch  of  the  serous 
and  subjacent  muscular  tunics.  Do  not  pull  the  stitches  very  tight;  all 
that  is  required  is  that  serous  coat  should  be  kept  in  touch  with  serous  coat 

(Fig-  563)- 

Step  4. — Review  the  wound.  Where  advisable  reinforce  the  line  of  union 
with  Lembert  sutures.  Beware,  however,  of  causing  too  much  invagination 
of  the  wound  and  thus  producing  stenosis. 


Fig.  561. — Mitchell-Hunner  stitch. 

The  late  Dr.  Chas.  T.  Parkes  made  use  of  the  continuous  Lembert  suture 
in  the  manner  described,  but  omitted  the  provisional  suture  which  penetrates 
all  the  coats  of  the  gut.  Parkes  writes,  apropos  of  his  experimental  work: 
"The  greatest  number  of  mishaps  followed  drawing  the  sutures  too  tightly, 
which,  if  done,  leads  to  death  of  the  applied  edges,  and,  of  course,  to  failure 
They  must  be  drawn  only  sufficiently  close  to  bring  the  surfaces  fairly  in  con- 
tact; the  subsequent  swelling  from  obstructed  circulation  will  hold  the  sur- 


FiG.  562.  Fig.  563. 

Figs.  562  and  563. — -Circular  enterorrhaphy. 

faces  firmly  together  until  glued  to  each  other  by  the  rapidly  forming  adhesive 
material." 

End-to-end  anastomosis  is  most  easily  performed  with  the  aid  of  clamps. 
Any  good  intestinal  clamps,  with  rubber  tubing  over  the  blades,  are  suitable. 

Step  I. — Clamp  each  of  the  segments  of  gut  about  one  inch  from  their 
open  ends.     Place  the  clamps  and  contained  gut  side  by  side  (Fig.  564). 

Step  2. — Introduce  the  posterior  row  of  continuous  Lembert  sutures 
(AB,  Fig.  564). 


MAUNSETT  S    OPERATION 


419 


Step  3. — Beginning  at  the  mesenteric  attachment,  introduce  a  Connell 
suture  (Figs.  564  and  565)  completely  around  the  gut,  closing  it  entirely. 

Step  4. — -Complete  the  introduction  of  the  continuous  Lembert  suture 
(AB,  Fig.  566). 


Fig.  564.  Fig.  565. 

Figs.  564  and  565. — Connell's  suture. 

Step  5. — Close  the  rent  in  the  mesentery. 

MaunseWs  Operation. — A  portion  of  gut  is  supposed  to  have  been  excised. 

Step  I. — Unite  the  severed  ends  of  the  gut  by  two  sutures  involving  the 

whole  thickness  of  the  intestinal  wall.     One  suture  is  inserted  near  the  mesen- 


.^aii,. 


Fig.  566. — Circular  cnterorrhaphy. 


tery,  the  other  on  the  opposite  side  of  the  intestine.  The  ends  of  both  sutures 
are  left  long  (Fig.  567). 

Step  2.- — On  the  free  margm  of  the  larger  segment  of  gut  (Fig.  567)  make 
the  longitudinal  cut  "a"  at  least  one  inch  from  the  point  of  insertion  of  sutures. 

Step  3. — With  an  eyed  probe  push  the  long  sutures  through  the  lumen 
of  the  gut  and  out  of  the  cut  "a."     Pull  upon  the  threads  until  the  divided 


420 


OPERATIONS    Oy    THE    IN'TESTINE^S 


ends  of  the  gut  emerge  through  the  opening  "a."  Looking  at  the  double 
tube  of  gut  protruding  through  the  opening  "a"  note  that  their  peritoneal 
surfaces  are  in  contact  (Figs.  568  and  569). 

Step  4. — Pass  a  straight,  fine  seamstress'  needle  through  the  protruded  tube 
of  gut  and  thus  introduce  about  ten  sutures  of  fine  horse-hair  or  silkworm-gut. 
The  sutures  should  be  inserted  about  ^  of  an  inch  from  the  cut  edge  of  gut. 
Pick  up  the  sutures  as  they  pass  through  the  lumen  of  the  gut  and  divide  them, 
thus  obtaining  twenty  sutures  in  position  instead  of  ten.     Tie  the  sutures. 


Fig.  567.  Fig.  568.  .  Fig.  569. 

Figs.  567,  568,  569  and  570. — Maunsell's  operation. 


Fig.  570. 
(Maylard.) 


lodoformize  the  line  of  stitches.  Cut  short  the  temporary  stitches.  Pull  the 
protruded  portion  of  bowel  back  into  its  normal  position. 

Step  5. — Close  the  wound  "a"  by  appropriate  sutures.  Repair  the  mesen- 
tery (Fig.  570). 

End-to-end  Union  by  Means  of  the  Murphy  Button. — This  operation  is 
practically  the  same  as  that  described  for  lateral  anastomosis.  The  only 
point  to  be  specially  noticed  is  the  method  of  closing  the  mesenteric  space  or 
insertion  with  the  purse-string  suture.  Figs.  558,  571,  572,  573  explain  them- 
selves. 

An  endless  number  of  contrivances — decalcified  bone  plates  and  bobbins, 
rawhide  plates,  catgut  rings,  segmented  rubber  rings,  vegetable  plates,  etc. — 
have  been  invented  to  simplify  intestinal  anastomosis,  but  most  have  been  dis- 
carded as  cumbersome  and  unnecessary.  The  same  may  be  said  of  numerous 
devices  to  support  or  distend  the  lumen  of  the  gut  while  stitches  are  being 
inserted. 

Of  these,  Harrington's  segmented  metal  ring  is  probably  by  far  the  best. 
(See  "Trans.  Am.  Surg.  Assoc,"  vol.  xxii.) 

The  operation  of  lateral  implantation,  i.e.,  where  the  end  of  one  segment 
of  gut  is  anastomosed  to  the  side  of  another,  is  a  combination  of  end-to-end 
and  of  lateral  anastomoses,  and  is  sufficiently  explained  by  Figs.  574  and  575. 
Figs.  576  to  580  show  a  number  of  varieties  of  intestinal  anastomosis  and 
implantation. 

ConneWs  method  of  enterorrhaphy  is  similar  to  Maunsell's  in  that  the  sutures 
penetrate  the  whole  thickness  of  the  gut- wall,  and  differs  from  it  in  the  absence 
of  the  second  incision  into  the  gut. 


ANASTOMOSIS 


421 


Fig.  571. 


Fig.  572. 


V//.  ,     ,■  1  .  ,  iVVv 


Fig.  573. 
Figs.  571,  572  axd  573. — Use  of  Murphy's  button.     (DaCosla.) 


Fig.  574.  Fig.  575. 

Figs.  574  .axd  575. — Lateral  implantation. 


422 


OPERATIONS    ON    THE    INTESTINES 


Fig.  576. 


I-'IG.  577- 


Fig.  578 


V^ 


Wi-,^ 


Fig.  570- 


Fig.  580. 


Fig.  581.  Fig.  582. 

Figs.  581  and  582. — Connell's  suture. 


REMARKS    ON    ANASTOMOSIS 


423 


Step  I. — Place  the  ends  of  the  gut  in  apposition,  with  the  mesenteric  attach- 
ment of  one  side  corresponding  to  that  of  the  other.  Introduce  two  or  more 
fixation  sutures,  F  (Fig.  581),  to  insure  accuracy  and  uniformity  in  stitching. 
Instead  of  fixation  sutures,  miniature  volsellae  may  be  employed.  Introduce 
the  continuous  suture  (S)  as  shown  in  Fig.  581.  In  this  manner  fully  two- 
thirds  or  even  three-fourths  of  the  circumference  of  the  gut  may  be  united. 
The  remaining  third  or  fourth  of  the  wound  is  not  so  simply  united,  but  if 
Fig.  582  is  carefully  studied,  the  method  will  be  clearl}'^  understood.  When 
the  two  portions  of  gut  are  united  and  the  suture  pulled  sufficiently  tight,  the 
two  ends  of  the  suture  T,  S  emerge  at  the  same  point  (Fig.  583,  x). 

Step  2. — Introduce  through  the  line  of  suture  at  the  point  Y  (Fig.  583)  a 
threaded  needle.  Make  the  eye-end  of  the  needle  emerge  alongside  the  sutures 
T  and  S,  at  the  point  x.  Pass  the  ends  of  T  and  S  through  the  loop  of  the 
thread  in  the  needle  and  with  the  needle  pull  them  out  through  the  point  Y. 


Fig.  583.  Fig 

Figs.  583  and  584. — Connell's  suture. 


Step  3.— Slight  traction  on  T  and  S  will  bring  the  mucous  surface  of  the  gut 
at  the  point  x  into  contact  with  the  mucous  surface  at  the  point  Y  (Fig.  584). 
If  now  the  sutures  T  and  S  are  tied  tightly  together  and  the  knot  allowed  to  slip 
through  the  line  of  union  at  the  point  Y,  this  will  sufiiciently  fasten  the  sutures. 
The  student  is  strongly  advised  to  familiarize  himself  thoroughly  with  this 
method  before  attempting  it  on  the  living.  An  old  coat  makes  a  good  model 
on  which  to  practise  this  operation.  Imagine  the  wrist  ends  of  the  sleeves 
to  be  open  ends  of  gut,  and  unite  them.  A  few  minutes  of  such  practice  with 
a  coarse  needle  and  thread  makes  easy  the  comprehension  of  this  rather  puzzling 
stitch. 

Remarks  on  Anastomosis. — In  the  preceding  pages  many  methods  have 
been  described  by  which  union  between  various  segments  of  the  gastro-intestinal 
canal  may  be  effected  for  various  purposes.  The  experienced  surgeon  has 
no  difficulty  in  making  a  selection  of  the  method  which  will  serve  his  purpose 
best;  a  hint  suffices  to  equip  him  for  the  performance  of  some  modified  operation 
with  the  details  of  which  he  was  not  previously  familiar.  With  the  beginner 
in  operative  surgery  it  is  entirely  different.     He  ought  to  select  a  general  method 


424  OPERATIONS    ON    THE    INTESTINES 

of  operating  suitable  for  almost  all  cases,  he  ought  to  practise  this  method  ad 
nauseam  on  intestines  removed  from  hogs  (vivisection  is  here  unnecessary) 
until  he  almost  can  carry  out  the  minutest  details  with  his  eyes  blindfolded. 
Having  once  established  for  himself  a  basal  or  normal  method  of  operating, 
excursions  into  the  more  refined  elegancies  of  technic  become  easy  and  often 
desirable. 

Lateral  anastomosis  is  the  most  universally  applicable  method  of  uniting 
one  segment  of  gut  to  the  other.  It  is  the  basal  method  of  operating  and  must 
be  mastered  in  every  detail  by  the  surgeon  before  he  presumes  to  open  the  ab- 
domen for  any  purpose,  as  in  the  course  of  the  simplest  of  intra-abdominal 
operations  circumstances  may  arise  which  compel  interference  with  the  in- 
testinal canal. 

The  following  operations  are  either  identical  or  almost  identical  with  lateral 
anastomosis: 

A.  Gastro-gastr ostomy  in  Hour-glass  Stomach. — (a)  Union  of  the  two  stomach 
pouches  by  a  moderate-sized  opening.  (Identical  with  lateral  anastomosis. 
(b)  Union  of  the  two  pouches  with  restoration  of  the  normal  shape  of  the 
stomach.  This  procedure  is  practically  the  same  as  Finney's  operation. 
(Almost  identical  with  lateral  anastomosis.) 

B.  Finney's  Operation. — Gastro-duodenostomy.  (Almost  identical  with  lat- 
eral anastomosis.) 

C.  G  astro-enter  ostomy. — (Identical  with  lateral  anastomosis.) 

D.  Cholecystenter ostomy. — (Identical  with  lateral  anastomosis.) 

E.  Enter o-enter ostomy. — ^Lateral  anastomosis — indicated  after  excision  of  gut 

{e.g.,  in  gangrenous  hernia,  tumor,  etc.) 
or  for  purposes  of  intestinal  exclusion. 

E.  Enter o-colostomy. — ^Lateral  anas- 
tomosis. 

G.  Monari's  uretero-ureter ostomy  is 
practically  identical  with  lateral 
anastomosis. 

Resection    of    a   Portion    of    Small 

c/amp.       Intestine. — The     indications     for     this 

operation    are    localized    malignant    or 

benign    tumors;     localized    tuberculous 
Fig.  585. — Enterectomy.  ,     .  °  ^  .        . 

lesions;     gangrene;     trauma     extensive 

enough  to  contraindicate  local  suturing,  etc. 

The  Operation. — Step  i. — Open  the  belly  in  the  middle  line. 

Step  2.— Pull  the  affected  loop  of  gut  outside  the  belly  and  protect  the 
peritoneal  cavity  with  gauze  pads. 

Step  3.— Empty  the  contents  from  the  intestinal  loop  by  "stripping"  with 
the  fingers.     Apply  clamps. 

Step  4.— Note  the  blood-supply  as  it  passes  through  the  mesentery.  Ligate 
the  vessels  supplying  the  portion  of  gut  to  be  removed. 

Step  5. — Divide  the  intestine  on  each  side  of  the  disease  at  a  point  where 
it  is  well  supplied  with  blood  (Fig.  585).  Section  of  the  gut  should  be  made 
obliquely,  more  of  the  free  border  being  removed  than  of  the  mesenteric.     This 


ENTERECTOMY  425 

is  done:  (a)  because  when  obliquely  divided  the  open  ends  of  gut  have  a  greater 
circumference  than  when  cut  transversely,  and  hence  allow  for  the  loss  of 
diameter  occasioned  by  suturing;  (b)  because  the  gut- wall  on  the  non-attached 
border  is  more  liable  to  be  well  nourished.  If  desirable,  excise  a  V-shaped 
portion  of  mesentery  corresponding  to  the  segment  of  gut  removed. 

Step  6. — Either  unite  the  ends  of  the  gut  by  an  end-to-end  anastomosis  or 
close  them  by  means  of  suture,  preferably  purse-string,  and  provide  for 
intestinal  continuity  by  a  lateral  anastomosis. 

Step  7. — If  a  V-shaped  portion  of  mesentery  has  been  removed,  unite  its 
edges  by  suture.  If  this  has  not  been  done,  fold  any  redundancy  upon 
itself  and  secure  by  a  few  stitches,  being  careful  not  to  interfere  with  the 
nutrition  of  the  gut.  When  several  feet  of  intestine  have  been 
excised  and  especially  when  the  mesentery  is  loaded  with  much  fat 
it  is  impossible  to  suture  the  mesenteric  wound  neatly,  leaving  no  raw 
surfaces.  Even  after  much  has  been  accomplished  by  suturing  it  is  certain 
that  a  larger  or  smaller  mass  will  protrude  from  the  mesentery  and  if  un- 
covered by  peritoneum  will  invite  adhesion  and  consequent  ileus.  When 
such  a  raw  stump  is  present,  choose  a  suitable  portion  of  omentum;  ligate 
and  cut  it  oflf.  Spread  the  omental  sheet,  thus  obtained,  over  the  raw  stump 
and  fix  it  by  a  few  sutures. 

Step  8. — Review  the  wound.  Cleanse.  Remove  gauze  pads.  Return  the 
gut  into  the  belly.     Close  the  abdomen. 

Caecectomy  is  indicated  in  cases  of  malignant  or  tuberculous  disease,  in 
some  cases  of  intussusception,  as  well  as  in  some  cases  of  mobile  or  enlarged 
caecum.     Moynihan  writes  (Brit.  Med.  J.,  July  12,  1919): 

"Many  patients  who  suffer  from  vague  dyspepsias,  ascribed  perhaps  to 
intestinal  stasis,  or  to  chronic  appendicitis,  disclose  on  the  operation  table  this 
condition:  A  membranous  band,  broad  above,  where  it  takes  origin  from 
the  posterior  abdominal  wall,  the  under  surface  of  the  liver,  the  pelvis  of 
the  gall  bladder,  the  cystic  duct,  and  the  duodenum,  narrows  below  as  it  crosses 
the  ascending  colon  to  be  lost  on  the  peritoneum,  to  the  inner  side  of  the  ascend- 
ing colon,  and  on  the  enteric  mesentery.  Below  this  band,  which  is  quite  differ- 
ent from  a  "Jackson's  membrane,"  the  caecum  and  the  ascending  colon  are 
distended  and  soggy.  Very  often  the  appendix  looks  turgid,  thick,  and  stiff. 
Removal  of  the  appendix,  to  which  the  troubles  are  ascribed,  gives  little  or  no 
relief.  Division  of  the  band  allows  adhesions  to  re-form.  The  only  practice 
likely  to  give  good  results  is  the  removal  of  the  terminal  ileum,  ceecum,  and 
ascending  colon.  The  performance  of  gastro-enterostomy,  of  course,  makes 
matters  worse." 

Step  I. — Open  the  abdomen  in  right  semilunar  line;  expose  and  examine  the 
diseased  organs. 

Step  2. — Incise  the  posterior  parietal  peritoneum  at  the  outer  side  of  the 
caecum  and  ascending  colon.  Free  the  caecum  from  its  bed  by  finger  dissection. 
Ligate  and  divide  the  branches  of  the  ileocolic  artery  to  the  necessary  extent. 
Completely  mobilize  the  diseased  segment  of  gut.  The  caecum  may  be  so 
mobile,  i.e.,  so  well  provided  with  mesocaecum,  that  ligatures  or  clamps  may 
be  applied  directly  without  preliminary  dissection. 


426 


OPERATIONS    ON    THE    INTESTINES 


Step  3. — 'Treat  Ihe  mobilized  gut  as  in  Paul's  colectomy  or  proceed  as 
follows: 

With  two  crushing  forceps  applied  about  i  inch  apart  strongly  clamp  the 
ileum  at  a  point  6  to  8  inches  above  the  Ciccum.  Divide  the  gut  between  the 
forceps.     Cleanse  the  cut  surfaces. 

Treatment  of  the  proximal  segment  of  the  ileum:  (a)  With  a  continuous 
suture  tightly  close  the  open  end  of  the  gut  {i.e.,  distal  to  the  clamp);  (i) sur- 
round the  gut  about  13-2  inches  proximal  to  the  clamp  with  a  purse-string  suture; 
(c)  remove  the  clamp;  invaginate  the  sutured  end  of  (he  gut  and  tighten  the 
purse  string  sutures. 


I 


Duodeniim 


^    a.  Colica  dextra 


-f—a.  Colica 
i    Ileo-colica 


Peritoneum 


Ileum 


Fig.    586. — Ileum    anastomosed 
ascending  colon. 

Peritonealization  of  wound.     Divided  ends 
of  ileum  and  colon  closed. 


to  Fig.  587. — Lymphatics  and  vessels  of  cjecum. 


In  the  same  manner  with  crushing  forceps  doubly  clamp  and  divide  the 
ascending  colon  distal  to  the  disease.  Remove  the  diseased  segment  of  gut. 
Treat  this  distal  segment  of  colon  in  the  same  manner  as  the  ileum. 

Make  a  lateral  anastomosis  betw^cen  the  ileum  and  the  colon  or  sigmoid,  or, 
as  is  better,  unite  the  end  of  the  ileum  to  the  side  of  the  colon  as  described  in 
the  following  paragraphs. 

Repair  the  wound  in  the  peritoneum  (peritonealization)  (Fig.  586).  To  do 
this  it  may  be  necessary  to  mobilize  the  parietal  peritoneum  on  both  sides  of 
the  raw  surface  left  by  the  removal  of  the  caecum.  Unless  the  peritoneum  is 
mobilized  and  freed  from  the  ureter  when  sutures  are  inserted  and  tied,  the 
ureter  may  be  kinked. 

Jamison  and  Dobson  ("Lancet,"  April  27,  1907)  have  made  a  very  thorough 
study  of  the  lymphatic  system  of  the  cfficum.  The  relation  of  the  lymphatics 
training  the  caecum  and  ascending  colon  to  the  ileo-colic  vessels  is  shown  in 
Fig.  587- 


C^CECTOMY 


427 


Another  niethod  ol"  opcraUug  is  as  follows:  — 

Step  I.— Open  the  abdomen  freely  through  the  right  rectus  muscle.  Apply 
an  abundant  protecting  jnick  of  gauze  to  the  median  side  of  the  colon. 

Step  2. — Incise  the  parietal  peritoneum  along  its  line  of  reflection  on  to  the 
gut  throughout  the  whole  length  of  the  outer  side  of  the  ascending  colon.     By 


Fig.  588. — Mobilization    of    caecum    and    ascending    colon.     Note    duodenum    and     ureter 

exposed.     (Mayo.) 


finger  and  gauze  dissection  raise  the  caecum  and  colon  from  their  bed  and  con- 
tinue the  dissection  inwards  so  as  similarly  to  mobilize  the  ileo-colic  vessels, 
the  lymphatic  vessels  and  nodes  along  with  the  peritoneum  covering  them  on 
the  median  side  of  the  mobilized  gut  (Fig.  588).  The  ureter  and  part  of  the 
duodenum  are  exposed  by  the  dissection.  If  in  case  of  carcinoma  the  ureter 
is  involved  it  may  be  removed  and  the  kidney  with  it.     Doubly  ligate  the  ileo- 


428  OPERATIONS    OX    THE    INTESTINES 

colic  vessels  high  up.     Similarly  ligate  them  low  down,  not  far  from  their 
junction  with  the  superior  mesenteric  vessels  supplying  the  terminal  ileum. 

Step  3. — Apply  two  crushing  clamps  to  the  ileum  about  three  inches  from 
the  ileocecal  valve  and  divide  it  between  the  clamps  with  the  cautery. 

Step  4. — From  below  up  divide  the  mesentery  of  the  caecum  and  colon. 
Ligate  and  separate  the  omentum  from  the  right  one-third  of  the  transverse 
colon.  (If  the  operation  is  being  performed  for  non-malignant  disease  it  is 
unnecessary  to  remove  so  much  mesentery  or  to  excise  the  lymphatics.) 

Step  5. — Divide  the  transverse  colon  with  the  cautery  between  crushing 
clamps.     Remove  the  mobilized  segment  of  bowel. 

Step  6. — By  stripping  with  the  fingers  push  away  the  contents  of  the  trans- 
verse colon  for  about  four  inches  from  the  crushing  clamp  and  apply  an  intes- 
tinal forceps  there.  Before  removing  the  crushing  clamps  introduce  a  chromi- 
cized  catgut  suture  as  shown  in  Fig.  594  but  do  not  yet  tighten  it.  Remove 
the  clamp  and  between  the  sutures  pass  the  female  (spring)  part  of  a  Murphy 
button  into  the  bowel.  Complete  the  suture  of  the  end  of  the  colon.  Leave 
the  ends  of  the  suture  long.  Manipulate  the  button  within  the  bowel  so  that 
its  tube  is  pressed  against  one  of  the  longitudinal  muscular  bands  about  2}-^ 
inches  from  the  end  of  the  bowel.  Make  a  crucial  incision  over  the  tube  of 
the  button  just  large  enough  to  permit  the  tube  to  emerge  and  be  tightly  hugged 
by  the  gut  walls.  Secure  the  edge  of  the  button  with  a  hemostat.  Similarly 
control  the  contents  of  the  ileum  by  means  of  an  intestinal  clamp,  remove  the 
crushing  clamp,  surround  the  open  end  of  the  gut  with  purse-string  suture, 
insert  the  other  half  of  the  Murphy  button  and  secure  it  by  the  purse-string. 

Push  the  two  halves  of  the  button  together  in  the  usual  fashion,  if  necessary 
inserting  a  few  supporting  sutures.  This  gives  an  end  to  side  anastomosis. 
Close  the  opening  in  the  mesentery  beside  the  anastomosis. 

The  Mayo's  strongly  recommend  the  "button"  operation  in  this  locality 
but  the  anastomosis  can  easily  be  made  by  sutures.  A  side  to  side  anastomosis 
is  often  used  but  the  blind  ends  may  dilate  and  cause  trouble  as  the  author  has 
found  in  at  least  one  case. 

Step  7. — By  judicious  suturing  cover  the  raw  surfaces  with  peritoneum. 

Step  8. — Bring  the  blind  end  of  the  colon  into  but  not  through  the  muscular 
layer  of  the  abdominal  wound.  Permit  the  long  suture  left  attached  to  the 
colonic  stump  to  emerge  from  the  wound.  Pack  the  wound  down  to  the  intestinal 
stump.  Suture  all  the  rest  of  the  wound.  If  there  is  great  distension  of  the 
blind  end  of  the  gut  between  the  fourth  and  sixth  days  the  gas  may  be  let  out 
by  puncturing  the  gut  under  guidance  of  the  suture.  If  there  is  no  need  of  punc- 
ture the  suture  may  be  cut  short,  the  small  gauze  pack  removed  and  the  wound 
permitted  to  heal. 

Step  6  may  be  modified  so  as  to  secure  an  end-to-end  anastomosis.  A 
difl&culty  to  be  overcome  is  the  smallness  of  the  circumference  of  the  ileum  com- 
pared to  that  of  the  colon  but  a  small  longitudinal  incision  along  the  ileum  on 
the  side  remote  from  the  mesentery  will  so  increase  the  extent  of  free  edge  that 
the  end-to-end  union  becomes  easy.  Oblique  section  of  the  ileum  fulfils  the 
same  purpose. 


COLECTOMY  429 

Partial  Colectomy.* — The  sigmoid  or  the  transverse  colon  may  be  removed 
in  the  same  manner  as  described  under  the  title  "Enterectomy"  except 
when  the  sigmoid  is  not  sufficiently  mobile.  The  ascending  and  descending 
portions  of  the  colon  are  usually  well  fixed  to  the  parietes  and  require 
special  treatment.  Excision  of  the  ascending  colon  is  practically  the  same 
as  caecectomy. 

When  colectomy  is  demanded  because  of  practically  complete  obstruction 
due  to  carcinoma,  Desmarest  urges  a  preliminary  caecostomy.  The  opening 
into  the  caecum  should  be  large  so  as  to  permit  complete  evacuation  of  the  bowel 
contents  and  frequent  lavage  for  some  days  before  the  colectomy  is  attempted. 
The  preliminary  treatment  has  an  added  value  in  that  it  favors  the  dis- 
appearance of  oedema  from  the  gut  walls  near  the  site  of  obstruction. 

Under  local  anesthesia  open  the  abdomen  over  the  caecum  by  the  gridiron 
incision.  The  distended  caecum  immediately  pushes  into  the  wound.  Punc- 
ture the  caecum  with  a  small  trocar  to  get  rid  of  gas.  Exteriorize  a  large  cone 
of  caecum  and  apply  an  intestinal  clamp  to  the  base  of  the  cone.  Proximal 
to  the  clamp  suture  the  bowel  to  the  edges  of  the  peritoneal  wound.  Place 
gauze  under  the  clamp  to  protect  the  wound.  Open  the  gut  widely  and  clean 
the  mucosa  with  tincture  of  iodine.  Suture  the  wound  in  the  gut  to  the  skin 
in  such  a  manner  as  to  make  the  mucosa  overlap  the  skin  wound  a  little.  Be 
particularly  careful  to  accurately  suture  both  angles  of  the  wound.  To  do  this, 
insert  a  '  U '  suture  through  the  angle  of  the  wound  in  the  gut  and  pass  both 
ends  of  the  suture  from  within  out  through  the  skin.  As  the  intestinal  clamp 
is  being  removed  tie  the  U  suture. 

Excision  of  Descending  Colon. — Step  i. — Open  the  abdomen  in  the  left 
semilunar  line.  Explore.  Protect  the  rest  of  the  abdomen  with  warm  gauze 
pads.  Desmarest  (La  Pr.  Med.  July  3,  1919)  strongly  recommends  a 
transverse  incision  on  the  left  side  above  the  umbilicus.  This  not  only 
gives  very  free  exposure  but  permits  of  convenient  posterior  drainage. 

Step  2. — Incise  the  parietal  peritoneum  immediately  external  and  parallel 
to  the  descending  colon.  This  incision  ought  to  extend  well  above  and  below 
the  level  of  the  disease  in  the  colon.  By  blunt  dissection  with  finger  and  gauze 
it  is  easy  to  raise  not  only  the  colon  from  its  bed  but  the  colonic  vessels  as  well, 
along  with  the  posterior  parietal  peritoneum,  to  the  inner  side  of  the  colon.  An 
artificial  mesocolon  is  thus  formed  containing  the  blood-vessels  but  only 
covered  by  peritoneum  on  one  (the  inner)  side  (see  Caecectomy).  Be  careful 
to  avoid  injuring  the  ureter.  Continue  mobilizing  the  colon  (if  necessary  even 
its  splenic  flexure)  until  all  the  diseased  segment  can  be  delivered  through  the 
abdominal  wound  without  tension.  If  care  has  been  used  in  the  blunt  dis- 
section no  harm  has  been  inflicted  on  the  blood-vessels.  Bring  the  diseased 
segment  of  gut  out  through  the  abdominal  wall. 

Step  3. — Doubly  ligate  and  divide  the  vessels  going  to  the  diseased  segment 
of  gut,  thus  leaving  that  segment  completely  free  except  for  its  continuation 
above  and  below.  The  ligation  should  be  done  high  up  on  the  vessels  so  that 
the  lymphatic  glands  may  be  reached.     The  vessels  may  be  tied  either  from 

*For  Transversectomy,  see  page  435. 


430 


OPERATIONS    ON    THE    INTESTINES 


behind  after  the  gut  has  been  mobilized  or  from  in  front  as  may  be  convenient. 
Dissect  all  fat  and  lymphatic  tissue  from  the  site  of  ligation  towards  the  gut 
along  with  those  portions  of  the  vessels  attached  to  the  gut.  Ligation  of  the 
vessels  near  their  origin  is  most  important,  but  it  necessarily  devitalizes  a  large 
extent  of  bowel  and  all  of  the  devitalized  gut  must  of  course  be  removed  which 


Fig.  589. — (C.  L.  Gibson.) 


is  really  an  advantage  as  ultimate  success  depends  on  thorough  removal  of 
the  disease.  Of  course  in  non-malignant  disease,  e.^.,  diverticulitis,  such  ex- 
tensive resection  is  entirely  unnecessary. 

Step  4. — At  a  safe  distance  above  the  disease  and  the  devitalized  bowel 
apply  a  crushing  clamp  to  the  gut,  and  an  inch  or  an  inch  and  one-half  higher 
up  apply  an  intestinal  clamp  to  the  gut.  Divide  the  gut  between  the  clamps 
and  sterilize  the  stumps  with  the  cautery,  carbolic  acid  or  tincture  of  iodine. 


COLECTOMY 


431 


Similarly  apply  clamps  (the  crushing  clamp  nearer  the  diseased  segment)  below 
the  disease  and  divide  the  gut.     Remove  the  diseased  segment. 

Step  5.^ — ^Approximate  the  divided  ends  of  the  intestine.  This  is  usually 
possible  if  mobilization  has  been  sufficiently  free.  Moynihan  urges  that  thor- 
ough mobilization  of  the  splenic  flexure,  without  injury  to  its  vascular  supply, 
is  often  necessary  to  secure  approximation  of  the  intestine  after  resection. 

Method  A. — Restore  the  continuity  of  the  gut  by  means  of  Murphy's  button 
or  by  the  ordinary  circular  enterorrhaphy. 

Method  B. — C.  L.  Gibson's  method  ("Annals  Surg.,"  July,  1910).  Seize 
the  upper  cut  edge  of  gut  with  two  Kocher's  forceps  and  push  it  into  the  lumen 
of  the  lower  end  as  far  down  as  possible.  Rotate  "the  upper  segment  about 
a  quarter  circle  so  that  the  non-peritoneal  surfaces  do  not  entirely  approximate 
.in  the  circumference."  Introduce  a  sufficient  number  of  Lembert  sutures  as 
shown  in  Fig.  589.  When  tying  the  sutures  tuck  in  or  invaginate  the  upper 
edge  of  the  lower  segment  as  shown  in  Fig.  5 go. 


Fig.  590. — (C.  L.  Gibson.) 


Method  C. — The  diseased  segment  of  gut  has  been  delivered  and  its  vessels 
ligated  and  divided  as  in  Step  3,  but  the  gut  has  not  been  divided.  Make 
a  lateral  anastomosis  between  the  afferent  and  efferent  loops  of  gut.  Doubly 
clamp  the  afferent  segments  between  the  anastomosis  and  the  disease.  Divide 
the  gut  between  the  forceps.  Close  with  sutures  the  open  end  of  the  gut 
next  the  anastomosis;  remove  the  clamp;  invaginate  the  stump  by  means  of 
a  purse-string  suture  or  a  line  of  Lembert  sutures.  Do  the  same  with  the 
efferent  loop.     Suture  the  two  stumps  to  the  parietal  peritoneum. 


432 


OPERATIONS    ON    THE    INTESTINES 


Method  D. — If  it  has  been  necessary  to  remove  the  splenic  flexure  along  with 
the  descending  colon,  close  the  open  ends  of  the  gut  and  make  a  lateral  anas- 
tomosis between  the  transverse  and  the  remnant  of  the  descending  colon  or 
the  sigmoid.  If  the  whole  colon  and  caecum  have  been  excised  perform  ileo- 
sigmoidostomy. 

Method  E. — Stephen  Fenwick  (Trans.  R.  Soc.  Med.  Surg.  Sect.,  VII,  No.  5) 
after  excising  a  tumor  of  the  sigmoid  along  with  a  V  of  mesentery  found  that 
an  interval  of  about  3  inches  existed  between  the  segments  of  gut  to  be  united, 
even  after  he  had  pulled  the  rectum  up  as  far  as  possible.  To  fill  the  gap  he 
selected  a  convenient  loop  of  ileum  about  5  inches  in  length,  applied  two  intes- 
tinal clamps  at  each  end  of  this  loop,  divided  the  gut  between  the  clamps  and 
carried  the  incisions  up  the  meso-ileum  between  its  vessels.  He  next  united 
the  proximal  and  distal  segments  of  ileum  by  end-to-end  anastomosis,  and  im- 
planted the  mobilized  segment  of  gut,  by  means  of  two  medium-sized  Murphy 
buttons,  to  fill  the  defect  in  the  sigmoid.  The  holes  in  the  mesentery  were 
carefully  sutured.  Recovery  took  place  in  spite  of  various  compHcations. 
The  bowel  action  was  satisfactory  and  in  three  years  there  was  no  recurrence. 
Step  6. — Repair  the  wound  in  the  peritoneum.  Close  the  abdomen. 
Partial  Colectomy  in  Two  Stages. — Steps  i,  2,  and  3  as  in  the  preceding 
operation. 

Step  4. — Method  A. — Exactly  as  in  Step  5,  method  C  of  preceding  operation, 
make  an  anastomosis  between  the  afferent  and  efferent  loops  of  gut  but  do  not 

yet  excise  the  disease.  Partially  close  the  abdominal 
wound  around  the  protruding  intestine.  Apply 
dressings. 

Method  B. — Deliver  the  diseased  segment  of 
gut.  Unite  with  sutures  the  afferent  to  the 
efferent  loops  as  they  pass  through  the  abdominal 
wall.     Partially  close  the  abdominal  wound. 

In  both  methods  A  and  B  the  diseased  segment 
of  gut  is  excised  after  the  lapse  of  from  12  to  48 
hours.  No  anesthetic  is  usually  necessary  while 
removing  the  disease  but  bleeding  is  usually  very 
free  requiring  many  ligatures  or  sutures  to  be 
applied  to  the  mucosa  and  submucosa.  The  result 
is  of  course  a  fecal  fistula  which  maybe  closed  later. 
Method  C. — (Paul's  Colectomy.)  Sew  together 
the  healthy  segments  of  gut  as  they  pass  through 
the  abdominal  wound.  Make  an  incision  into  the  prolapsed  gut  above  and 
below  the  disease.  Into  each  intestinal  opening  pass  a  glass  tube  (Paul's, 
MLxter's)  andligateit  there.  Fig.  591.  Cut  away  the  diseased  portion  of  gut. 
Partially  close  the  wound.     Apply  dressings. 

Complete  Colectomy. — The  transverse  colon  may  be  removed  in  the  manner 
described  under  the  title  "Enterectomy,"  hemostasis  being  effected  by  a  chain 
of  ligatures  applied  to  the  transverse  mesocolon  and  the  great  omentum 
between  the  stomach  and  colon.  This  method  necessarily  sacrifices  the  great 
omentum  and  leaves  clumsy  stumps  which  it  is  difiicult  to  peritonealize 
satisfactorily. 


Fig.  591. — Paul's  colectomj-. 
{Maylard.) 


COLECTOMY 


433 


The  writer  has  found  the  following  operation  devised  by  Lardennois  (Journ. 
de  Chir.,  June,  1914)  to  be  unexpectedly  easy  while  by  it  the  omentum  is 
saved,  hemostasis  is  simplified,  clumsy  stumps  are  avoided  and  if  mobilization 
of  the  hepatic  and  splenic  flexures  is  necessary  such  is  easily  accomplished. 

Slep  I. — After  opening  the  abdomen  and  making  a  thorough  exploration, 
pull  the  great  omentum  and  transverse  colon  out  of  the  abdomen  and  reflect 
them  upwards.  If  slight  traction  is  made  upwards  on  the  omentum 
and   downwards    on    the   colon   numerous   delicate   peritoneal  folds   will   be 


Fig.  592. — Separation  of  omentum  from  transverse  colon.     {Lardemiois,  Journ.  de  Chir.) 


seen  passing  from  the  omentum  on  to  the  colon  (Fig.  592).  Divide 
some  of  these  folds  carefully  close  to  the  gut  and  begin  separating  the  omentum 
from  the  colon  with  scissors,  guided  by  the  finger,  introduced  through 
the  original  cut.  Often  during  this  dissection  the  operator  will  think  he  has 
button-holed  the  omentum  but  usually  his  fears  prove  baseless  but  if  this 
accident  has  occurred  it  is  not  of  much  importance  unless  a  very  large  hole  has 
been  torn.  Continue  the  separation  of  the  omentum  upwards  until  not  only 
the  colon  but  the  transverse  mesocolon  as  well,  lie  free  from  the  omentum 

28 


434 


OPERATIONS    ON    THE    INTESTINES 


which  is  reflected  upwards  out  of  the  way.  When  separation  of  the  omentum 
from  the  colon  is  done  to  gain  access  to  the  lesser  peritoneal  cavity  and  to  the 
posterior  wall  of  the  stomach  the  layer  covering  the  transverse  mesocolon  is 
not  elevated  but  is  divided  at  or  near  its  colonic  attachment.  Unless  mobiliza- 
tion of  the  flexures  is  necessary  or  total  colectomy  is  indicated  proceed  to  Step  3. 
Step  2. — Mobilization  of  the  ascending  and  descending  colon.  Placing  the 
finger  flatly  on  the  mesocolon  burrow  towards  the  left  under  the  suspensory 
ligament  of  the  splenic  flexure  and  divide  this  avascular  peritoneal  band.     This 


Fig.  593. — {Lardennois,  Journ.  de  Chir.) 


detaches  the  splenic  flexure  more  easily  than  is  possible  by  any  other  means. 
Retract  the  descending  colon  upwards  and  continue  the  incision  which  mobilized 
the  flexure,  downwards  through  the  parietal  peritoneum  close  to  its  reflexion 
on  to  the  descending  colon  and  with  the  finger  separate  the  colon  from  its  bed. 
This  mobilization  of  the  descending  colon  and  its  vessels  may  be  carried  out 
freely  even  to  a  point  not  far  from  the  middle  line.  In  a  similar  manner  the 
hepatic  flexure  and  the  ascending  colon  may  be  mobilized,  care  being  taken  to 
avoid  injuring  the  ureter. 


COLECTOMY 


435 


Step  3. — Return  the  great  omentum  into  the  abdomen.  Lift  the  colon 
into  the  air  so  as  to  spread  out  its  meson  and  make  its  blood-vessels  clearly 
visible.  If  the  transverse  colon  alone  is  to  be  excised,  doubly  clamp  the  vessels 
passing  to  that  part  of  the  gut,  divide  the  meson  between  the  clamps,  excise 
the  desired  portion  of  intestine  and  restore  intestinal  continuity  by  a  lateral 
or  preferably,  an  end-to-end  anastomosis.  If  a  more  complete  colectomy  is 
necessary  it  is  easy  to  assure  exact  hemostasis  by  applying  ligatures  to  the 
middle  and  right  colic  arteries  near  their  origin,  and  to  the  left  colic  vessels  at 
such  points  as  will  not  endanger  the  vitality  of  the  gut  which  is  to  be  retained. 
Divide  the  mesocolon  along  the  line  shown  in  Fig.  593. 

Step  4. — The  whole  colon  is  now  free  except  for  its  continuation  into  the 
caecum  and  sigmoid. 

Place  the  patient  in  Trendelenburg's  position  so  that  the  small  intestines 
can  be  kept  out  of  the  way. 

Choose  the  point  of  section  on  the  pelvic  colon.  Crush  the  gut  with  forceps 
(Doyen's;  Payr's)  and  apply  a  silk  ligature  tightly 
in  the  groove  left  by  the  forceps.  Apply  a  strong 
clamp  to  the  gut  a  little  above  the  ligature.  Divide 
the  gut  with  a  cautery  between  the  ligature  and  the 
clamp  and  place  the  clamped  (upper)  end  of  the  gut 
away  from  the  field  of  operation.  Insert  a  purse- 
string  suture  around  the  distal  (ligated)  segment  of 
gut  and  invert  the  stump.  Instead  of  removing  the 
Payr's  clamp  one  may  cut  between  it  and  the  clamp 
on  the  upper  segment  of  gut,  with  a  cautery,  being 
careful  to  destroy  all  the  tissue  between  the  two 
clamps  and  to  thoroughly  sear  or  desiccate  the  tissues 
crushed  between  the  blades  of  the  Payr's  clamp 
(distal  segment  of  gut).  Keeping  the  clamp  in  situ 
insert  a  continuous  suture,  the  alternate  stitches 
being  on  opposite  sides  of  the  clamp  (Fig.  594) 
and  the  loops  of  the  thread  passing  over  the  clamp.  Remove  the  clamp. 
The  crushed  and  burned  edges  of  the  wound  adhere  together  so  that  there  is 
no  danger  of  the  lumen  of  the  gut  opening  or  of  bleeding  occurring.  Trac- 
tion on  the  two  ends  of  the  silk  suture  causes  a  neat  and  thorough  invertion 
of  the  wound.     Fix  the  ends  of  the  suture  and  insert  a  second  row  of  sutures. 

Step  5. — Mobilize  the  caecum  and  lower  end  of  the  ileum  as  in  caecectomy. 
Ligate  the  ileocolic  artery  at  an  appropriate  point.  Choose  the  site  for  dividing 
the  ileum.  Immediately  distal  to  this  site  apply  a  crushing  forceps  (Ochsner's 
forceps)  to  the  ileum.  Above  this  line  of  section  apply  a  reliable  intestinal 
forceps.  Divide  the  gut  close  to  the  crushing  forceps.  This  completes  the 
excision  of  the  colon. 

Step  6. — Implant  the  end  of  the  ileum  into  the  side  of  the  pelvic  colon. 

Step  7. — Review  the  wound  left  by  the  removal  of  the  colon  and  cover  all 
raw  surfaces  with  peritoneum. 

Lane  at  this  stage  of  the  operation  has  an  assistant  pass  a  rubber  tube 
through  the  anus  and  the  surgeon  guides  it  through  the  anastomotic  opening. 


Fig. 


594- 


436  OPERATIONS    ON    THE    INTESTINES 

Such   direct    drainage  of    the  small    intestine  for  a   few    days   is  distinctly 
valuable. 

Subcaecal  Colectomy.— If  it  is  justifiable  to  preserve  the  caecum  when 
a  colectomy  is  indicated  Lardennois  thinks  it  is  very  advantageous  to  do  so, 
as  one  then  saves  the  very  active  terminal  ileum,  the  ileocaecal  valve  and  the 
caecum  itself  where  valuable  digestive  processes  take  place. 

The  Operation. — Mobilize  the  colon  and  divide  its  mesenteries  as  in  total 
colectomy  but  do  not  yet  interfere  with  the  caecum.  Choose  the  site  of  section 
in  the  ascending  colon.  Apply  a  crushing  clamp  (Payr's)  to  the  caecal  side 
of  the  line  of  section  and  a  strong  Ochsner's  clamp  to  the  distal  side.  Divide 
between  the  clamps  with  a  cautery.  Lay  aside  (well  protected)  the  clamped 
distal  segment  of  gut.  Apply  a  continuous  silk  or  chromicized  catgut  suture 
to  the  clamped  caecum  by  means  of  which  the  wound  is 
closed  and  inverted  when  the  clamp  is  removed  exactly  as 
the  pelvic  colon  was  treated  in  complete  colectomy. 
Choose  a  portion  of  the  sigmoid  which  can  be  brought 
without  tension  into  apposition  with  the  blind  fundus  of 
the  caecum.  At  this  site  apply  two  clamps  to  the  sigmoid 
(a  crushing  clamp  above,  an  intestinal  clamp  below)  and 
divide  the  gut  between  these  clamps.  The  resected  por- 
tion of  the  colon  is  now  removed.  Apply  an  intestinal 
clamp  to  the  fundus  of  the  caecum.  Anastomose  the  end  of 
the  sigmoid  to  the  fundus  of  the  caecum.  Fig.  595.  The 
■TIG.  595.  appendix  ought,  of  course,  to  be  removed.     ObHterate  all 

openings  through  which  a  loop  of  small  intestine  might  penetrate  and  give 
rise  to  obstruction. 

Lane's  Colectomy. — Lane  in  performing  colectomy  makes  no  endeavor  to 
save  the  omentum.  After  opening  the  abdomen  his  first  endeavor  is  to  separate 
the  "evolutionary  adhesions"  from  the  mesenteries  without  injury  to  the  latter 
structures.  This  greatly  facilitates  the  removal  of  the  bowel  and  as  little  or 
none  of  the  mesentery  is  denuded  of  its  peritoneal  covering  the  risk  of  dangerous 
adhesions  to  the  small  intestine  is  lessened.  In  ligating  the  vessels  no  large 
masses  of  mesentery  should  be  included.  "It  is  well  to  remember  that  one  of 
the  chief  immediate  risks  of  the  operation  is  hemorrhage,  which  may  result 
either  from  the  escape  of  a  vessel  from  the  ligature  in  a  fat  subject,  or  from  the 
friability  of  the  ligatured  vessels  in  a  thin  toxic  one."  The  ileum  is  divided 
as  in  ileo-colostomy.  The  pelvic  colon  is  drawn  up  out  of  the  pelvis  and  grasped 
with  two  pairs  of  forceps  (Ochsner's)  about  2  inches  above  the  pelvic  brim. 
The  end  of  the  ileum  is  attached  directly  to  the  cut  end  of  the  pelvic  colon  by 
the  usual  method  of  end-to-end  anastomosis.  When  the  circumference  of  the 
colon  is  considerably  greater  than  that  of  the  ileum  if  the  stitches  in  the  wider 
gut  are  inserted  more  widely  apart  than  in  the  narrower  gut  then  a  secure  union 
is  easily  obtained. 

The  cut  edges  of  the  ileal  and  colonic  mesenteries  must  be  carefully  united 

by  suturing  both  the  upper  and  lower  aspects  of  their  junction.    Lane  finds  the 

end-to-end  anastomosis  preferable  in  every  respect  to  the  lateral  or  end-to-side. 

In  the  treatment  of  intestinal  stasis  Lane  considers  colectomy  the  opera- 


C^COPEXY 


437 


tion  of  choice.  He  also  prefers  it  to  any  partial  operation  in  obstruction  due 
to  mobile  colonic  tumors  and  in  megalo-colon. 

Caecopexy. — Wilms'  Method.  Step  i. — Open  the  abdomen  by  a  right  rec- 
tus incision.  As  a  matter  of  routine  remove  the  appendix.  Select  a  site  in 
the  iliac  fossa  against  which  the  caecum  can  be  placed  without  the  production 
of  any  kinking  in  the  colon  or  ileum. 

Step  2. — Reflect  a  flap  of  peritoneum  from  the  iliac  fossa.  Place  the  caput 
coli  on  the  raw  surface  thus  prepared  and  suture  the  peritoneal  flap  over  the 
caecum,  Fig.  596. 


Fig.  596. — Caecopexy. 


Step  3. — Close  the  abdomen. 

Quenu  and  Duval's  Method  (Rev.  de  Chir.,  May  10,  1914). — Place  the  pa- 
tient in  Trendelenburg's  position.  Open  the  abdomen  in  the  ileo-caecal  region. 
Examine  the  caecum.  If  the  mobile  caecum  is  too  long  or  dilated,  lessen  its 
size  by  transverse  or  longitudinal  plication  or  by  both.  Introduce  a  retractor 
and  expose  the  whole  iliac  fossa.  Recognize  the  right  iliac  artery  and  make  an 
incision  through  the  iliac  peritoneum  external  and  parallel  to  the  vessel.  This 
cut  extends  from  the  middle  of  the  iliac  fossa  to  the  posterior  point  of  fixation 
of  the  caecum  in  the  lumbar  region.  If  the  colon  is  now  slightly  freed  from  its 
bed  by  dissection  it  is  advantageous.  Through  the  peritoneal  incision  expose 
the  tendon  of  the  psoas  parvus  muscle,  or  if  this  is  absent,  the  internal  border 
of  the  psoas,  in  which  case  it  is  necessary  to  retract  the  artery  inwards  to  per- 
mit suturing.  Introduce  three  or  four  non-absorbable  sutures  through  the 
tendon  of  the  psoas  parvus  and  then  through  the  posterior  longitudinal  caeco- 
colic  band.     When  these  sutures  are  tied  the  caecum  is  well  anchored  in  the 


438 


OPERATIONS    ON    THE    INTESTINES 


iliac  fossa.     Suture  the  edges  of  the  incision  in  the  iliac  peritoneum  to  the  head 
of  the  caecum. 

Caecopexy  plus  Caecoplication.— Roeder  ("Journ.  A.  M.  A.,"  Feb.  25,  1911) 
introduces  a  number  of  sutures  (hemp  or  silk)  into  the  outer  side  of  the  caecum 
in  the  manner  shown  in  Fig.  597.  The  last  bite  of  the  stitch  is  in  the  parietal 
peritoneum  just  external  to  the  root  of  the  meso-ca?cum.  The  number  of  bites 
each  stitch  takes  in  the  gut  is  regulated  by  the  amount  of  dilatation  present. 
The  number  of  stitches  used  is  of  course  in  proportion  to  the  length  of  intestine 
to  be  plicated  and  anchored. 


I  iG.   597. — [Roeder. ) 


DIVERTICULITIS 


The  papers  of  Cahier  ("Rev.  de  Chir.,"  September  19,  1906),  Brewer 
("Amer.  Journ.  Med.  Sc,"  October,  1907),  Mayo  ("Surg.,Gyn.  and  Obstetrics," 
July,  1907)  and  others  have  attracted  attention  to  a  condition  named  acquired 
diverticulitis.  A  few  words  explanatory  of  the  disease  may  assist  the  operator. 
Acquired  or  false  diverticula  are  simple  hernia?  of  the  mucous  and  submucous 
tunics  through  the  circular  muscular  coat  of  the  descending  colon  and  sigmoid 
at  points  where  the  musculosa  happens  to  be  weak.  Chronic  leakage  may  take 
place  through  the  diverticular  walls  and  give  rise  to  large  inflammatory  de- 
posits. The  result  of  the  inflammation  may  be:  (i)  Abscess.  This  requires 
free  drainage.  (2)  Acute  local  infection  plus  acute  obstruction.  This  re- 
quires free  drainage  plus  the  establishment  of  an  artificial  anus.  Subsequently, 
if  necessary,  the  diseased  segment  of  colon  may  be  excised.  (3)  Chronic  ob- 
struction with   inflammatory   tumor  but  no  abscess.     This  form   is   usually 


INTESTINAL   EXCLUSION  439 

mistaken  for  malignant  disease.  The  treatment  is  resection  of  the  involved 
segment  of  gut. 

Hirschsprung's  Disease.  (Megalo-colon.  Congenital  dilatation  of  colon.) 
This  disease  generally  but  by  no  means  always  occurs  in  young  children,  is 
characterized  by  inveterate  constipation,  the  dilated  colon  being  loaded  with 
hard  faeces.  The  use  of  purgatives  and  lavage  may  give  temporary  relief,  but 
sooner  or  later  colitis  shows  itself  by  the  symptom  of  diarrhea  alternating  with 
constipation.  The  mortality  in  cases  treated  medically  has  been  reported  as 
74  per  cent,  and  66  per  cent,  in  different  series,  while  in  those  treated  surgically 
it  has  been  48,  34  and  25  per  cent. 

Plastic  operations  and  suspension  of  the  colon  have  not  been  useful.  Ap- 
I)endicostomy  and  colostomy  have  been  useful  as  temporary  measures.  The 
ideal  treatment  seems  to  be  excision  of  the  whole  affected  segment  of  intestine. 
As  a  preliminary  to  colectomy  it  is  often  wise  to  divide  the  ileum  near  its  ter- 
mination and  to  unite  its  end  to  the  lowest  possible  point  in  the  rectum.  (End- 
to-side  anastomosis.)  In  children  the  open  pelvis  makes  the  low  anastomosis 
easier  than  in  adults.  Later  the  colon  may  be  removed.  After  recovery  care 
should  be  exercised  to  prevent  any  accumulation  of  scybalas  in  the  rectal  pouch. 

Finney's  article  on  Hirschsprung's  Disease  (Trans.  Am.  Surg.  Assoc,  1908, 
vol.  XXV,  475,  or  Surg.,  Gyn.  and  Obst.,  VI,  6)  gives  a  very  full  bibliography. 
See  also  W.  I.  Terry  (Journ.  A.  M.  A.,  LVII,  731)  and  Barrington-Ward  ("Brit. 
Jour,  of  Surg.,  I,  345). 

INTESTINAL  EXCLUSION  OR   SEGREGATION 

Exclusion  or  Segregation  of  Intestine. — In  some  cases  where,  from  extensive 
adhesions  or  from  other  causes,  it  seems  impossible  or  improper  to  excise  a 
certain  segment  of  gut,  good  results  may  be  obtained  by  protecting  it  from  the 
irritations  incident  to  the  performance  of  its  physiological  functions.  In  this 
way  faecal  fistulae  may  be  induced  to  close  and  some  neoplasms  may  develop  less 
rapidly.  The  operation  which  is  used  for  this  purpose  may  be  named  ^^ex- 
clusion oj  Ike  intestine.''^  Tuberculous  lesions  of  the  intestine,  unless  fairly  easy 
of  excision,  may  well  be  treated  by  exclusion. 

Ileo-colostomy.— Ileo-sigmoidostomy. — ^Lane's  Method.^ — Step  i . — During 
the  administration  of  the  anesthetic  begin  the  hypodermic  administration  of  salt 
solution  in  both  axillae  and  keep  it  up  during  the  operation.  Six  or  more  pints 
may  be  given. 

Step  2. — Open  the  abdomen  by  a  suitable  vertical  incision  to  the  left  of  the 
middle  line  so  as  to  divide  the  sheath  of  the  rectus  twice  and  thus  obtain  a 
secure  abdominal  scar. 

Step  3. — Pick  up  the  ileum  and  apply  two  Ochsner  (crushing)  clamps  to  it, 
close  together,  about  6  inches  from  its  termination.  Divide  the  gut  between 
the  forceps  by  means  of  a  cautery  thus  completely  sterilizing  the  stumps  of 
the  gut.  Close  the  distal  aperture  by  means  of  a  running  suture  applied  before 
and  tightened  during  removal  of  the  clamp.  Invaginate  the  closed  stump  by 
means  of  a  purse-string  suture  exactly  as  an  appendix  stump  is  invaginated. 


440  OPERATIONS    ON    THE    INTESTINES 

Step  4. — At  a  convenient  distance  from  the  crushing  clamp  apply  an  in- 
testinal clamp  to  the  proximal  segment  of  ileum  and  anastomose  its  end  to  the 
side  of  the  upper  part  of  the  pelvic  colon  using  the  usual  two  rows  of  suture. 
Should  the  junction  appear  insecure  at  any  point,  owing  to  tenuity  of  the  ileal 
wall,  to  inflammatory  changes  in  the  pelvic  colon  or  to  the  abundant  deposit  of 
fat  in  the  colonic  peritoneum,  reinforce  with  extra  stitches. 

Step  5. — Draw  the  intestines  out  of  the  pelvis.  Very  carefully  sew  the  ad- 
jacent surface  of  the  pelvic  colon  to  the  divided  margin  of  the  mesentery  of  the 
ileum.  This  is  so  important  that  it  is  wise  to  suture  not  merely  the  upper  but 
also  the  lower  aspect  of  the  junction,  otherwise  internal  hernia  may  result  or  the 
constant  pressure  of  the  small  intestines  may  cause  separation  of  the  mesenteries 
and  lead  to  trouble  or  disaster. 

Step  6. — Examine  the  fixation  of  the  sigmoid  to  the  pelvis.  If  what  Lane 
calls  the  "last  kink"  is  tightly  fixed  at  the  brim  of  the  pelvis  nothing  need  be 
done  to  it;  but  if  it  is  not  so  fixed,  sew  the  bowel  and  mesentery  very  securely  to 
the  brim  so  as  to  reduce  the  tendency  to  the  regurgitation  of  faeces  up  into  the 
iliac  colon. 

Step  7. — Have  an  assistant  pass  an  oesophageal  tube  through  the  anus  into 
the  pelvic  colon  and  guided  by  the  fingers  of  the  surgeon,  through  the  anasto- 
mosis into  the  ileum  for  a  distance  of  about  8  inches.  (The  tube  should  be 
secured  to  the  anus  by  a  stitch.)  "  If  any  difficulty  is  experienced  in  passing  the 
tube,  a  quantity  of  paraffin  is  injected  through  it  which  materially  facilitates  its 
introduction.  This  tube  prevents  the  accumulation  of  gas  in  the  small  intes- 
tines, and  permits  of  the  free  passage  of  the  fluid  contents  through  the  junction, 
and  their  collection  in  a  vessel  beneath  the  bed." 

Step  8.- — Introduce  two  or  more  pints  of  warm  saline  solution  into  the  per- 
itoneal cavity  in  an  endeavor  to  prevent  the  formation  of  adhesions  (to  reduce 
this  risk  still  further  the  patient  is  moved  from  side  to  side  at  frequent  intervals 
during  the  after-treatment).     Close  the  abdominal  wound. 

In  the  treatment  of  "Intestinal  Stasis"  Lane  recommends ileo-colostomy 
highly  when  the  preferable  operation  of  colectomy  seems  too  dangerous.  When 
colectomy  is  proper  its  immediate  risk  is  less  than  that  of  ileo-colostomy  and  the 
convalescence  is  much  less  stormy. 

In  the  belief  that  chronic  intestinal  stasis  is  the  predisposing  cause  of  tu- 
berculosis of  the  bones  and  joints.  Lane  begins  treatment  of  these  lesions  by 
performing  ileo-colostomy. 

An  operation  along  the  lines  of  ileo-sigmoidostomy  has  often  been  used  in  the 
treatment  of  idiopathic  dilatation  of  the  colon  (Hirschsprung's  disease).  It 
must  be  remembered,  however,  that  the  hugely  distended  sigmoid  colon  may 
subsequently  give  rise  to  volvulus.  In  at  least  one  case,  even  after  much  of 
the  sigmoid  was  excised  for  volvulus,  the  remnant  of  sigmoid  between  the 
anastomosis  and  the  rectum  became  hugely  dilated  and  once  more  occasioned 
volvulus.  Mr.  Makins  corrected  the  position  of  the  loop  and  fixed  it  with 
good  effect  (Hawkins,  "Brit.  Med.  Journ.,"  March  2,  1907). 

Yeomans  ("Am.  Journ.  of  Surg.,"  Jan.,  1913)  recommends  caeco-sigmoidos- 
tomy  instead  of  ileo-sigmoidostomy  in  suitable  cases  as  by  it  a  more  thorough 
drainage  of  the  segregated  or  excluded  colon  can  be  obtained. 


C^CO-SIGMOIDOSTOMY 


441 


Caeco-sigmoidostomy. — Typhlo-sigmoidostomy.— Put  the  patient  in  the 
Trendelenburg  position. 

Open  the  abdomen  by  a  free  median,  rectus  or  transverse  incision.  Explore 
the  abdomen. 

Push  the  small  intestines  out  of  the  way  and  protect  them  with  moist 
pads. 

If  the  CKCum  and  sigmoid  are  easily  apposed  proceed  with  the  operation. 
If  immobility  of  the  caecum  impedes  approximation,  mobilize  it  by  incising  the 


Fig.  598. — {Lardennois  and  Okinczyc,  Journ.  de  Chir.) 


parietal  peritoneum  along  its  outer  and  lower  border  and  raising  it  as  in  caecec- 
tomy.  Beware  of  injuring  the  ureter.  If  the  sigmoid  is  immobile  divide  the 
peritoneum  forming  the  external  or  inferior  layer  of  its  meson  and  mobilize 
it  exactly  as  the  descending  colon  is  mobilized  in  colectomy  but  carefully  avoid 
injury  to  the  vessels. 

With  a  fine  curved  needle  introduce  the  suture  shown  in  Fig.  598  (Larden- 
nois, and  Okinczyc,  Journ.  de  Chir.,  May,  19 13,  p.  542).  This  stitch  involves 
the  upper  or  inner  layer  of  the  meso-sigmoid,  the  median  parietal  peritoneum  and 
some  of  the  undersurface  of  the  meso-Ueum.     It  is  easy  to  avoid  injury  to  vessels 


442 


OPERATIONS    ON    THE    INTESTINES 


if  one  picks  up  the  parietal  peritoneum  with  forceps  before  introducing  the  needle 
at  any  point.     Apply  a  hemostat  to  each  end  of  the  stitch  and  put  it  aside. 

Remove  the  appendix.  Make  an  anastomosis  between  the  blind  end  of  the 
cfficum  and  a  convenient  part  of  the  sigmoid.  When  the  anastomosis  is  com- 
plete tighten  and  tie  the  suture  A  B,  and  so  prevent  the  possibility  of  a  peritoneal 
lacuna  being  formed  behind  the  anastomosis  with  its  dangers  of  internal  hernia. 
Some  surgeons  complicate  the  operation  as  follows:  Choose  a  portion  of  the 
pelvic  colon  as  low  down  as  practicable  and  there  divide  the  gut  between  intes- 
tinal forceps.  Anastomose  the  open  end  of  the  prox- 
imal loop  of  colon  to  the  side  of  the  distal  segment. 
Anastomose  the  open  end  of  the  distal  segment  to  the 
blind  end  of  the  caecum. 

In  the  following  description  it  is  assumed  that 
the  caecum  and  adjacent  segment  of  ileum  are  dis- 
eased and  require  to  be  segregated. 

(A)  Unilateral  Exclusion. — Step  i. — Open  the  ab- 
domen in  a  suitable  position.  Examine  the  diseased 
structures. 
Step  2. — Find,  empty,  and  doubly  clamp  the  afferent  segment  of  gut,  i.e., 
the  portion  of  healthy  gut  which  passes  into  the  diseased  segment.  Divide 
the  gut  between  the  clamps.  Close  each  end  of  the  gut  by  a  row  of  through- 
and-through  sutures  covered  by  a  row  of  continuous  Lembert  sutures.  (Fig. 
599,  X,  Y).*     If  desired,  the  purse-string  suture  may  be  employed. 

Step  3. — Make  an  anastomosis  between  the  afferent  loop  of  gut  and  the 
colon  in  a  suitable  place  (Fig.  599,  A). 
Step  4. — Close  the  abdomen. 

M  N 


Fig.  599. — Unilateral 
exclusion. 


Fig.  600. 

Figs.  600  and  601. 


Fig.  601. 
-Bilateral  exclusion  with  drainage. 


The  effect  of  unilateral  exclusion  is  that  while  the  contents  of  the  excluded 
segment  drain  into  the  colon,  no  material  from  the  ileum  passes  into  it — in  fact, 
a  short  circuit  is  established. 

(B)  Bilateral  Exclusion. — This  method  is  proper  only  when  a  fistula  leads 

from  the  skin  into  the  segment  to  be  excluded.     The  only  difference  between 

the  bilateral  and  the  unilateral  operation  consists  in  the  division  and  suture 

of  the  colon  distal  to  the  disease  and  proximal  to  the  anastomosis  (Fig.  600). 

*  Rutherford  Morison  has  shown  that  if  the  caecum  is  excluded  by  division  of  the  ascend- 
ing colon  and  mere  anastomosis  of  the  ileum  (without  complete  division  of  the  ileum)  to  the 
colon,  then  the  ca:cum  will  burst  unless  the  ileocaecal  valve  happens  to  be  incompetent.  This 
error  seems  to  the  author  so  bad  that  the  warning  ought  to  be  unnecessarj-  but  the  accident  has 
happened. 


OBSTRUCTION  443 

(C)  Bilateral  Exclusion  with  Drainage  of  the  Excluded  Segment. — Here  no 
fistula  leads  into  the  diseased  segment.  The  operation  is  identical  with  that 
of  bilateral  exclusion  up  to  the  point  where  the  colon  is  divided.  Now,  instead 
of  closing  both  ends  of  the  colon  at  the  point  of  section,  only  the  distal  segment 
is  closed  (Fig.  60 1,  N),  while  the  open  end  of  the  diseased  segment  is  united 
to  the  skin  and  permits  drainage  (Sk.). 

Vautrin  thinks  and  has  proved  that  drainage  from  one  end  of  the  excluded 
segment  of  gut  is  onl)'-  suflicient  if  the  disease  is  of  comparatively  limited  extent. 
Where  the  disease  is  extensive  and  the  gut  to  be  drained  is  more  or  less  coiled, 
then  both  ends  of  the  segregated  segment  should  be  united  to  the  skin  at  con- 
venient points;  if  necessary,  special  openings  being  made  through  the  belly- 
wall.  This  permits  of  thorough  drainage  and  lavage,  whereby  the  diseased 
gut  lumen  may  be  kept  clean  and  ulcerations  may  receive  local  treatment. 

INTESTINAL  OBSTRUCTION 

Whichever  form  of  obstruction  is  present  and  demands  operation,  there  are 
certain  points  common  to  the  treatment  of  all  of  them,  and  which  will  be  con- 
sidered here. 

Before  assuming  that  true  obstruction  is  present  it  is  of  vast  moment  to 
examine  the  urine.  In  the  opinion  of  Paul  Delbet  ("La  Presse  Med.,"  Aug.  24, 
1907)  the  possible  existence  of  constipation  in  the  course  of  uremia  is  most 
important  because  if  one  considers  that  uremia  may  long  remain  latent;  that 
it  may  provoke  as  its  first  symptoms,  gastric  intolerance  with  vomiting  first 
alimentary  then  bilious;  that  there  may  be  subnormal  temperature  and  a 
slackening  of  pulse,  one  can  understand  that  constipation  accompanied  by 
these  symptoms  may  give  the  appearance  of  true  intestinal  obstruction  to  a 
complaint  which  is  entirely  non-surgical. 

As  a  matter  of  routine,  the  rectum  must  be  explored;  the  omission  to  do  this 
has  too  often  led  the  surgeon  to  operate  unnecessarily  or  to  miss  the  aid  of  valu- 
able information  when  operating.*  There  is  often  not  much  time  in  which  to 
prepare  the  patient.  Enemata  will  almost  certainly  have  been  used  before  the 
question  of  operating  has  been  decided,  and  hence  the  lower  gut  is  empty.  It 
is  wise  to  clean  out  the  stomach  with  the  stomach-tube.  When  there  are  great 
nervousness  and  depression,  a  small  dose  of  morphine  has  a  quieting  and  steady- 
ing effect  which  outweighs  any  ill  which  it  may  do.  Usually  the  abdomen 
is  opened  in  the  middle  line  below  the  umbilicus.  Through  this  opening  any 
obstruction  may  be  reached  and  treated. 

How  to  Find  the  Point  of  Obstruction.- — Theoretically  one  might  proceed, 
as  is  usually  advised,  in  the  following  methodical  manner:  Pass  the  finger  or 
hand  into  the  right  iliac  region  and  palpate  the  caecum.  If  the  caecum  is  dis- 
tended, pass  the  hand  along  the  colon,  as  the  obstruction  must  be  lower  down. 
If  the  caecum  is  not  distended,  the  obstruction  must  be  in  the  small  intestine. 
Find  a  segment  of  gut  which  is  not  distended.     Trace  the  mesentery  of  the 

*Mackenzie  ("Brit.  Med.  Journ.,"  June  20,  1906)  maintains  that  violent  pain  (peris- 
taltic) across  the  middle  of  the  abdomen,  not  below  the  umbilicus,  signifies  that  the  site  of  the 
obstruction  is  in  the  small  intestine  while  hypogastric  pain  means  that  it  is  in  some  part  of  the 
large  intestine 


444  OPERATIONS    ON    THE    INTESTINES 

loop  of  gut  under  examination  to  its  origin  from  the  spine  and  find  which  is 
its  upper  surface.  Remember  that  the  right  layer  of  the  mesentery  is  also  its 
upper  layer.  Having  found  the  upper  or  right  surface  of  the  mesentery,  that 
portion  of  gut  which  goes  to  the  left  is  the  upper  segment,  and  if  followed  will 
assuredly  lead  to  the  point  of  obstruction.  Trace  the  gut  up  to  the  point  of 
obstruction,  but  do  not  let  the  intestines  come  out  of  the  belly  cavity. 

But  the  belly-walls  are  generally  tense,  the  intestines  are  ballooned  with 
gas,  the  transverse  colon  is  pushed  up  under  the  diaphra'gm,  and  to  carry  out 
the  methodical  examination  described  would  be  very  hazardous,  even  if  pos- 
sible. Greig  Smith  gave  excellent  advice  as  to  finding  the  obstruction.  He 
noted  that  wherever  the  obstruction  is  located  it  is  probable  that  the  most 
dilated  coils  will  rise  to  the  surface;  and,  the  greater  amount  of  bowel  being 
within  three  inches  of  the  umbilicus,  it  is  probable  that  the  most  dilated  coils 
will  be  within  sight.  Very  gently  move  the  coils  from  side  to  side  and  up  and 
down,  and  fix  on  the  most  dilated  coil,  which  will  be  at  the  same  time  the  most 
congested.  Follow  this  coil  in  the  direction  of  increasing  distention  and  con- 
gestion. "It  will  certainly  lead  to  the  stricture.  The  whole  manipulation 
may  be  carried  out  with  two  fingers."  If  this  method  fail,  Greig  Smith  recom- 
mended to  let  the  most  distended  coil  escape  from  the  belly,  protected  by  a 
large  pad.  One  end  of  the  coil  escapes  less  readily  that  the  other  and  appears 
more  congested;  this  end  of  the  coil  will  lead  to  the  obstruction. 

When  the  intestines  are  very  much  distended  with  gas,  there  are  certain 
dangers  to  be  feared  and  combated  during  the  operation: 

1.  During  the  necessary  manipulations  the  pressure  of  the  fingers  or  hand 
may  cause  rupture  of  the  gut. 

2.  If  rupture  is  avoided  and  the  direct  cause  of  obstruction  relieved,  the 
ballooning  of  the  gut  may  cause  kinking  or  valve  formation  of  individual  loops 
and  so  prevent  emptying  of  the  bowel. 

3.  Prolonged  overdistention  so  paralyzes  or  weakens  the  intestinal  muscles 
that  they  are  unable  to  contract. 

4.  The  operation  being  completed,  it  may  be  impossible  to  close  the  abdom- 
inal wound  over  the  dilated  intestines. 

Greig  Smith  held  that  "no  operation  for  intestinal  obstruction  is  properly 
completed  if  the  patient  leaves  the  operating-table  with  a  greatly  distended 
abdomen." 

Dahlgren  (" Centralblatt  f.  Chir.,"  April  15,  1905),  after  incising  the  intes- 
tine, "milks"  it  throughout  its  whole  length,  using  gloved  hands  or  a  special 
instrument  consisting  of  two  cylinders  like  bobbins  held  together  by  a  spring. 
This  he  finds  specially  useful  in  general  peritonitis  with  intestinal  paralysis. 
In  ileus  without  mechanical  obstruction  he  finds  atropin  sulphate  hypoder- 
mically,  i  milligramme  repeated,  of  great  value.  He  began  using  the  atropin 
without  faith  as  a  last  resort,  but  has  learned  its  value  (has  given  5  to  7  milli- 
grammes in  twelve  to  fifteen  hours).     Pituitrin  is  of  great  value. 

After  the  direct  cause  of  the  obstruction  has  been  located  and  treated,  or, 
if  more  convenient,  before  that  is  done,  permit  one  of  the  most  distended  loops 
of  gut  to  protrude  from  the  belly.  Protect  the  abdominal  cavity  with  hot  pads 
or  soft  towels.     Make  an  incision  into  the  gut  (either  transverse  or  longitudinal) 


OBSTRUCTION  445 

and  encourage  its  contents  to  escape  into  a  suitable  vessel.  When  the  con- 
tents cease  to  escape,  clean  the  wound  and  close  it  with  a  continuous  Lembert 
suture.  If  necessary,  repeat  this  procedure  on  other  distended  loops.*  A  prac- 
tical detail  which  may  be  of  value  in  carrying  out  the  above  is  to  have  a  com- 
petent assistant  assigned  to  incise,  clean  and  close  the  gut,  and  that  for  his  work 
he  should  be  provided  with  instruments,  sutures,  and  sponges  entirely  separate 
from  those  used  by  the  operator.  The  object  of  this  detail  is,  of  course,  that 
the  operator  and  his  first  assistant  may  avoid  soiling  their  hands.  The  use 
of  rubber  gloves  which  can  be  changed  is  of  much  value. 

Before  closing  the  last  of  the  enterotomy  wounds  one  may,  through  it,  in- 
troduce into  the  gut  an  ounce  of  sulphate  of  magnesia  in  solution,  or  one  may 
inject  the  solution  into  the  gut  by  means  of  a  syringe  with  a  suitable  cannula, 
subsequently  closing  the  puncture  with  one  or  more  stitches. 

When  operating  for  ileus  particularly  following  pelvic  inflammations  and 
appendicitis,  an  obstruction  is  often  found  affecting  the  ileum  not  very  far 
from  the  ileo-caecal  junction.  After  removing  this  obstruction  it  is  well  to 
examine  the  sigmoid  or  pelvic  colon  as  not  infrequently  there  is  also  an  ob- 
struction present  where  that  gut  passes  the  brim  of  the  pelvis  (Ileus  Duplex, 
Sampson  Handley,  Lancet,  May  i,  1915). 

If  the  patient  is  very  much  collapsed  or  if  it  is  difficult  to  find  and  treat  the 
direct  cause  of  the  obstruction,  the  surgeon  should  throw  aside  all  ambition  to 
do  a  complete  operation  and  content  himself  with  bringing  the  most  distended 
coil  of  intestine  into  the  abdominal  wound  and  fixing  and  opening  it  there 
(enterostomy).  If  the  patient's  strength  is  equal  to  the  strain,  it  may  be  well 
to  precede  the  enterostomy  by  evacuating  the  gut  at  several  places  in  the  man- 
ner already  described,  as  the  intestine  may  refuse  to  empty  itself  through  one 
opening. 

Very  many  lives  have  been  saved  by  means  of  enterostomy  which  would 
have  been  sacrificed  had  a  more  complete  operation  been  attempted.  When 
sufficient  strength  has  been  gained,  the  patient  must  be  submitted  to  a  second 
and  radical  operation.  It  must  be  remembered  that  death  from  obstruction  is 
practically  always  due  to  intestinal  intoxication.  Clairmont  and  Ranzi  found 
that  while  the  filtrate  from  the  contents  of  the  normal  intestine  produced  no 
harmful  effects  when  injected  into  animals,  a  similar  filtrate  prepared  from  the 
contents  of  a  loop  of  strangulated  bowel  produced  serious  and  often  fatal  results 
when  injected.  When  obstruction  of  the  large  intestine  below  the  caecum  is 
complete,  by  far  the  best  results  are  to  be  obtained  from  the  formation  of  an 
artificial  anus  which  may  be  closed  later.  When  the  obstruction  is  actually  at 
the  ileo-caecal  valve  and  it  is  necessary  to  open  the  small  bowel,  Paul  prefers  an 
anastomosis  because  "  there  are  such  decided  objections  to  a  faecal  fistula  con- 
nected with  the  small  intestine,  and  usually  such  favorable  prospects  for  short 
circuiting  in  this  situation,  that  the  additional  immediate  risk  may  be  accepted 
unless  paresis  and  collapse  have  already  supervened,  when  an  artificial  anus  is 
imperative." 

If  the  complete  obstruction  is  known  to  be  in  the  large  intestine  distal  tc  the 

*  This  evacuation  is  by  no  means  always  required.     It  should  be  done  onlj'  if  distension  is 
so  great  that  the  gut  will  probably  be  unable  to  empty  itself  in  the  natural  manner. 


446 


OPERATIONS    ON    THE    INTESTINES 


caecum  and  is  not  due  to  a  twist  in  the  sigmoid  thou  a  simple  right  lumbar 
colostomy  is  the  operation  of  choice.  The  artificial  anus  is  only  intended  to  be 
temporary  and  its  posterior  position  is  out  of  the  way  when  laparotomy  is  per- 
formed later  to  treat  directly  the  lesion  causing  the  obstruction  (Paul,  "Brit. 
Med.  Journ.,"  July  27,  191 2). 


Fig.  603. 


Fig.  604. 
Figs.  602  to  605. 


-Intussusception. 


Fig.  605. 
(Guibe.) 


Intussusception. — Open  the  abdomen.  Discover  the  site  of  the  obstruc- 
tion and  attempt  to  reduce  it. 

Reduction  of  the  Intussusception. — With  the  fingers  of  one  hand  gently  grasp 
the  entering  bowel  close  to  the  invagination;  with  the  other  hand  take  hold  of 
the  bowel  immediately  below  the  intussusceptum  and  gently  press,  stroke,  coax, 
or  milk  the  intussusceptum  upwards.     Make  no  traction  or  massage.     If  reduc- 


INTUSSUSCEPTION 


447 


tion  is  obtained,  examine  the  involved  gut  most  carefully,  lest  it  should  be  in- 
jured. If  an  elongation  of  the  mesentery  seems  to  have  had  anything  to  do 
with  the  production  of  the  intussusception,  it  is  easy  to  shorten  it  by  throwing 
it  into  folds  and  inserting  a  few  stitches.  If  this  is  done,  be  careful  not  to  inter- 
fere with  the  free  passage  of  blood  to  the  gut  through  the  mesentery.  If  reduc- 
tion is  impossible,  and  it  frequently  is,  several  methods  of  treatment  are  possible: 
I.  Excision  of  the  portion  of  gut  involved.  The  operation  is  identical 
with  the  enterectomy  described  elsewhere,  and  is  only  permissible  when  the 
intussusception  is  limited  in  extent. 


/?  C  Oo^rcf 


i  f%iM 


»^y   /ftClSlOf^ 


Fig.  boO. — Intussusception.     {Cofey,  Annals  of  Surgery.) 


2.  Excision  of  the  intussusceptum.  (Figs.  602,  603,  604,  605  explain  the 
operation  fully.) 

R.  C.  Coffey  in  a  remarkable  paper  on  intussusception  ("Annals  of  Surgery," 
January,  1907)  recommends  the  following  operation:  After  exposing  the  af- 
fected gut  by  laparotomy  make  the  primary  incision  (Fig.  606)  into  the  intus- 
suscipiens.  Withdraw  the  intussusceptum  and  wrap  it  in  gauze  (Fig.  606). 
Pack  the  distal  end  of  the  intestine  with  gauze  (Fig.  606).  Cut  the  middle 
layer  of  the  intussusceptum  by  a  circular  incision  (  Fig.  607).  Catch  any  bleed- 
ing points  with  forceps  (Fig.  607).  Doubly  clamp  and  divide  the  healthy  in- 
testine (Fig.  607  and  Fig.  608).  Complete  the  primary  incision,  laying  open 
the  distal  end  of  the  ileum  and  freeing  the  intestine  to  be  removed  (Fig.  607). 
Close  the  distal  end  to  the  gut  with  sutures  (Fig.  608).  (Coffey  advises  making 
this  closure  only  partial  so  as  to  anastomose  the  proximal  segment  of  the  ileum 


448 


OPERATIONS    ON    THE    INTESTINES 


/  Primary  Inchon 


R.  C.  Corner 


Fig.  607. 

2.  Intussusception  withdrawn.  3.  Pack  in  distal  end  gut.  S.  Circular  incision  of  middle  layer  in- 
tussusceptum.  5.  Forceps  on  vessels.  6,  7.  Ileum  divided  between  clamps.  8.  Completion  of  primary 
incision.      (Coffey,  Annals  of  Surgery.) 


d/sT/iL  e//i>  or  luuM 

\  3 


10  11 


fW/ff/iAr /Mien  fttinr  iu/t/fieo  \ 


fnuiiat  iw  MfiSMotii 


pnO/IH/IL  CND  OF  /L£U/f 


f{  C.  Corrcr 


Fig.  608. 

9.  Partial  suture  distal  and  ileum.     10.  Mesentery  ligated.     11.  Division  of  mesentery.      12.  Proximal 
gut  closed.     (Coffey,  Annals  of  Surgery.) 


INTUSSUSCEPTION 


449 


to  it.  It  will  probably  be  better  to  close  the  gut  entirely  and  make  a  lateral 
anastomosis.)  Ligate  the  mesentery  (Fig.  608).  Divide  the  mesentery  and 
remove  the  gangrenous  gut  (Fig.  608).  Close  the  proximal  end  of  the  ileum 
(Fig.  608).  Make  an  anastomosis  between  the  pro.ximal  and  distal  segments 
of  ileum. 

K.  Israel  impressed  by  the  dangers  of  soiling  the  peritoneum  during  exci- 
sion first  delivers  the  intussuscipiens,  sutures  its  serous  coat  to  the  parietal 
peritoneum,  then  opens  it  and  excises  the  intussusceptum  as  above.  He  advises 
this  method  in  all  types  of  intestinal  stricture  producing  a  temporary  artificial 
intussusception  as  in  Maunsell's  operation. 

3.  Ellsworth  Eliot,  Jr.,  suggests  that  the  aflfected  portion  of  gut  be  brought 
near  the  abdominal  wound;  a  small  incision  (0)  (Fig.  609)  be  made  near  the 
end  of  the  intussusceptum  through  the  gut  wall  just  below  the  lesion;  a  soft 
catheter  (T)  be  passed  through  this  wound  and  through  the  canal  of  the  intus- 
susceptum into  the  gut  above;  the  incised  gut  be  sutured  to  the  parietal  wound 


Fig.  609. — Intussusception. 

(W)  (Fig.  609).  The  result  is  an  artificial  anus  below  the  obstruction,  pre- 
venting increase  of  the  intussusception  and  providing  intestinal  drainage  through 
the  catheter.  Eliot  thinks  the  method  may  be  of  use  in  the  case  of  young 
children.     It  is  only  mentioned  here  as  a  suggestion. 

4.  Instead  of  enterectomy,  the  operation  of  segregation  may  be  employed, 
or  an  anastomosis  may  be  established  between  the  open  gut  above  and  below 
the  lesion. 

5.  Under  certain  circumstances,  e.g.,  prostration,  etc.,  it  may  be  wise  to 
make  an  artificial  anus,  whether  accompanied  by  excision  of  the  intussuscep- 
tion or  not.  The  prognosis  must  always  be  bad  when  the  intussusception  is 
left  unreduced,  even  though  the  continuity  of  faecal  circulation  is  provided  for, 
as  gangrene  or  inflammation  of  the  involved  intestine  is  liable  to  occasion  a 
fatal  peritonitis. 

The  vital  importance  of  early  operation  in  intussusception  is  clearly  demon- 
strated by  Clubbe's  statistics.  ("Brit.  Journal  Children's  Diseases,"  July, 
1909.)  During  the  year  1908  there  were  thirty-three  cases  of  intussuscep- 
tion treated  in  the  Royal  Alexandra  Hospital  for  sick  children  in  Sydney  with 
only  two  deaths.  During  the  same  period  Clubbe  himself  treated  twenty-six 
cases  without  a  death.  These  remarkable  results  Clubbe  attributes  to  the 
early  diagnoses  made  by  the  physicians  who  first  saw  the  cases.     None  of  the 

29 


450  OPERATIONS    ON    THE    INTESTINES 

patients  were  seen  by  him  later  than  fifty-three  hours  from  the  beginning 
of  the  trouble.  In  his  opinion  laparotomy  constitutes  the  only  treatment. 
Clubbe's  total  experience  consists  of  157  operations  for  intussusception  with 
the  following  striking  results:  Of  the  first  fifty  patients  twenty-five  died,  i.e., 
50  per  cent.;  of  the  second  fifty  patients  twelve  died,  i.e.,  25  per  cent.;  of  the 
third  fifty  patients  four  died,  i.e.,  8  per  cent.;  of  the  last  seven  patients  none 
died,  i.e.,  o  per  cent. 

The  stomach  may  become  twisted  on  itself,  the  axis  of  the  twist  correspond- 
ing more  or  less  to  the  lesser  curvature.     Gastric  volvulus  may  be: 

A.  Total,  i.e.,  almost  the  whole  of  the  greater  curvature  with  attached  gastro- 
colic omentum  passes  forwards  and  upwards  to  lie  between  the  lowered  lesser 
curvature  and  the  diaphragm.  The  torsion  may  be  to  180°  as  described  above 
and  the  true  posterior  surface  of  the  organ  present  anteriorly  often  covered  by 
the  mesocolon,  as  the  colon  is  commonly  dislocated  with  the  stomach  and  lies 
under  the  diaphragm.  Total  volvulus  occasions  occlusion  of  both  the  cardiac 
and  pyloric  orifices.  Occasionally  the  torsion  is  posterior,  i.e.,  the  greater 
curvature  passes  backwards  and  upwards  behind  the  lesser  curvature.  Total 
volvulus  is  acute  and  usually  primary. 

B.  Partial  Volvulus  of  Stomach. — Frequently  secondary  to  inflammatory 
lesions,  to  neoplasms  or  to  diaphragmatic  hernia.  The  trouble  is  commonly 
chronic.  Here  the  torsion  is  of  the  pylorus  and  pyloric  end  of  the  stomach. 
Both  total  and  partial  volvulus  demand  operation.  In  partial  volvulus  the 
trouble  will  most  commoftly  be  discovered  during  operation  for  the  primary 
lesion  and  the  treatment  will  consist  of  detorsion  and  correction  of  the  primary 
lesion,  e.g.,  division  of  adhesions;  cure  of  diaphragmatic  hernia;  treatment  of 
hour-glass  stomach,  etc.,  etc. 

In  total  volvulus  diagnosis  has  on  several  occasions  been  made  prior  to,  but 
more  frequently  during  operation.  The  story  of  the  operation  is  usually  as 
follows:  Median  incision  from  the  ensiform  cartilage  to  the  umbilicus.  On 
opening  the  abdomen  a  large  cyst  presents  covered  by  a  vascular  membrane, 
the  mesocolon.  It  is  impossible  to  orient  the  cyst  because  of  tension,  etc.  Tear 
a  hole  through  a  non-vascular  area  of  the  membrane.  Protect  the  abdominal 
cavity  very  thoroughly  with  gauze  pads.  Puncture  the  cyst  as  high  up  as  pos- 
sible and  drain  its  contents  through  a  cannula.  Close  the  puncture  in  the  cyst  by 
a  double  row  of  sutures;  the  second  row  being  of  the  Lembert  sort.  Exploration 
is  now  easy  and  the  cyst  is  found  to  be  the  stomach  which  is  recognized  by  the 
arrangement  of  its  arteries  and  the  attachment  of  the  great  omentum.  Usually 
detorsion  is  easy.  If  the  patient's  strength  permits  it  is  recommended  to  insure 
against  recurrence  by  performing  gastropexy,  i.e.,  by  fixing  the  anterior  surface 
of  the  stomach  near  the  lesser  curvature  to  the  abdominal  wall  by  a  row  of 
sutures.  Lenormant  ("La  Press.  Med.,"  May  11, 191 2)  has  collected  11  cases  of 
total  volvulus  with  7  recoveries  and  6  cases  of  partial  volvulus  with  5  recoveries. 
(For  information  regarding  gastric  volvulus  see  Payr,  "Mittheilungen  d.  Grenz- 
geb.,"  XX,  686;  Lenormant,  "LaPresse  Med.,"  May  11, 191 2 ;  Tuffier  and  Jeanne, 
"Rev.  de  Gyn.  et  Chir.  Abdom.,"  Jan.,  1912.) 

Volvulus.— Open  the  abdomen.  Find  the  site  of  obstruction.  Empty  the 
gut  by  incision.     Gently  endeavor  to  unravel  the  knotted  or  twisted  intes- 


VOLVULUS.      BANDS  45 1 

tine.  If  reduction  is  impossible  and  there  is  no  interference  with  the  blood- 
supply  of  the  involved  gut,  establish  an  anastomosis  between  the  gut  above 
and  below.  If  the  blood-supply  is  threatened  or  if  for  other  reasons  the  step 
seems  proper,  excise  the  involved  gut.  Where  radical  treatment  is  impossible, 
the  operation  of  intestinal  exclusion  or  segregation  may  be  employed. 

Finsterer  ("Zent.  flir  Chir.,"  No.  30,  191 2)  finds  that  simple  detorsion  has  a 
mortality  of  35  per  cent,  and  there  were  13  recurrences  in  48  cases.  Colopexy 
(of  course  following  detorsion)  gives  a  mortality  of  20  per  cent., and  is  no  surety 
against  recurrence.  Entero-anastomosis  has  a  mortality  of  50  per  cent.  When 
gangrene  is  present  resection  is  compulsory  and  should  be  done  in  two  stages; 
even  when  the  gut  is  not' gangrenous,  resection  gives  the  best  results  (mortality 
7.6  per  cent.).  If  the  general  condition  of  the  patient  permits,  the  operation 
may  be  done  in  one  sitting.     (In  23  operations,  i  death.) 

A  curious  cause  of  chronic  obstruction  and  the  most  frequent  cause  of 
volvulus  of  the  sigmoid  colon  is  the  so-called  "retractile  meso-sigmoiditis." 

From  some  ill-defined  cause  the  base  of  the  meso-sigmoid  becomes  covered 
transversely  by  bands  of  scar  tissue  which  contract  and  in  severe  cases  may 
bring  both  segments  of  the  sigmoid  together  like  the  barrels  of  a  gun.  This  of 
course  can  cause  narrowing  of  the  lumen  and  obstruction  with  subsequent 
dilatation  of  part  of  the  sigmoid  loop  and  of  the  descending  colon.  Distention 
of  the  bowel  and  interference  with  the  circulation  are  liable  to  lead  to  ulcera- 
tion of  the  mucosa,  etc.  Fixation  or  stiffening  of  the  sigmoid  is  a  predisposing 
cause  of  volvulus. 

Treatment. — If  the  bowel  does  not  seem  severely  affected,  divide  the  bands 
of  scar  tissue  which  contract  the  meson;  in  some  cases  this  permits  the  meson 
to  spread  out  to  its  normal  condition.  If  the  above  measure  fails  to  release  the 
meson  or  if  the  gut  is  much  affected  it  is  advised 
to  resect  the  involved  intestine.  In  some  cases 
an  anastomosis  might  overcome  the  trouble. 
(Duval,  "Arch,  des  malad.  de  I'appar.  digestif,"" 
1907,.  No.  i;  "Ref.  Centralblatt  flir  Chir.," 
1907,  No.  37). 

Bands,  Etc. — Bands  or  strands  of  omentum, 

etc.,    causing   obstruction   are    to    be    doubly 

ligated  and  divided,  or  rather  excised.     When      ^  ^  ,       ,    , 

,.    .  ,.  ,     ,        1  •  1  f   11  Fig.  610. — Summers  method. 

dividmg  such   bands   examme   them   caret ully 

lest  they  should  consist  of  diverticula  with  mucous  lining,  in  which  case 
they  must  be  treated  in  the  same  fashion  as  the  stump  left  by  the  excision  of 
the  vermiform  appendix. 

Sometimes  bands  pressing  on  the  gut  cause  gangrene,  the  gangrene  involv- 
ing all  or  nearly  all  of  the  circumference  of  the  gut  while  it  involves  little  of  the 
long  axis  of  the  gut.  This  segment  of  gut  may  be  excised  though  it  is  probably 
much  better,  especially  in  the  feeble,  to  invaginate  the  gangrenous  gut  by  a 
row  of  Lembert  sutures.  The  invaginated  tissue  is  dead  and  soon  sloughs 
off  leaving  the  lumen  of  the  gut  patent  (Fig.  610).  This  operation  was  de- 
vised by  J.  E.  Summers  and  carried  out  successfully  by  him  in  three  cases; 


452  OPERATIONS    ON    THE    INTESTINES 

two  of  these  were  stranojulated  herniic  and  one  was  of  gun-shot  wound  of 
the  intestines. 

Adhesions. — The  best  treatment  for  obstruction  from  adhesions,  to  use  an 
Irishism,  is  not  to  have  the  adhesions.  The  principal  prophylactic  means 
to  this  end  is,  when  operating,  to  leave  as  few  raw  surfaces  as  possible 
within  the  belly.  Wherever  possible,  raw  surfaces,  pedicles,  etc.,  should  be 
covered  with  peritoneum,  even  if  some  plastic  work  be  required  for  this  pur- 
pose. Where  it  is  impossible  to  cover  the  surfaces  with  neighboring  perito- 
neum, portions  of  omentum  may  be  ligated  and  cut  off,  and  these  fragments 
plastered  over  the  raw  surface.  Finton  and  Peet  (Surg.,  Gyn.  and  Obst., 
Sept.,  1919)  find  that  these  omental  grafts  in  the  abselice  of  infection  are  alive 
and  good  after  the  lapse  of  six  months.  If  infection  is  present  they  are  useless 
except  as  temporary  means  of  preventing  extravasation  of  intestinal  contents 
until  protection  adhesions  form.  These  authors  find  that  under  sterile  condi- 
tions, free  omental  flaps  prevent  the  formation  of  adhesions.  The  active 
treatment  of  adhesions  is  to  break  them  up,  either  by  sharp  or  blunt  dissec- 
tion, and  cover  the  raw  surface  as  above  described.  When  a  gut  is  adherent 
to  the  parietal  peritoneum  or  to  an  organ  of  lesser  importance,  and  in  freeing  it 
injury  to  one  or  the  other  is  probable,  be  careful  to  sacrifice  the  less  rather  than 
the  more  important  organ.  If  it  is  impossible  safely  to  separate  the  adhesion 
causing  obstruction  restore  the  faecal  circulation  by  establishing  an  anastomosis 
between  the  gut  above  and  below  the  obstruction. 

Foreign  Bodies. — For  the  treatment  of  obstruction  due  to  this  cause  see 
remarks  on  enterotomy  (page  411). 

Enterostomy.— The  term  "enterostomy"  signifies  an  operation  to  establish 
a  communication  between  any  portion  of  the  intestine  and  the  exterior  of  the 
body,  whether  this  opening  be  used  for  the  introduction  of  food,  etc.,  or  for  the 
evacuation  of  intestinal  contents. 

Jejunostomy. — This  operation  is  of  value  in  providing  absolute  rest  to  the 
stomach  in  cases  of  hemorrhage  when  other  more  direct  methods  of  treat- 
ment are  unavailable.  Mayo  Robson  ("Brit.  Med.  Journ.,"  Jan.  6, 191 2)  thinks 
jejunostomy  of  great  value  in  jejunal  ulcer  following  gastro-enterostomy  when 
the  patient  is  too  feeble  to  permit  of  more  extensive  work.  He  finds  it  also 
valuable  in  "  ulcer  near  the  cardiac  end  of  the  stomach,  or  along  the  lesser  curva- 
ture as  also  in  some  ulcers  of  the  duodenum  that  have  failed  to  yield  to  medical 
treatment"  if  there  is  no  pyloric  stenosis,  v.  Milkulicz  considers  jejunostomy 
"inhuman"  when  used  to  prolong  life  in  cases  of  stenosis  from  gastric  cancer. 

The  Operation. — Expose  and  examine  the  stomach  exactly  as  in  gastro- 
enterostomy in  order  to  prove  that  some  other  and  better  operation  than  jejun- 
ostomy may  not  be  possible.  Bring  a  loop  of  jejunum,  6  to  8  inches  below  the 
duodenojejunal  angle,  into  the  abdominal  wound  and  suture  it  to  the  fascia 
and  skin.  Close  the  excess  of  parietal  wound.  Either  at  the  same  sitting  or  a 
few  days  later  make  an  opening  into  the  exposed  portion  of  jejunum  of  a  size 
sufficient  for  the  introduction  of  a  soft-rubber  catheter.  Feed  with  predigested 
food  through  the  catheter. 

An  imitation  of  the  Stamm-Kader  operation  may  be  used  or,  better  still,  of 
the  Witzel  gastrostomy.     The  great  objection  to  jejunostomy  is  the  constant 


COLOSTOMY  453 

and  inevitable  escape  of  bile  and  pancreatic  juice  through  the  fistula.  To 
obviate  this  evil  Alaydl,  after  exposing  the  jejunum,  divides  it  transversely 
about  8  inches  below  its  origin;  the  open  end  of  the  upper  segment  he  implants 
into  the  side  of  the  lower,  about  8  inches  below  the  line  of  section,  and  then 
unites  the  open  end  of  the  lower  segment  to  the  skin.  The  principle  is  identical 
w'<^h  that  of  Roux's  gastro-enterostomy,  and  is  most  excellent;  the  only  criticism 
on  it  is  that  patients  requiring  jejunostomy  are  usually  in  a  very  feeble  condition 
and  cannot  withstand  much  operative  interference. 

Instead  of  a  rather  complicated  Maydl  operation,  one  may  take  an  entero- 
enterostomy  between  the  afiferent  and  efferent  segments,  and,  if  desired,  ob- 
literate the  lumen  of  the  afferent  segment,  by  means  of  a  purse-string  suture, 
between  the  site  of  the  anastomosis  and  the  fistula. 

Colostomy  (often  called  colotomy). — The  most  common  indication  calling 
for  colostomy  is  obstruction,  and  then,  according  to  the  method  of  operating 
adopted,  either  a  part  or  the  whole  of  the  intestinal  contents  escape  through 
the  artificial  anus.  When  operation  is  indicated  for  the  application  of  remedies 
(douches,  etc.)  to  the  inside  of  the  colon  some  method  is  adopted  by  which 
escape  of  faeces  is  prevented  (see  cgecostomy)  or  appendicostomy  is  substituted 
for  colostomy. 

Lumbar  Colostomy. — The  operation  is  practically  the  same  whether  it  is 
done  on  the  right  or  the  left  side.  Right  lumbar  colostomy  is  very  valuable  in 
colonic  obstruction  when  the  cause  of  the  obstruction  can  be  subsequently 
removed.  For  permanent  artificial  anus  the  left  inguinal  region  is  preferable. 
The  following  description  applies  to  the  left  lumbar  colostomy: 

Step  I. — Place  the  patient  on  his  right  side  with  a  firm  rounded  pillow 
under  his  right  loin.  Find  a  point  on  the  crest  of  the  ilium  midway  between 
its  anterior  and  posterior  superior  spines.  From  a  spot  a  little  in  front  of  and 
I  inch  above  the  mid-point  of  the  ilium,  make  an  incision,  3  to  4  inches  in  length 
along  an  imaginary  line  leading  to  the  junction  of  the  spine  and  the  last  rib 
(Bryant's  incision).  Divide  the  skin  and  subjacent  muscles  along  the  whole 
length  of  the  superficial  incision.  Attend  to  hemostasis.  Expose  and  divide 
the  transversalis  fascia,  exposing  the  subperitoneal  fat. 

Step  2. — With  blunt  dissection  penetrate  the  exposed  fat  in  which  the  colon 
is  to  be  found.  The  colon  may  always  be  discovered  in  front  of  the  lower 
border  of  the  kidney.  Be  careful  not  to  open  the  peritoneum;  but  if  this  ac- 
cident occurs,  make  use  of  the  opening  to  aid  in  locating  the  colon;  which  being 
done,  close  the  peritoneum  either  by  suture  or  ligature. 

Step  3. — Method  A. — Having  found  the  colon,  pull  it  up  into  the  wound 
and  pass  a  stout  suture  through  the  skin  (not  the  muscles)  on  one  side  of  the 
wound,  through  the  colon,  and  out  through  the  skin  on  the  other  side.  Clean 
the  lumbar  wound  and  close  its  deep  parts  with  a  few  catgut  sutures.  Close 
the  superficial  lumbar  wound  with  silkworm-gut,  except  opposite  the  prolapsed 
gut.  Make  a  small  opening  into  the  gut  over  the  suture  which  traverses  its 
lumen.  Pick  up  and  pull  out  the  centre  of  the  suture  traversing  the  gut  and 
divide  it.  Tie  the  two  halves  of  the  suture  and  thus  fix  the  sides  of  the  in- 
testinal opening  to  the  skin.  Introduce  any  more  sutures  which  may  be 
necessary. 


454  OPERATIONS    OX    THE     IXTESTIXES 

Method  B. — Operate  as  above,  but  instead  of  merely  incision  of  tlie  colon, 
completely  divide  it,  close  its  lower  segment  completely,  and  suture  the  whole 
circumference  of  the  upper  segment  to  the  skin  (Madelung). 

Method  C. — Bring  a  knuckle  of  gut  outside  the  wound,  protect  it  with 
dressings,  and  open  it  after  the  lapse  of  three  or  four  days.  Any  lumbar 
wound  which  is  in  excess  of  what  is  required  for  the  passage  of  the  gut  must 
be  closed  by  sutures.  It  is  unnecessary  to  fix  the  gut  in  the  wound  by  means 
of  sutures. 

Inguinal  Colostomy. — When  the  operation  is  done  on  the  left  side,  it  may  be 
named  sigmoidostomy,  but  the  operation  is  practically  the  same  whether  it 
be  a  right  inguinal  colostomy  or  a  sigmoidostomy.  A  sigmoidostomy  will  be 
here  described. 

Step  I. — Draw  an  imaginary  line  from  the  anterior  superior  spine  to  the 
umbilicus;  make  an  incision  2}'^  inches  long,  crossing  this  line  at  right  angles 
and  distant  1)4,  inches  from  the  anterior  superior  spine.  One-half  the  cut 
is  above  the  line  and  one-half  below  (Harrison  Cripps'  incision). 

Step  2. — Find  the  colon,  recognizable  from  its  longitudinal  muscular  bands 
and  appendices  epiploicae.     Pull  it  into  the  wound. 

Step  3. — Method  A. — Pass  two  silk  sutures,  two  inches  apart,  through  the 
free  margin  of  the  gut.  These  are  for  traction  purposes  and  serve  as  guides. 
Suture  the  loop  of  gut  to  the  edges  of  the  inguinal  wound.  If  the  case  is  urgent, 
open  the  gut  at  once;  if  there  is  no  urgency,  apply  dressings  and  incise  the  colon 
after  the  lapse  of  three  or  four  days.  In  this  operation  there  is  no  attempt  made 
to  compel  the  complete  evacuation  of  the  bowel  through  the  artificial  opening; 
much  of  the  colonic  contents  are  at  liberty  to  pass  down  into  the  lower  gut. 

Method  B. — Gently  pull  out  of  the  wound  as  much  of  the  upper  segment 
of  gut  as  will  come  down  and  push  it  back  again  through  the  lower  angle  of 
the  wound.  This  is  done  so  that  the  intestinal  opening  may  be  made  in  a  part 
of  the  gut  well  supported  by  mesentery,  and  thus  prolapse  be  avoided.  In- 
troduce traction  sutures  as  in  Method  A.  Suture  the  protruded  loop  of  gut  to 
the  abdominal  wound.  The  sutures  should  be  so  placed  that  at  least  two- 
thirds  of  the  circumference  of  the  gut  is  external  to  the  line  of  stitches.  Open 
the  gut  either  immediately  or  after  the  lapse  of  3  or  4  days.  The  object  of 
making  so  much  gut  protrude  is  to  form  a  spur  or  obstacle  to  the  passage  of 
faeces  into  the  lower  segment  of  bowel.  Paul  thinks  a  spur  is  usually  disadvan 
tageous  and  so  does  not  permit  so  much  of  the  circumference  of  the  gut  to  be 
external  to  the  line  of  stitches. 

Method  C  is  almost  the  same  as  Method  B.  After  pulling  the  gut  down- 
wards so  as  to  obtain  mesenteric  support,  pass  a  glass  rod  under  the  selected 
loop  of  gut,  through  its  mesentery.  The  ends  of  the  glass  rod  rest  on  each  side 
of  the  skin-wound  and  support  the  loop  of  gut  (Fig.  611).  Close  the 
belly-wound,  leaving  sufficient  room  for  the  passage  of  the  loop  of  gut  held 
in  place  by  the  glass  rod.  Apply  dressings.  Remove  the  glass  rod  and 
open  the  gut  after  union  has  taken  place  between  the  gut  and  the  parietes. 
In  opening  the  gut  it  is  best  to  divide  it  transversely  and  slowly  with  the 
thermocautery.  If  there  is  an  excess  of  gut  protruding,  it  may  well  be 
excised   with    the   cautery.     No   anaesthetic  is  necessary,  as   the  intestine  is 


COLOSTOMY 


455 


not  sensitive.  This  is  a  convenient  and  good  method.  A  variant  in  the 
method  is  (i)  after  opening  the  abdomen  suture  the  parietal  peritoneum  to 
the  skin.  (2)  After  the  glass  rod  is  in  position  suture  the  intestinal  serosa  to 
the  parietal  peritoneum  or  to  the  skin. 

Method  D. — Find  the  colon,  pull  it  downwards  so  as  to  provide  mesenteric 
support.  Apply  clamps  to  the  gut  and  divide  it.  Close  the  lumen  of  the  lower 
segment  by  inverting  its  cut  edges  and  suturing.  Suture  the  whole  circum- 
ference of  the  upper  segment  to  the  skin.  Close  the  excess  of  skin-wound  after 
removing  the  clamps. 

Position  0/  Farietal 
■}  Wound 


ient 


Fig.  611. 


Figs.  611  axd  612.- 


Fig.  6i2. 
-Colostom\'. 


Methods  E  and  F. — ^Instead  of  dividing  the  gut,  and  before  opening  it, 
Mosetig-Moorhof  creates  a  valvular  obstruction  in  the  lower  segment  by  insert- 
ing a  few  Lembert  sutures  (Fig.  612).  The  same  object  may  be  attained  by  en- 
circling the  gut  with  a  loop  of  wire  or  with  a  purse-string  suture  of  silk. 

Method  G  (Wyeth's  Operation). — x\ll  the  methods  already  described  have 
been  devised  in  the  belief  that  prolapse  of  the  afferent  segment  of  the  gut  is  the 
principal  trouble  after  colostomy.  This  belief  is 
not  correct.  The  chief  trouble  is  that  there  is  no 
rectum  to  act  as  a  natural  reservoir  for  faeces.  The 
following  operation  provides  such  a  reservoir  and 
also  prevents  any  great  prolapse  of  mucous 
membrane. 

Step  I. — Make  an  incision  through  the  skin 
alone,  parallel  to  and  i}-^  inches  below  the 
Harrison  Cripps' line  of  incision  (page  454).  Pull 
the  superior  edges  of  the  skin  incision  upwards  so 
as  to  expose  the  deep  structures  of  the  belly-wall 
at  the  Harrison  Cripps'  line  (Fig.  613).  Divide  the 
deep  structures  along  this  line  and  so  open  the  belly. 

Step  2. — ^Pull  the  sigmoid  flexure  out  of  the  wound;  push  all  excess  of 
sigmoid  up  into  the  belly  so  that  as  little  gut  is  left  below  the  eviscerated  loop 
as  possible,  i.e.,  the  portion  of  gut  to  be  united  to  the  belly- wall  is  chosen  as 
low  down  the  intestine  as  is  possible.  By  this  means  a  faecal  reservoir  is 
provided. 

Step  3. — Treat  the  eviscerated  segment  of  gut  in  much  the  same  manner 
as  is  recom.mended  in  the  preceding  methods.     If  it  is  desired  to  open  the  gut 


Fig.  613. — Cripps'  incision. 


456 


OPERATIONS    ON    THE    INTESTINES 


at  once,  it  is  wise  to  fasten  a  tube  into  it  by  means  of  a  purse-string  suture,  much 
in  the  manner  described  in  Paul's  colectomy.  Some  surgeons  strongly  advise 
against  suturing  the  parietal  peritoneum  to  the  skin,  as  when  tTiis  is  done  there 
is  not  such  good  union  between  the  gut  and  the  parietes.  Excise  all  the  appen- 
dices epiploicae  from  the  eviscerated  segment  of  gut,  as  otherwise  they  will 
surely  slough  off,  slowly  and  with  much  stench.  In  applying  dressings  always 
separate  the  dressings  from  the  exposed  gut  by  a  layer  of  rubber  tissue  or  perfo- 


FlG.  614. 


-JMixters  anterior  colostomy. 
Line  of  incision. 


(Gould.) 


rated  oiled  silk.  This  simple  device  saves  much  trouble  from  the  sticking  of 
dressings  to  the  parts  and  is  very  conducive  to  cleanliness  and  avoidance  of 
stench.  In  time  the  opening  in  the  skin  and  that  through  the  deeper  structures 
come  to  lie  close  to  each  other;  not  so  close,  however,  as  to  do  away  with  the 
valve  action  desired. 

Method  H. — Mixter's  anterior  colostomy. 

Step  I.— Make  the  incision  shown  in  Fig.  614.     The  outer  portion  of  the 


COLOSTOMY 


457 


incision  must  be  a  short  distance  inside  of  the  outer  edge  of  the  rectus  muscle. 
This  incision  divides  the  skin,  subcutaneous  tissue  and  the  rectus  fascia.  Reflect 
outwards  the  quadrilateral  flap  outlined.  It  seems  an  unnecessary  complica- 
tion to  make  the  rectangular  flap  of  skin.  A  vertical  incision  answers  every 
purpose  and  can  be  closed  under  the  protruding  portion  of  gut  in  the  same  way 
as  or  together  with  the  rectus  muscle  and  sheath. 


Fig.  615. — -Anterior  colostomy.     [Gould.) 
Sigmoid  withdrawn,  mesentery  pulled  taut  and  incised.     Rectus  muscle  sewed  together  between  afferent 

and  efferent  coils. 


Step  2. — Split  the  rectus  muscle  near  its  outer  margin.     Open  the  abdomen. 

Step  3. — Deliver  a  loop  of  the  sigmoid  as  in  Step  2,  Method  G. 

Step  4. — Split  the  meso-sigmoid  for  about  2  inches  at  a  right  angle  to  the 
long  axis  of  the  bowel.  Suture  the  two  edges  of  the  middle  portion  of  the 
separated  rectus  muscle  together  through  the  opening  in  the  meso-sigmoid 
(Fig.  615). 


458 


OPERATIONS    (JN    THK    INTESTINES 


Step  5. — Push  the  reflected  flap  of  skin  and  rectus  fascia  tlirough  the  open- 
ing in  the  meso-sigmoid  and  suture  it  in  its  original  position  (F'ig.  616). 

After  four  or  five  days  the  exposed  coil  of  sigmoid  may  be  resected,  when 
bleeding  from  the  cut  ends  of  the  intestine  may  be  controlled  h\'  a  continuous 
suture  of  catgut.     The  proximal  and  distal  openings  are  wide  a[)art  and  the 


Fig.  616. — Anterior  colostomy.     [Gould.) 
Flap  fastened  into  original  position  under  arch  of  sigmoid,  with  two  layers  of  sutures. 


Mixtertube  in  place 


rectus  acts  as  a  sphincter.  Through  the  distal  opening  it  is  easy  to  flush  the 
rectum  (Fig.  617).  If  obstruction  is  acute  one  may  open  the  bowel  in  Step 
5  and  insert  a  glass  tube  (Paul's  tube;  Mixter's  tube). 

Method  I. — Littlewood' s  Colostomy. — Make  a  vertical  incision  from  the  tip 
of  the  twelfth  rib  on  the  left  side  downwards  to  a  point  behind  the  anterior 
superior  iliac  spine.  Expose  the  descending  colon  and  open  it  as  far  back  as 
possible  on  its  outer  side  so  as  to  leave  no  chance  for  the  small  intestine  to 
find  a  niche  in  which  it  may  become  strangulated.  This  operation  has  a 
number  of  important  advantages.     The  new  anus  is  far  from  hairs  and  hence 


COLOSTOMY 


459 


is  comparatively  sanitary.     Almost  any  belt  around  the  waist  will  suffice  to 
hold  an  occlusive  pad  in  position. 

Method  J. — McGavin's  Transversostomy  (Clin.  Soc.  Trans.,  1906;  Brit.  Med. 
Journ.,  May  10,  1913). — -Make  a  vertical  incision  2  inches  to  the  left  of  the 
linea  alba  and  with  its  upper  end  2  inches  below  the  costal  margin.     Split 


Fig.  617. — Anterior  colostomy.     (Gould.) 

Sigmoid  resected  H  to  \i  inch  above  skin  level.     Circumference  of  cut  edges  sewed  with  catgut. 


the  rectus.  Open  the  abdomen.  Pull  out  the  transverse  colon  so  as  to  form  a 
good  "spur"  and  complete  the  operation  as  in  Method  C.  There  is  much  to 
be  said  in  favor  of  McGavin's  method.  The  patient  can  subsequently  care  for 
himself  easily.  An  occlusive  pad  is  efficient  and  easily  worn.  The  rectus 
muscle  forms  a  fairly  good  sphincter.  The  colonic  contents  are  not  so  foul  as 
are  those  of  the  sigmoid  and  while  not  so  solid  are  yet  sufficiently  so.  The 
new  anus  is  remote  from  the  disease. 

Method  K. — Ccecostomy. — The  author  has  found  this  operation  of  value 
as  a  substitute  for  appendicostomy.     In  autopsies  on  those  dying  from  corrosive 


460 


OPERATIONS    ON    THE    INTESTINES 


sublimate  poisoning,  C.  C.  Conover  found  that  the  mucosa  of  the  pyloric  end  of 
the  stomach  is  affected  being  black  in  color,  but  that  the  muscular  and  peritoneal 
tunics  are  not  seriously  involved,  that  the  small  intestine  escapes  damage,  that 
the  caecum  and  colon  are  the  sites  of  severe  ulceration.  The  colonic  ulceration 
begins  within  twenty-four  hours  of  the  swallowing  of  the  poison  and  death 
occurs  usually  within  thirty-six  hours.  Adami  (Brit.  Med.  Journ,,  Jan.  24, 
1914)  writes,  "we  have  clear  evidence  that  the  mucosa  of  the  colon  is  a  region  of 
active  excretion;  we  know,  for  example,  that  antimony  and  mercury  are  dis- 
charged from  the  blood  by  this  path. ' '  Conover  suggested  that  early  caecostomy 
with  lavage  of  the  colon  every  three  hours  (better  continuous  lavage)  kept  up  for 
from  two  to  four  days  might  prevent  the  colonic  ulceration.  Conover's  treat- 
ment has  been  carried  out  in  a  few  cases  at  the  Kansas  City  General  Hospital 
with  uniformly  good  results. 

L.  L.  McArthur  finds  that  irrigation  of  the  colon  through  an  appendicostomy 
or  caecostomy  opening  is  of  actual  curative  value  in  tuberculous  ulceration  in 

any  portion  of  the  gut  distal  to  the  caput  coli.     This 
includes  of  course  the  sigmoid  and  rectum. 

Step  I. — Expose  the  caecum  by  means  of  the 
McArthur-McBurney  muscle-splitting  method. 

Step  2. — Choose  a  part  of  the  caecum  which  can 
be  easily  approximated  to  the  abdominal  wound 
and  introduce  a  purse-string  suture  of  catgut  (Fig. 
618)  penetrating  the  whole  thickness  of  the  caecal 
wall. 

Step  3. — Incise  the  gut  inside  the  circle  formed 
by  the  purse-string  suture.  Through  this  incision 
pass  the  bulb  of  a  Pezzer's  self-retaining  catheter  into 
the  lumen  of  the  gut.  Tie  the  purse-string  snugly 
around  the  shaft  of  the  catheter  but  not  tightly 
enough  to  obstruct  its  lumen.  No  faecal  matter  can 
now  escape  alongside  the  catheter  and  no  bleeding  from  the  intestinal  wound 
is  possible.     Cleanse  the  field  of  operation. 

Step  4. — At  a  distance  of  ^^  to  ^^  inch  from  the  catheter  introduce  a 
purse-string  suture  of  hemp  or  silk  and  tie  this  line  of  suture  snugly  (but 
not  too  tightly)  around  the  shaft  of  the  catheter.  Leave  the  ends  of  the 
suture  long.  Instead  of  the  above  method  a  modification  of  the  Witzel  plan  for 
gastrostomy  may  be  used. 

Step  5. — ^Pull  the  free  end  of  the  catheter  through  the  abdominal  wound  so 
as  to  bring  the  caecum  into  apposition  with  the  parietal  peritoneum.  Stitch 
the  long  ends  of  the  purse-string  suture  to  the  parietal  peritoneum.  Close 
the  abdominal  wound.  Before  applying  dressings  pull  the  catheter  in  such 
a  fashion  that  its  bulb  (inside  the  caecum)  will  bring  the  caecum  into  con- 
tact, with  the  parietal  peritoneum.  Before  closing  the  abdominal  wound, 
the  caecum,  near  the  catheter,  may  if  desired  be  united  to  the  parietal 
peritoneum  by  one  or  two  stitches.  This  is  rarely  necessary.  Before  in- 
troducing the  catheter  into  the  caecum  its  free  end  may  be  clamped  by  a 
hemostat. 


Fig.  618. — Caecostomy. 


CLOSURE    F^CAL    FISTULA  461 

The  catheter  is  left  in  situ  as  long  as  it  is  required  for  irrigation  of  the  colon. 
To  remove  the  catheter  cut  it  flush  with  the  skin  and  with  a  probe  passed 
through  the  lumen  of  the  remnant  poke  the  bulb  into  the  gut.  Owing  to  the 
invagination  of  the  caecal  wall  the  fistula  closes  promptly  as  soon  as  the  catheter 
is  removed. 

Weir  suggested  that  the  appendix  might  be  used  in  the  formation  of  a  fistula 
through  which  the  colon  could  be  irrigated.  The  operation  is  only  feasible 
when  the  appendix  has  a  lumen  large  enough  to  permit  the  passage  of  a  small 
catheter  and  when  absence  of  adhesions  and  presence  of  sufficiently  long  meso- 
appendix  permit  its  being  brought  out  through  the  abdominal  wall  without 
interference  with  its  nutrition. 

Step  I. — Open  the  abdomen  through  a  small  incision  as  for  appendectomy. 

Step  2. — Bring  the  appendix  out  through  the  wound  without  twisting  or 
exerting  undue  pressure  on  its  meson. 

Step  3. — Prevent  retraction  of  the  appendix  into  the  abdomen  either  by 
uniting  the  caecum  or  the  appendix  to  the  parietes  by  one  or  more  sutures, 
or  by  passing  a  safety-pin  through  the  meso-appendix  exactly  as  a  rubber 
drainage-tube  is  secured. 

Step  4.— Close  the  abdominal  wound  being  careful  not  to  exert  pressure  on 
the  appendix  or  its  blood-supply.  After  adhesions  have  formed  between  the 
appendix  and  the  wound  cut  off  the  protruding  tip  of  the  appendix  flush  with 
the  skin  and  introduce  a  soft-rubber  catheter  into  the  caecum  as  often  as  may  be 
required.  When  it  is  desired  to  close  the  fistula  remove  the  mucosa  of  the 
appendix  either  by  the  cautery  or  by  dissection  or  remove  the  appendix  itself. 

Closure  of  Artificial  Anus  or  of  Faecal  Fistulae.— If  the  colostomy  opening 
is  small  the  patient  may  be  kept  in  comfort  by  careful  regulation  of  the 
bowels  and  by  plugging  the  fistula  with  a  mushroom-shaped  aluminum  plug 
held  in  place  by  a  pad  and  belt.  When  colostomy  has  been  performed 
as  a  preliminary  step  in  excision  of  the  rectum  or  for  therapeutic  pur- 
poses, or  when  the  obstruction  which  called  for  it  has  been  removed,  it 
becomes  necessary  to  close  the  artificial  anus.  When  no  "spur"  preventing 
the  onward  passage  of  faeces  is  present,  all  that  may  be  required  is  to  dissect 
the  mucous  membrane  free  from  the  skin,  turn  it  inwards,  stitch  its  edges  together, 
and  then  suture  the  now  raw  edges  of  the  abdominal  wound.  When  a  "spur" 
is  present  {vide  Methods  B  and  C,  page  454),  one  may  apply  a  clamp  to  the  spur 
and  leave  it  in  position  until  by  pressure  it  causes  the  "spur"  to  slough  away 
(Fig.  619).  This  takes  away  all  opposition  to  the  onward  flow  of  the  contents, 
and  the  fistula  may  be  closed  in  the  manner  already  described.  Such  was  the 
manner  of  operating  devised  by  Dupuytren,  and  until  comparatively  recently 
was  the  accepted  method.  The  dangers  of  the  method  are:  (a)  peritonitis; 
{b)  accidental  inclusion  of  a  knuckle  of  intestine  within  the  clamps.  Other 
and  more  precise  methods  are  now  in  use. 

The  Operation.—Mummery  (Surg.,  Gyn.  and  Obst.,  Sept.,  1919,  p.  312)  ad- 
vises very  careful  preparation.  The  skin  is  commonly  much  excoriated  around 
the  fistula  especially  in  fistulae  of  the  small  intestine  or  caecum,  and  this  must 
be  corrected.  Give  opium  in  doses  sufficient  to  produce  considerable  constipa- 
tion and  if  possible  solid  stools.     Protect  the  skin  by  ointments.     After  a  week 


462 


OPERATIONS    ON    THE    INTESTINES 


or  more  there  will  be  much  improvement.  Before  operation  do  not  purge,  but 
empty  the  gut  by  lavage. 

Step  I. — Cleanse  the  skin  around  the  fistula  and  scrub  the  fistula  itself. 
Cauterize  the  fistulous  opening  with  the  thermocautery,  liquid  carbolic  acid,  or 
pure  formalin.  Close  the  opening  tightly  with  a  purse-string  suture  after 
packing  it  with  a  small  plug  of  gauze.  A  suture  is  inserted  in  the  skin,  and 
when  tied  prevents  soiling  of  the  neighborhood  by  intestinal  contents  (Fig. 
620,  L).     Once  more  cleanse  the  field  of  operation. 

Step  2. — Make  an  incision  through  the  parietes  at  a  point  above,  below,  or 
to  the  side  of  the  fistula,  and  open  the  abdominal  cavity.  In  choosing  where 
to  make  this  incision  endeavor  to  find  a  spot  close  to  the  fistula  where  the  tissues 
are  not  much  altered,  and  where  the  viscera  are  not  adherent  to  the  parietal 
peritoneum. 


Fig.  619. 


Fig.  620. 


KiG.  621. 


Figs.  619,  620  and  621. — Closure  of  ftecal  fistulas.     {Esmarch  and  Kowalzlg.) 

Step  3. — Introduce  the  finger  into  the  belly  and  explore  the  relations  of  the 
adherent  gut  to  the  abdominal  wall.  Guided  by  the  exploring  finger,  enlarge 
the  incision,  making  it  run  around  one  side  of  the  fistulous  opening  (Fig.  620, 
I,N). 

Step  4. — ^Retract  the  flap  formed  by  the  incision  I,  N.  This  exposes  the 
gut  and  its  connection  with  the  inner  surface  of  the  parietes  at  the  fistula  (Fig. 
621,  X,Y). 

Step  ^.—Method  A. — -If  the  connection  between  the  gut  and  the  parietes  is 
small  in  extent,  empty  the  gut  of  its  contents  by  stripping  it  with  the  fingers, 
and  keep  it  empty  by  suitable  clamps.  Protect  the  abdomen  with  pads; 
divide  the  union  between  the  gut  and  the  parietes;  close  the  hole  in  the  gut  by  a 
double  row  of  sutures,  as  is  done  in  enterotomy. 

Method  B. — If  the  connection  between  the  gut  and  the  parietes  when  sepa- 
rated leaves  such  a  defect  that  simple  closure  would  lead  to  stenosis,  either 
counteract  the  effect  of  the  stenosis  by  anastomosing  the  afferent  and  efferent 
loops  or  excise  the  injured  portion  of  gut  and  restore  the  continuity  of  the  gut 
as  is  done  after  any  enterectomy. 

Method  C. — If  the  union  between  the  gut  and  the  parietes  is  very  extensive, 
and  if  for  any  reason  the  above  methods  are  inapplicable, — e.g.,  presence  o 


rr^OSURE    F^CAL    FISTULA  463 

extensive  and  dense  adhesions,  or  the  inaccessible  location  of  the  fistula, — then 
the  operation  of  bilateral  exclusion  may  be  performed.  In  this  case  the  next 
step  in  the  operation,  after  the  exclusion  has  been  accomplished,  would  be 
closure  of  the  abdominal  wound  and  removal  of  the  purse-string  suture  around 
the  fistula,  as  that  opening  is  required  for  the  drainage  of  the  excluded  segment 
of  gut.  A  cure  of  the  fistula  may  be  expected,  but  only  after  a  lapse  of  much 
time.  The  method  by  " exclusion "  and  "segregation "  is  not  a  method  of  choice, 
but  of  necessity,  and  when  done,  removal  of  the  mucous  membrane  from  the 
segregated  gut,  if  possible,  is  an  advantage. 

Step  6. — The  continuity  of  the  gut  having  been  established,  excise  the  fistula 
and  as  much  of  the  surrounding  sclerosed  tissue  as  may  be  necessary  to  secure 
health}^  structures  for  suturing.  As  a  rule,  in  severe  cases,  the  whole  of  the 
flap  outlined  by  the  cut  I,  N,  Fig.  620,  will  require  removal,  and  sometimes 
even  more  tissue  must  be  sacrificed. 

Step  7. — Close  the  abdominal  wound,  preferably  without  drainage. 

The  operation  thus  described  will  generally  be  found  satisfactory.  Its  ex- 
tent is  rendered  necessary  from  the  fact  that  the  fistula  is  usually  surrounded 
by  much  scar  tissue  which,  unless  thoroughly  extirpated,  will  almost  surely 
lead  to  the  formation  of  a  post-operative  hernia.  In  a  few  cases  where  there  is 
not  much  deposit  of  scar  tissue  and  where  the  fistulous  track  is  short  and  leads 
directly  into  the  gut,  a  much  simpler  procedure  may  be  adopted. 

Step  I . — After  thorough  cleansing  of  the  fistula  and  the  whole  neighboring 
skin  make  an  incision  around  the  fistula  at  the  junction  of  the  skin  and  mucous 
membrane.  Through  this  incision  dissect  the  fistulous  track  free  from  its  sur- 
roundings until  the  gut  is  reached. 

Step  2. — The  fistulous  track  is  now  attached  to  the  gut  alone,  and  hangs  on 
it  very  much  as  the  vermiform  appendix  hangs  on  the  caecum  after  the  appen- 
dicular mesentery  is  divided.  Remove  the  fistulous  track  in  the  same  manner 
as  the  appendix  is  excised  and  treat  the  resulting  stump  similarly. 

Step  3. — Close  the  abdominal  wound  with  or  without  drainage. 

Instead  of  operating  as  above,  one  may  open  the  belly  in  the  middle  line, 
find  the  loops  of  gut  leading  to  and  from  the  artificial  anus,  and  make  an  anas- 
tomosis between  them,  subsequently  closing  the  fistula.  In  this  method  it  is 
much  easier  to  keep  the  peritoneum  from  being  soiled  than  in  the  preceding. 

When  it  becomes  desirable  to  close  the  artificial  anus  made  by  dividing 
completely  the  gut,  closing  and  dropping  its  lower  segment  into  the  belly,  and 
suturing  the  upper  segment  to  the  abdominal  wound,  the  operation  to  be  chosen 
is  one  done  on  the  following  lines: 

Empty  the  bowels  by  means  of  purgatives  or  enemata.  Administer  an 
opiate  shortly  before  operating  to  lock  up  the  bowels.  Pack  the  artificial  anus 
with  gauze  to  prevent  escape  of  contents  during  the  operation.  Open  the 
belly,  preferably  in  the  middle  line.  Find  the  lower  segment  of  gut.  Find  the 
loop  of  gut  which  is  attached  to  the  skin  and  forms  the  artificial  anus.  Make 
an  anastomosis  between  the  lower  segment  of  gut  and  loop  of  gut  above  that 
which  forms  the  artificial  anus.  Close  or  excise  the  artificial  anus  either  at  the 
same  sitting  or  subsequently.     Close  the  abdominal  wound. 


464 


VERMIFORM    APPENDIX    AND    PER'TONEUM 


Mummery  (Lor.  cil.)  gives  advice  very  similar  to  thai  ^ixcn  in  the  preced- 
ing paragraphs  l)ut  is  especially  insistent  on  the  following  ])rinciples.  (1) 
Open  the  abdomen  freely  to  one  side  of  and  well  away  from  the  fistula.  (2) 
Completely  free  the  gut  and  fistula  in  one  piece,  draw  them  out  of  the  abdomen 
and  thus  complete  the  operation  with  comparative  freedom  from  risk  of  peri- 
toneal contamination.  (3)  Cut  away  in- 
\()lve(l  bowel  until  unmistakably  healthy 
tissue  is  reached.  This  may  require 
complete  resection  of  a  segment  of  bowel 
or  as  is  more  common  may  require  closure 
of  a  large  wound  in  the  gut.  (4)  Large 
wounds  should  be  trimmed  as  in  Fig.  622 
so  that  their  edges  are  freely  nourished. 
The  cut  edges  which  are  going  to  be 
joined  should  form  roughly  an  angle  of 
45°  with  the  mesenteric  border.  (5)  Dur- 
ing the  days  following  operation  the  rectum  ought  to  be  kept  clear  by  means 
of  lavage  (do  not  inject  water  under  any  pressure)  and  the  bowels  kept  open 
by  giving  paraffin  oil  and  small  doses  of  salts. 


Fig.  622. 


CHAPTER   XXXV 


THE   VERMIFORM  APPENDIX  AND  PERITONEUM 
OPERATIVE  TREATMENT  OF  APPENDICITIS 

Appendicectomy. — As  different  methods  have  been  devised  for  carrying  out 
almost  every  step  of  appendicectomy,  it  may  be  convenient  to  describe  shortly 
a  number  of  these  methods  under  the  headings  Step  1,2,  etc. 

Step  I. — Opening  the  Abdomen. — (A)  McBiirney  Method  *— This  method  is 
especially  suitable  where  no  drainage  of  the  abdominal  cavity  is  required; 
drainage,  however,  may  be  effected  either  through  the  w^ound  itself  or  better, 
through  a  special  stab  wound  made  in  a  convenient  position.  Under  proper 
conditions  the  method  is  ideal.  The  principle  involved  is  avoidance  of  trans- 
verse division  of  muscles  or  tendinous  fibres,  so  that  w'hen  healing  has  taken 
place  there  is  no  post-operative  weakness  of  the  belly- wall. 

The  Operation. — Make  a  three-inch  incision  through  the  skin  and  subcu- 
taneous fat.  The  cut  begins  at  a  point  one  inch  above  a  line  joining  the  anterior 
superior  spine  of  the  ilium  and  the  umbilicus,  and  crosses  it  at  a  point  one  and 
one-half  inches  from  the  anterior  superior  spine.  The  incision  runs  downwards 
and  inwards  in  the  same  direction  as  the  fibres  of  the  external  oblique  muscle 
and  aponeurosis.  Separate  the  fibres  of  the  external  oblique  for  the  whole 
length  of  the  wound  without  cutting  any  of  them  transversely.     With  retrac- 

*L.  L.  McArthur  undoubtedly  devised  and  carried  out  this  muscle-splitting  operation 
in  about  thirty  cases  before  McBurney  did  so.  Unfortunately  he  failed  to  publish  his  method 
promptly  enough.  Needless  to  say  McBurney  was  not  acquainted  with  the  above  fact 
when  he  described  his  operation. 


INCISIONS  465 

tors  pull  apart  the  edges  of  the  wound  in  the  external  oblique  and  expose 
the  underlying  internal  oblique  and  transversalis  muscles,  whose  fibres  run 
approximately  at  right  angles  to  the  superficial  wound.  With  blunt  dissec- 
tion traverse  these  muscles  so  as  to  make  a  wound  in  them,  parallel  to  their 
fibres  and  at  right  angles  to  wound  in  the  external  oblique.  Blunt  retractors 
are  introduced  to  keep  this  wound  open  and  expose  the  fascia  transversalis, 
which  is  divided  in  the  same  direction  as  the  wound  of  the  internal  oblique. 
After  this  the  peritoneum  is  picked  up  in  forceps  and  opened.  Special  care 
has  to  be  taken  in  opening  the  peritoneum,  as  it  is  frequently  found  adherent 
to  the  CcTCum  or  other  abdominal  contents.  The  same  rules  apply  to  the 
opening  of  the  peritoneum  as  to  the  opening  of  the  sac  in  cases  of  hernia. 

Closure  of  the  Wound. — Separate  suture  of  the  peritoneum  and  of  the  trans- 
versalis fascia.  The  wound  in  the  internal  oblique  and  transversalis  muscles 
requires  but  one  or  two  points  of  suture.  Suture  of  the  external  oblique. 
Suture  of  the  skin.  Suture  material  varies  according  to  the  fancy  of  the  opera- 
tor.    The  author  prefers  catgut.  » 

If  the  appendix  is  long  and  extends  far  up  towards  the  liver  its  distal  end 
may  be  exposed  through  a  second  incision  entirely  similar  to  the  first  but  at  a 
higher  level.  Working  through  both  incisions  a  difficult  operation  may  be 
much  facilitated  and  no  greater  danger  of  post-operative  hernia  incurred. 

In  order  to  obtain  more  room  Weir,  after  splitting  the  fascia  of  the  external 
oblique,  separates  it  from  the  anterior  surface  of  the  rectus,  splits  the  internal 
oblique  and  transversalis  like  McBurney,  but  continues  the  split  or  incision 
transversely  through  the  anterior  layer  of  the  sheath  of  the  rectus,  retracts  the 
rectus  itself  towards  the  middle  line,  and  lastly  divides  the  posterior  layer  of 
the  rectus  sheath  along  with  the  peritoneum.  Closure  of  this  wound  presents 
no  special  difficulties.  Note  that  in  dividing  the  posterior  layer  of  rectus  sheath 
the  epigastric  vessels  ought  to  be  found  and  ligated  before  division.  In  Weir's 
operation  retraction  of  the  rectus  inwards  may  possibly  injure  or  tear  the  nerves; 
therefore  the  author  modifies  the  method  by  dividing  the  rectus  as  far  as  neces- 
sary after  suturing,  in  two  lines,  the  aponeurosis  covering  it  anteriorly  to  the 
muscle.  He  also  often  reverses  the  steps  of  the  operation,  beginning  by  trans- 
verse section  of  the  rectus  in  the  interspinous  line  and  afterwards,  if  necessary, 
enlarging  the  wound  outwards  and  upwards  in  the  gridiron  fashion. 

H.  A.  Shaw  (Northwest  Med.,  May,  191 6)  uses  the  gridiron  incision  in  acute 
appendicitis  but  centers  it  one  inch  lower  than  in  the  original  operation.  This 
gives  very  direct  access  to  the  appendix  and  avoids  the  danger  of  injuring  the 
twelfth  intercostal  nerve.  If  more  room  is  required  it  may  be  obtained  by 
employing  Harrington's  extension  which  is  sufficiently  explained  in  Figs.  623, 
624  and  625. 

(B)  G.  G.  Davis  Incision  ("Annals  of  Surg.,"  Jan.,  1906). — ^Locate  the  outer 
border  of  the  right  rectus  at  the  level  of  the  anterior  superior  spine.  Make 
a  transverse  incision  through  the  skin  i^^  inches  long,  having  the  edge  of  the 
rectus  as  its  mid-point  (Fig.  626).  Divide  the  aponeurosis  of  the  external 
oblique  obliquely  to  the  direction  of  its  fibres,  but  directly  in  the  line  of  the  skin 
wound.  Split,  do  not  cut,  the  internal  oblique  and  transversalis  muscles.  Open 
the  peritoneum.     Carry  the  cut  inwards  through  the  anterior  layer  of  the 

30 


466 


VERMIFORM    APPENDIX    AND    PERITONEUM 


sheath  of  the  rectus.     Retract  the  rectus  towards  the  middle  line.     Divide 
the  posterior  layer  of  rectus  sheath  along  with  the  peritoneum. 

If  more  room  is  required,  prolong  the  incision  outwards  towards  or  even  to 
the  anterior  superior  spine  and,  if  requisite,  inwards  through  the  rectus  sheath 
to  within  an  inch  of  the  median  line. 


Fig.  623. — (S/iaw.) 


Fig.  624. — (Shaw.) 


(C)  Rectus  Incision. — ^Locate  the  outer  border  of  the  right  rectus.  Begin- 
ning at  a  point  one  inch  above  a  line  joining  the  anterior  superior  spine  to  the 
umbilicus,  make  an  incision  downwards,  about  one-half  inch  internal  and 
parallel  to  the  edge  of  the  rectus.  The  incision,  2)-^  inches  in  length,  may  be 
increased  if  necessary.  Expose  and  split  the  anterior  layer  of  rectus  sheath. 
Split  the  rectus  muscle  or  retract  the  muscle  (Kammerer;  Lennander;  Battle; 


Fig.  625. — {Shaw 


Jaboulay)  inwards  to  expose  the  posterior  layer  of  sheath.  Divide  the  pos- 
terior layer  of  rectus  sheath  and  open  the  abdomen.  This  incision  is  good  in 
almost  all  cases  of  appendicitis  except  when  there  is  a  large  abscess  present 
and  located  more  or  less  externally.  The  wound  may  be  closed  in  layers  or 
by  through-and-through  sutures. 

CD)  Incision  through  the  linea  semilunaris  requires  no  special  description. 

(E)  Oblique  Incision. — ^Locate  the  outer  border  of  the  right  rectus  muscle. 
Beginning  at  a  point  one  inch  above  an  imaginary  line  joining  the  anterior 


INCISIONS 


467 


superior  iliac  spine  to  the  umbilicus,  make  an  incision  parallel  to,  and  about 
^4  of  an  inch  external  to,  the  edp;e  of  the  right  rectus  muscle.  This  cut  runs 
downwards  and  slightly  inwards  for  about  3  inches.  The  fibres  of  the  external 
oblique  and  its  aponeurosis  can  be  split  longitudinally  by  blunt  dissection; 
the  deeper  structures  are  divided  in  the  direction  of  the  wound.     The  usual 


..A 

-  C 
_  D 

-  C 


Fig.  626. — Davis'  incision. 

X.  Ant.  sup.  spine.     A.   Ext.  edge  rectus.     B.  Umbilicus.     C.   Fascia  of  external  oblique. 

D.  Exposed  rectus. 


care  must  be  exercised  in  opening  the  peritoneum.  A  good  practical  rule  to 
adopt  in  operating  is  as  follows:  Make  a  3-inch  incision  as  above  described 
down  to  the  external  oblique;  make  a  small  opening  through  the  remainder 
of  the  belly-wall;  introduce  the  forefinger  to  explore;  if  it  is  easy  to  complete 
the  removal  of  the  appendix  through  the  small  opening,  do  so;  if  not,  enlarge 
the  wound  to  the  necessary  extent.  The  size  of  the  skin-wound  is  of  little 
importance — the  smaller  the  wound  of  the  deep  structures  (of  the  essential 
belly- wall),  the  less  danger  will  there  be  of  hernia.     The  wound  must  be  large 


468 


VERMIFORM    APPENDIX    AND    PERITONEUM 


enough  to  permit  of  easy  access  to  the  field  of  work.  After  completing  the 
appendicectomy,  the  wound  may  be  closed  in  layers  or  by  one  layer  oi  sutures 
traversing  the  whole  thickness  of  the  belly-wall. 

(F)  Inferior  or  External  Incision. — From  a  point  about  two  finger-breadths 
internal  to  the  right  anterior  superior  iliac  spine  and  one  inch  above  the  line 
joining  the  umbilicus  and  the  iliac  spinous  process  make  a  3-inch  incision 
crossing  the  above  line  at  right  angles.  Having  made  the  skin-incision,  follow 
the  rules  laid  down  for  Method  E. 

(G)  Through  one  of  the  previous  incisions  an  abscess  has  been  found  but 
not  opened.     This  abscess  lies  posteriorly  and  ought  to  be  evacuated  through 

the  loin,  i.e.,  extraperitoneally.  Guided  by  the 
finger  in  the  belly  make  an  incision  directly 
over  or,  better,  to  the  outer  side  of  the  abscess. 
After  incising  the  parietes,  but  before  opening 
into  the  abscess,  close  the  exploratory  wound, 
penetrate  the  abscess  cavity,  cleanse  and  drain 
it.  In  the  same  manner  when' large  abscesses 
have  been  opened  through  the  primary  incision, 
one  or  more  counter  openings  may  be  made  to 
secure  efficient  drainage. 

(H)  In  exceptional  cases  the  primary  open- 
ing may  be  made  wherever  the  abscess  tumor 
indicates,  e.g.,  the  writer  has  opened  an  appendi- 
cial  abscess  in  the  left  iliac  region. 

Step  2. — Search  for  and  isolation  of  the  ap- 
pendix. 

(a)  Digital  exploration.  The  forefinger  or, 
if  necessary,  two  fingers  are  introduced  into  the 
belly  and  the  ascending  colon  is  recognized.  The  finger  follows  the  colon  to 
the  end  of  the  caecum  and  is  systematically  moved  about  its  blind  extremity, 
separating  gently  any  adhesions  which  may  be  present  and  which  interfere 
with  the  search.  If  the  adhesions  are  firm  or  resist  the  gentle  manipulations 
advised,  then  the  next  method  to  be  described  must  be  employed.  The 
appendix  may  lie  in  any  position  near  the  end  of  the  caecum  and  may  be  either 
curled  up  on  itself  or  extended.  Having  found  the  appendix,  gently  separate 
it  from  its  surroundings  and  deliver  it  through  the  wound.  The  mesentery 
of  the  appendix  is  transfixed  close  to  the  appendix  and  colon,  a  ligature 
drawn  through,  the  mesentery  ligated  and  divided  (Fig.  627).  If  the  mesen- 
tery is  voluminous,  it  may  be  necessary  to  apply  two  interlocked  liga- 
tures. When  the  meson  is  voluminous  enough,  Shaw's  suture  ligature  gives 
perfect  hemostasis  and  peritonealization.  Fig.  628'  shows  how  the  suture  is  in- 
serted while  Fig.  628^  shows  how  the  cut  edge  of  the  meson  is  folded  over  when 
the  two  ends  of  the  suture  are  pulled  upon.  When  the  suture  is  tied  the  meson 
is  bunched  together  in  pleats  and  hemostasis  is  assured.  The  digital  explora- 
tion may  be  accomplished  as  follows:  Pass  the  finger  along  the  outer  surface 
of  the  colon  over  the  brim  of  the  pelvis  into  the  true  pelvis.  Feel  for  the  pul- 
sating iliac  artery.     Slip  the  finger  upwards  on  the  surface  of  the  artery  and 


Fig.  627. — Ligation  mesoappendix. 


ISOLATION    OF    APPENDIX 


469 


bring  the  finger  out  of  the  true  pelvis.  If  the  finger  is  slightly  hooked  while 
being  brought  out  of  the  pelvis  it  will  bring  up  a  loop  of  small  intestine.  This 
loop  of  small  intestine  is  the  ileum  close  to  the  caecum  and  is  within  an  inch  of 
the  base  of  the  vermiform  appendix.  The  treatment  of  the  appendix  itself 
belongs  to  Step  3. 

(b)  If  it  proves  difficult  to  find  and  isolate  the  appendix  by  Method  a, 
the  wound  must  be  enlarged  so  that  the  eye  may  aid  in  the  exploration.  First 
recognize  the  ascending  colon.  This  is  easily  done  by  noting  its  longitudinal 
muscular  bands.  Follow  the  anterior  muscular  band  downwards;  it  leads 
directly  to  the  base  of  the  appendix.*  The  isolation  of  the  appendix  may 
be  accomplished  in  two  ways:  If  one  readily  finds  its  distal  end,  one  begins 
isolating  there  and  works  towards  the  base.     Any  rigid  adhesions  should  be 


Fig.  628. — {After  ^haw.) 


ligated  with  fine  silk  or  catgut  and  divided.  If  adhesions  to  intestines  are 
firm  and  short,  one  must  remember  a  cardinal  rule  in  abdominal  surgery,  viz., 
sacrifice  part  of  what  is  being  removed  if  non-malignant,  rather  than  injure 
the  viscus.  If  necessary,  a  thin  layer  of  the  appendicular  wall  (never  con- 
taining mucosa)  may  be  left  attached  to  a  gut  so  as  to  avoid  laceration  of 
the  gut-wall.  If  it  is  difficult  to  find  the  distal  extremity  of  the  appendix, 
isolation  may  be  begun  at  its  base.  When  the  base  of  the  appendix  is  isolated, 
dissection  may  be  much  facilitated  by  passing  a  ligature  through  the  mesen- 
teriolum  (this  ligature  may  be  later  used  to  ligate  the  organ  or  its  meson). 
Traction  on  the  ligature  brings  the  base  of  the  appendix  into  the  wound  (Lili- 
enthal.  Am.  J.  Surg.,  Ap.  1908).  If  there  are  many  adhesions,  after  traction  and 
dissection  have  exposed  more  of  the  appendix,  another  traction  ligature  may 

*Kolliker  remarks  that  if  the  appendix  is  much  adherent  it  drags  upon  the  longitudinal 
band  and  as  a  consequence  if  the  appendix  is  retrocaecal  the  drag  makes  the  band  curve  with 
its  convexity  towards  the  middle  line;  if  the  appendix  is  median  or  if  it  lies  in  the  pelvis  the 
band  is  curved  with  its  convexity  external.  Occasionally  anatomic  anomalies  puzzle  the 
operator.  They  must  be  borne  in  mind.  When  the  caecum  cannot  be  found  in  the  right 
iliac  fossa,  pickup  the  omentum  and  use  it  as  a  guide  to  the  transverse  colon;  this  little  "dodge" 
has  been  useful  to  the  author.  Transposition  of  viscera  is  a  condition  which  must  be 
remembered. 


47°  VERMIFORM    APPENDIX    AND    PERITONEUM 

be  passed  through  the  mesenteriolum  further  along.  This  little  '"dodge"  is 
of  great  aid  and  lessens  handling  of  neighboring  viscera.  It  is  occasionally 
necessary  to  divide  the  appendix  at  its  base  before  it  can  be  removed.  If  this 
is  necessary,  one  applies  a  clamp  to  or  ties  a  ligature  around  the  organ  distal 
to  the  point  of  section  and  cauterizes  the  cut  surface.  This  prevents  contamina- 
tion by  the  appendi.x  while  being  isolated  and  while  its  caecal  extremity  or  stump 
is  being  treated.  Under  such  circumstances  Step  3  is  proceeded  with  before  the 
appendix  itself  is  removed. 

Not  infrequently  the  longitudinal  muscular  band  of  the  colon  passes  over  the 
end  of  the  cascum  and  disappears  at  the  reflection  of  the  caecal  peritoneum  to  the 
parietes,  and  no  appendix  is  visible.  In  such  a  case  the  appendix  is  retroperito- 
neal and  retrocascal.  It  may  be  discovered  as  follows:  Pull  the  caecum  towards 
the  middle  line.  Incise  the  parietal  peritoneum  immediately  external  and 
parallel  to  the  caecum.  Introduce  the  finger  into  the  newly  made  peritoneal 
wound  and  insinuate  it  behind  the  caecum  so  as  to  mobilize  that  gut,  raising 
it  from  its  bed.  This  exposes  the  appendix  which  must  be  shelled  out  of  its 
lair.  It  has  no  meson  in  this  situation.  Attend  to  the  stump  as  in  Step  3, 
Method  A. 

Remarks. — For  some  years  it  was  the  ambition  of  many  surgeons  to  remove 
the  appendix  through  an  extremely  small  incision,  but  recognition  of  the  fact 
that  many  other  conditions  may  symptomatically  resemble  appendicitis  calls 
for  thorough  abdominal  exploration  through  a  reasonably  large  cut.  Healthy 
appendices  have  been  on  innumerable  occasions  called  "clubbed"  and  accused 
of  crimes  of  which  they  were  entirely  innocent.  It  is  true  that  their  removal 
often  accidentally  relieved  the  conditions  causing  the  symptoms,  but  often  failure 
resulted  when  larger  exposure  would  have  demonstrated  the  real  disturber  of 
the  abdominal  peace. 

Step  3. — Treatment  of  the  stump. 

Method  A . — Tie  a  ligature  tightly  around  the  appendix  close  to  the  caecum. 
Before  ligating  it  is  best  to  crush  the  base  of  the  appendix  with  a  strong  clamp 
and  then  to  place  the  ligature  in  the  groove  left  by  the  clamp.  Cut  away 
the  appendix  about  one-fourth  of  an  inch  beyond  the  ligature.  Thoroughly 
cauterize  the  lumen  of  the  stump  with  liquid  carbolic  acid.  Wipe  away  the 
carbolic  acid  with  alcohol.  This  method  is  simple  and  gives  excellent  results. 
The  main  objection  to  the  above  is  that  the  ligature  may  possibly  be  applied 
beyond  a  stricture  of  the  appendix,  and  so  there  may  be  recurrence  of  the 
disease  in  the  stump. 

Method  B  avoids  the  disadvantage  pertaining  to  the  preceding  method 
(McBurney).  The  appendix  is  divided  one-fourth  inch  from  the  colon,  the 
edges  of  the  stump  are  seized  with  forceps,  a  probe  is  passed  through  its  lumen 
into  the  colon,  its  mucous  membrane  is  destroyed  by  the  application  either  of 
liquid  carbolic  acid  or  the  fine  point  of  a  cautery.  Only  after  the  mucous 
membrane  is  destroyed  does  one  apply  a  ligature  around  the  stump  close  to 
the  colon.  This  is  a  thoroughly  reliable  and  simple  method.  To  eliminate 
the  raw  surfaces  left  by  this  method  George  Gray  sutures  the  stump  of  the  meso- 
appendix  to  that  of  the  appendix  itself  (Fig.  629). 


TREATMENT    OF    STUMP 


471 


Method  C. — At  a  point  about  one-fourth  of  an  inch  from  the  colon  a  cir- 
cular incision  is  made  through  the  serous  coat  of  the  appendix,  leaving  the 
muscular  and  mucous  coats  intact.  The  serous  coat  is  separated  from 
the  muscular  up  to  the  colon.  Close  to  the  colon  a  ligature  is  tied  around  the 
tube,  composed  of  muscularis  and  mucosa,  and  the  appendix  removed.  The 
serous  cuflf  is  brought  forwards  over  the  stump  and  there  sutured  (Figs.  630, 
631,  632).     The  method  is  safe,  but  cumbrous  and  unnecessary. 


3tump  of  meson 
Stump  01"  Appendix. 


Fig 


Gray's  treatment  of  stump. 


Fig.  631.  Fig.  632. 

Figs.  630,  631  and  632. — Cuff  method  of  treating  stump. 


Fig.  633. — Dawbarn's  method. 


Fig.  634. — Fabrique's  method. 


Method  D. — Cut  away  the  appendix  flush  with  the  colon  and  treat  the 
defect  as  a  perforation  of  the  gut — i.e.,  sew  up  the  hole  that  is  left  in  the  colon 
by  a  row  of  through-and-through  sutures  covered  by  a  series  of  continuous 
Lembert  sutures. 

Method  E. — Dawbarn  applies  a  purse-string  suture  of  fine  silk  or  hemp 
through  the  serous  and  muscular  coats  of  the  colon  around  the  base  of  the 


472 


VERMIFORM    APPENDIX    AND    PERITONEUM 


appendix  and  about  one-half  inch  distant  from  it  (Fig.  633);  cuts  off  the 
appendix;  leaving  a  stump  one-half  inch  in  length;  dilates  the  lumen  of  the 
stump;  crushes  the  stump  with  a  heavy  forceps  and  the  invaginates  the 
stump  into  the  colon,  at  the  same  time  tightening  and  tying  the  purse-string 
suture. 

To  facilitate  insertion  Dawbarn  suggests  picking  up  a  loop  of  the  purse- 
string  at  B  (Fig.  633);  when  this  loop  and  the  free  ends  of  the  thread  are  lifted 
up,  inversion  becomes  easy. 

Fig.  634  shows  a  better  method  of  using  the  purse-string  suture  (Fabrique's 
method).  The  ends  of  the  suture  being  on  opposite  sides  of  the  wound  per- 
mit better  closure  of  the  wound.  Most  surgeons  ligate  the  base  of  the  appen- 
dix before  burying  it  as  a  number  of  cases  of  serious  or  even  fatal  hemorrhage 
into  the  intestine  from  the  stump  have  been  reported. 

Method  F. — This  is  a  useful  variant  of  Dawbarn's  method.  Introduce  a 
purse-string  suture  as  in  Method  E.  Clamp  the  base  of  the  appendix  very 
firmly  with  a  strong  clamp.     Cut  away  the  appendix  flush  with  the  clamp 

and  wipe  the  cut  surface  clean.  Remove  the 
clamp  which  has  thoroughly  crushed  the  in- 
cluded tissues.  With  a  dissecting  forceps  grasp 
the  stump  and  push  it  into  the  caecum.  Pull 
the  purse-string  suture  tight  and  tie.  The 
needle  still  remains  attached  to  the  purse- 
string  suture;  with  it  unite  the  stump  of  the 
mesoappendix  of  the  caecum  at  the  point  of 
invagination  of  the  remnant  of  the  appendix 
(Fig.  635). 

Method  G. — With  forceps  crush  the  base  of 
the  appendix.  Apply  a  fine  ligature  to  the 
groove  made  by  the  crushing  forceps.  Remove  the  appendix.  Bury  the 
stump  by  means  of  Gould's  mattress  suture. 

Step  4. — If  there  has  been  no  infection  outside  the  appendix,  sponge  the 
field  of  operation  with  moist  pads  and  close  the  wound  without  drainage. 

The  operation  of  appendicectomy  by  any  of  the  methods  described  in  the 
preceding  paragraphs  is  suitable  particularly  in  cases  of  chronic  or  recurrent 
disease  and  in  those  acute  cases  subjected  to  early  operation  before  perfora- 
tion, or  before  periappendicular  suppuration  has  developed.  Although  when 
the  abdomen  is  opened  there  is  no  expectation  that  pus  will  be  met,  yet  the 
peritoneal  cavity  must  always  be  protected  by  gauze  pads  while  the  appen- 
dix is  being  delivered  and  removed.  The  young  operator  is  very  apt  to  be 
afraid  to  boldly  pull  the  caecum  (when  it  is  not  bound  down  by  adhesions) 
out  of  the  abdomen  while  he  operates  upon  the  appendix.  It  does  no  harm  to 
pull  out  the  caecum  where  this  is  possible,  but  facilitates  the  work  and  renders 
it  safer,  besides  avoiding  a  great  deal  of  unnecessary  trauma  to  neighboring 
intestines  which  gives  rise  to  much  post-operative  pain.  The  whole  operation 
of  appendicectomy  ought,  if  possible,  to  be  carried  out  external  to  the  belly 
cavitv. 


Fig.  63: 


APPENDICEAL   ABSCESS  473 

Operation  in  Acute  Suppurative  Appendicitis  without  Large  Abscess. — 

The  operation  is  very  similar  lo  tlial  for  recurrent  disease. 

Step  I. — Incision  C,  D,  E  (page  466). 

Step  2. — Method  B  (page  469)  is  advisable,  as  the  aid  of  the  eye  is  most 
valuable.  During  the  manipulations  necessary  for  the  discovery  and  isola- 
tion of  the  appendix,  the  general  peritoneal  cavity  must  be  protected  by  pads 
of  gauze  placed  inside  the  belly-walls,  around  the  field  of  operation,  unless 
the  introduction  of  the  pads  would  spread  the  infection  which  is  already  pres- 
ent. With  the  same  object,  to  wit,  peritoneal  protection,  it  is  wise  to  avoid  the 
separation  of  any  adhesions  which  might  give  protection  and  yet  do  not  inter- 
fere with  access  to  the  appendix.  While  isolating  the  appendix  and  breaking 
down  adhesions  larger  or  smaller  pockets  of  pus  may  be  encountered.  The 
contents  of  such  must  be  carefully  removed  by  sponging  before  further  progress 
is  attempted.  The  appendix,  having  been  recognized  and  isolated,  is  found 
to  be  acutely  inflamed,  generally  rigid,  often  rotten,  and  sometimes  perforated 
or  gangrenous.  It  must  be  removed.  Its  stump  must  be  treated  either  by 
Methods  A  or  B  or  by  Method  D  (page  471).  Method  D  is  chosen  if  the 
stump  is  too  soft  and  friable  to  hold  a  ligature.  The  appendix  being  out  of 
the  way,  a  gentle  search  is  made  for  other  pockets  of  pus;  if  such  are  found, 
they  are  treated  as  already  described.  If  the  appendix  is  retro-caecal  it  may  be 
reached  as  described  in  Step  2.  Remember  that  retro-caecal  pus  is  liable  to 
burrow  upwards  behind  the  colon  and  liver  as  well  as  towards  the  pelvis,  and 
that  it  is  often  best  drained  by  a  tube  passed  through  a  stab  wound  at  the  outer 
margin  of  the  lumbar  mass  of  muscles.  The  whole  field  of  operation  is  most 
carefully  cleansed  with  sponges  soaked  in  normal  salt  solution.  The  protect- 
ive pads  surrounding  the  field  of  work  are  removed  and  a  split  rubber  tube 
or  a  cigarette  drain  is  passed  down  to  the  bottom  of  the  abscess  cavity.  The 
drain  may  be  brought  out  through  a  stab  wound  and  the  original  wound  closed 
completely.  Occasionally  instead  of  using  tubular  or  cigarette  drains  the  whole 
infected  area  may  be  loosely  filled  with  strips  of  plain  or  iodoform  gauze  the 
ends  of  which  come  out  at  the  wound.  As  much  of  the  abdominal  wound 
as  is  not  required  to  provide  for  drainage  and  future  access  to  the  field  of  con- 
tamination is  sutured  with  silkworm-gut.  Very  abundant  aseptic  dressings  are 
applied.  The  outer  dressings  will  generally  be  found  soaked  with  discharge 
within  twelve  hours  and  must  then  be  changed. 

Operation  in  Appendicitis  with  Large  Localized  Abscess. — Access  to  the 
abscess  is  usually  obtained  by  Method  F,  G  or  H  (page  468).  The  external 
incision  is  especially  good  because  the  pus  must  generally  be  sought  to  the 
outer  side  of  the  caecum.  When  cutting  through  the  parietes,  oedema  of  the 
tissues  may  be  noticed.  If  any  part  of  the  wound  shows  more  evidence  of 
oedema  than  another,  one  may  be  sure  that  pus  is  not  far  distant,  and  that 
the  oedematous  tissues  will  act  as  a  guide  to  it.  When  the  abscess  is  reached 
it  must  be  opened  with  great  care.  For  this  purpose  blunt  dissection  or  scratch- 
ing with  a  director  is  safe.  The  danger  of  opening  some  adherent  intestine 
must  not  be  forgotten.  A  small  opening  having  been  made  into  the  abscess, 
it  is  enlarged  by  blunt  force.     Enlarging  the  opening  into  the  abscess  by  means 


474  VERMIFORM    APPENDIX    AND    PERITONEUM 

of  cutting  with  scissors  or  knife  is  improper  if  it  can  be  avoided.  Many  care- 
ful surgeons  end  the  operation  at  this  stage,  contenting  themselves  with  the 
introduction  of  a  drainage-tube  and  perhaps  some  gauze  packing.  They  apply 
generous  dressings  which  are  soon  soaked  with  discharge  and  must  be  changed. 
The  practice  is  safe.  Other  surgeons  explore  the  abscess  cavity  with  the  fin- 
ger so  as  to  remove  any  faecal  concretions  or  find  the  appendix.  Often  the 
appendix  has  sloughed  and  lies  free  in  the  pus.  Great  care  must  be  taken  to 
avoid  breaking  down  any  protecting  adhesions,  otherwise  the  general  peritoneum 
may  become  infected.  If  the  appendix  is  found  attached  to  the  caecum  and 
can  be  isolated  without  too  great  danger,  it  should  be  removed  and  its  stump 
treated  as  already  described.  If  it  cannot  be  found  without  prolonged  search, 
or  if  its  isolation  would  endanger  the  integrity  of  the  wall  of  adhesions  pro- 
tecting the  peritoneal  cavity,  most  surgeons  let  it  alone.  A  few  operators 
insist  that  the  appendix  should  always  be  removed,  but  to  the  writer  this 
appears  an  eminently  unsafe  doctrine.  The  abscess  cavity  is  gently  but  thor- 
oughly wiped  with  gauze  moistened  in  warm  salt  solution,  and  loosely  packed 
with  iodoform  gauze,  which  may  surround  a  rubber  drainage-tube.  Fre- 
quently a  sponge  stick  may  be  passed  from  the  abscess  into  the  true  pelvis, 
where  another  pocket  of  pus  may  be  found.  Remember  that  infection  may 
pass  up  the  ascending  colon  and  give  rise  to  subhepatic,  subphrenic,  or  even 
pleural  suppuration.  Abundant  external  dressings  are  applied.  The  after- 
treatment  is  the  same  as  that  required  for  any  other  abscess.  To  the  inexperi- 
enced it  is  astonishing  at  times  to  see  the  amount  of  pus  obtained  in  such  cases 
when  there  has  been,  as  is  commonly  the  case,  no  fluctuation  and  the  tumor  has 
been  small.  Cases  such  as  have  been  described  very  frequently  heal  slowly, 
and  most  stubborn  sinuses  may  persist  and  require  subsequent  operation. 
When  healing  takes  place,  the  scars  are  not  very  resistant  to  pressure,  hence 
post-operative  herniae  are  not  uncommon. 

If  the  appendix  has  not  been  removed  when  the  abscess  was  opened,  it 
ought  to  be  sought  and  extirpated  after  recovery  has  been  obtained.  This 
secondary  operation  gives  an  opportunity  to  repair  any  hernia  which  may  be 
present.  It  has  been  stated  dogmatically  that  the  appendix  is  absolutely  de- 
stroyed in  the  vast  majority  of  cases  in  which  abscess  has  formed.  Morison, 
however,  finds  that  in  90  per  cent,  of  instances  the  appendix  is  not  destroyed 
but  soon  recovers  after  its  contents  have  been  discharged  by  sloughing  or 
perforation. 

The  foregoing  description  of  operation  when  large  abscess  is  present  pre- 
supposes the  possibility  of  gaining  access  to  the  abscess  without  opening  the 
peritoneal  cavity.  Frequently  an  abscess  forms,  is  surrounded  by  adherent 
intestines,  omentum,  and  a  great  mass  of  exudate,  but  is  at  no  point  adherent 
to  the  anterior  parietes.  To  gain  access  to  the  tumor  it  is  necessary  to  open 
the  peritoneal  cavity  and  the  pus  must  be  evacuated  by  the  transperitoneal 
route.  In  such  cases  the  abdomen  is  opened  directly  over  the  tumor;  the  re- 
lations of  the  tumor  are  discovered  b}^  the  finger  used  with  the  utmost  delicacy; 
the  peritoneal  cavity  is  most  carefully  and  thoroughly  protected  by  pads  of 
gauze;  a  line  of  cleavage  is  found  in  the  tumor  and  the  finger  is  made  to  enter 
the  abscess  cavity.     The  opening  into  the  abscess  should  not  be  made  large 


PERITONITIS  475 

at  first  or  the  whole  wound  and  packing  will  be  flooded  by  pus.  It  is  desirable 
that  the  pus  escape  so  slowly  that  it  can  be  wiped  away  at  once  with  gauze. 
After  most  of  the  pus  has  been  removed,  the  opening  into  the  abscess  may  be 
enlarged  and  the  interior  cleaned  as  well  as  possible  with  moist  gauze.  If 
the  appendix  is  easily  found,  it  should  be  removed.  Now,  the  abscess  may  be 
drained  by  a  tube  or  loose  gauze  packing. 

Operation  for  General  Peritonitis  Secondary  to  Appendicitis. — The  object 
of  operation  is  to  prevent  further  leakage  of  septic  material  into  the  perito- 
neum, to  remove  as  much  as  possible  of  the  septic  material  already  present, 
and  to  provide  for  drainage.  The  patients  are  suffering  not  merely  from  in- 
flammation but  from  shock  and  intense  intoxication. 

The  Operation. — -Make  a  large  incision  in  the  right  inguinal  region  over  the 
seat  of  the  appendix.  Remove  the  appendix.  Frequently  the  inflammation 
has  been  so  acute  that  no  adhesions  are  present;  if  there  are  any,  they  should  be 
broken  down  to  permit  of  more  thorough  flushing.  With  wet  sponges  mop  away 
all  foreign  material,  such  as  faecal  concretions,  etc.,  which  may  be  found  in 
the  peritoneal  cavity.  Systematically  douche  the  peritoneum  with  a  large 
stream  of  hot  normal  salt  solution.  The  solution  should  be  of  such  a  heat  that 
the  hand  can  be  kept  immersed  in  it  without  discomfort  (ii8°  F.).  The  solu- 
tion may  be  poured  from  a  pitcher,  but  it  is  better  to  conduct  it  by  means  of 
large  tubing  to  the  furthest  recesses  of  the  abdomen,  so  that  the  flow  of  con- 
taminated solution  may  be  outwards.  When  the  solution  returns  clean,  the 
abdominal  subcavities — e.g.,  Douglas's  cul-de-sac  and  the  subrenal  cavities — 
are  to  be  gently  mopped  dry  with  gauze  pads.  Drainage  is  provided  for  by 
glass  or  rubber  tubes  leading  to  Douglas's  pouch.  Abundant  aseptic  dressings 
must  be  applied.  The  external  dressings  will  be  found  soaked  with  discharge 
in  a  few  hours  and  must  be  changed.  If  a  glass  tube  has  been  used,  it  must  be 
aspirated  at  intervals  of  a  few  hours  and  removed  generally  in  thirty-six  to 
forty-eight  hours. 

Joseph  A.  Blake  ("Transactions  Am.  Surg.  Association,"  1903)  advocates 
early  operation;  lavage  of  the  peritoneum  with  large  quantities  of  saline  solu- 
tion; closure  of  the  peritoneal  cavity  without  drainage,  unless  the  latter  is  abso- 
lutely indicated  by  the  presence  of  non-absorbable  amounts  of  necrotic  material. 
Blake's  published  results  are  remarkably  good. 

One  of  the  gravest  dangers  in  generalized  peritonitis  is  the  absorption  of 
toxins  into  the  circulation.  The  peritoneum  of  the  upper  part  of  the  abdo- 
men has  greater  absorbing  power  than  that  of  the  lower,  hence  to  let  gravity 
aid  in  drainage  and  to  hinder  absorption  as  much  as  possible.  Fowler  recom- 
mends that  patients  be  kept  in  an  inclined  position,  the  upper  end  of  the  bed 
being  raised.  The  principle  of  this  is  admirable  and  good  results  have  followed 
its  use  by  most  surgeons. 

A  method  of  operating  followed  by  some  surgeons  in  cases  of  early  general- 
ized peritonitif  is  to  open  the  abdomen  in  or  near  the  middle  line.  Guided  by 
the  hand  inside  the  abdomen  it  is  easy  to  make  an  opening  about  i}-^  inches  in 
length  in  each  inguinal  region  and  through  these  insert  split  rubber  tubes  con- 
taining strands  of  iodoform  gauze.  Rapidly  cleanse  the  abdomen  with  salt 
solution  and  close  the  median  wound.     Return  the  patient  to  bed  and  keep  him 


476  VERMIFORM    APPENDIX    AND    PERITONEUM 

propped  by  bed-rest  and  pillows  in  a  greatly  exaggerated  Fowler  position.     The 
results  obtained  are  said  to  be  excellent. 

Le  Conte  ("Annals  of  Surg.,"  February,  1906),  struck  by  the  superiority 
of  the  results  obtained  by  Murphy  over  those  in  his  own  very  efficient  hands,  has 
adopted  practically  in  toto  the  methods  of  the  Chicago  surgeon  when  dealing 
with  diffuse  septic  peritonitis.     The  essentials  of  the  technic  are: 

1.  Rapid  elimination  of  the  cause  of  the  peritonitis  (gangrenous  appendix, 
rupture  of  gut,  rupture  of  pus  tube,  etc.).  This  with  the  least  possible  handling 
of  the  viscera. 

2.  Tubular  drainage  of  the  lowest  portion  of  pelvis  through  a  suprapubic 
opening  and  free  drainage  through  the  operative  incision. 

3.  Elimination  of  all  time-consuming  procedures  at  the  time  of  operating. 
Do  not  attempt  to  clean  the  peritoneum  by  mopping  or  flushing. 

4.  Fowler's  position  after  operation. 

5.  Absorption  of  large  quantities  of  salt  solution  through  the  rectum. 
This  reverses  the  current  in  the  lymphatics  of  the  peritoneum,  making  the  sur- 
face of  that  membrane  a  secreting  instead  of  an  absorbing  one  and  this  also 


Fig.  636. — Murphy's  nozzle. 

increases  the  secretion  of  urine.  Method  of  introducing  the  water  into  the 
rectum:  Insert  a  nozzle  containing  three  or  Jour  openings,  into  the  anus.  Attach 
tubing  of  fountain  syringe  to  nozzle.  Fill  bag  of  syringe  with  water  and  ele- 
vate it  a  few  inches  above  plane  of  rectum,  in  fact  only  high  enough  to  let  the 
water  slowly  trickle  into  the  rectum  at  the  rate  of  about  one  pint  per  hour. 
Do  not  permit  fluid  to  accumulate  in  the  bowel,  just  introduce  the  water  at  the 
rate  at  which  it  is  absorbed.  Do  not  in  any  way  interfere  with  the  caliber  of 
the  tubing  (this  should  be  fairly  large).  It  is  very  important  that  there  should 
be  a  free  exchange  of  fluid  between  the  gut  and  the  water  reservoir.  The  level 
of  the  water  in  the  reservoir  should  only  be  high  enough  so  that  the  water  in  the 
rectum  merely  covers  the  end  of  the  anal  tube.  If  the  intrarectal  pressure  in- 
creases (due  to  gas,  etc.)  the  water  in  the  rectum  is  pressed  back  into  the  reser- 
voir, the  gas,  etc.,  escapes,  and  as  soon  as  the  pressure  is  relieved  the  water 
flows  back  into  the  rectum.  Much  ingenuity  has  been  expended  in  devising 
means  to  regulate  the  flow  of  water  into  the  rectum  and  to  utterly  spoil  the 
simplicity  and  value  of  the  Murphy  method. 


PERITONITIS  477 

6.  Prevent  peristalsis  by  withholding  all  food  or  liquids  by  the  mouth. 
Opium  is  objectionable  but  may  be  required. 

Most  surgeons  who  have  themselves  undergone  an  abdominal  operatio  are 
liberal  in  their  interpretation  of  the  indications  for  giving  opiates.  Their 
personal  experience  with  its  humanitarian  result  is  supported  by  Crile's  obser- 
vation on  the  valuable  effect  of  Morphine  in  sepsis. 

H.  F.  Waterhouse  (Lancet,  Feb.  5,  191 5),  in  acute  peritonitis  of  almost 
any  origin,  advocates  the  local  use  of  ether.  (In  this  he  follows  Morestin). 
After  opening  the  abdomen  and  treating  the  initial  lesion,  pass  a  rubber  drain 
into  the  pelvis.  This  drain  must  have  two  lateral  openings  near  its  pelvic 
end.  Close  the  wound  snugly  around  the  drain.  Through  a  funnel  pour  2 
to  3  oz.  of  ether  into  the  abdomen  by  means  of  the  tube.  Clamp  the 
outer  end  of  the  tube.  After  about  3  hours  the  clamp  may  be  removed. 
Out  of  59  cases  of  peritonitis  treated  as  above  there  were  but  two  deaths. 
In  all  cases  of  appendicitis  (24)  the  pulse  rate  was  above  100;  in  several 
it  was  120-140;  many  of  them  were  examples  of  perforated  or  gangrenous 
appendicitis. 

Johnson  in  1906  (Crisler  and  Johnson,  Southern  Med.  J.,  March,  1913) 
began  treating  acute  peritonitis  by  pouring  into  the  abdomen,  an  alcoholic 
solution  of  iodine  (23'^  to  3  per  cent.).  Usually  a  quart  of  the  solution  is  used — 
sometimes  a  gallon.  The  amount  does  not  matter  so  long  as  it  penetrates  every 
infected  part  of  the  abdomen.  The  result  reported  by  Crisler  and  Johnson 
are  remarkably  good.  Fort  (Am.  Journ.  of  Surg.,  Feb.,  1915)  strongly  indorses 
the  iodine  treatment. 

When  ought  one  to  advise  operation  in  appendicitis? 

Many  surgeons  answer  the  above  question  in  a  most  simple  manner  by 
saying,  "When  appendicitis  is  diagnosed  then  is  the  time  to  operate."  Most 
surgeons  are  less  radical.  All  surgeons  approve  of  operating  in  the  interval 
between  attacks  of  chronic  or  relapsing  appendicitis.  In  acute  appendicitis 
all  surgeons  approve  of  operating  while  it  is  reasonable  to  suppose  that  the 
infection  is  confined  within  the  appendix  itself — i.e.,  within  thirty-six  or  even 
forty-eight  hours  of  the  beginning  of  the  attack,  but  the  earlier  the  better.  All 
are  agreed  on  the  necessity  of  evacuating  abscesses  when  symptoms  of  absorp- 
tion are  grave  or  increasing.  In  all  other  cases  marked  differences  of  opinion 
exist.  The  author's  personal  views  are  as  follows,  and  are  those  common  to 
many  other  operators. 

1.  If  possible,  operate  within  forty-eight  hours  of  the  inception  of  the  dis- 
ease. Within  twenty-four  hours  is  better  than  forty-eight,  and  within  twelve 
hours  is  better  than  twenty-four.     The  earlier  the  better. 

2.  After  the  lapse  of  forty-eight  hours  it  is  safer  to  adopt  Ochsner's  plan  of 
non-operative  treatment.  (Ochsner,  "Clinical  Surgery.")  This  consists  in 
— (a)  Rest  in  bed.  {b)  Avoidance  of  purgatives,  (c)  Absolute  denial  of  food 
and  drink  to  the  stomach,  {d)  If  nausea  or  pain  is  present,  lavage  of  the  stom- 
ach. To  nervous  patients  give  morph.  gr.  J-^  hypodermatically  half  an  hour 
prior  to  lavage  and  spray  or  swab  the  pharynx  with  a  local  anesthetic.  The 
patient  should  be  in  the  lateral  decubitus,     (e)  Exclusive  rectal  alimentation 


478  VERMIFORM   APPENDIX    AND    PERITONEUM 

(one  ounce  of  concentrated  predigested  food  in  three  ounces  of  salt  solution, 
every  four  hours). 

The  exceptions  to  this  rule  are  cases  in  young  children  and  in  the  aged. 
The  former  cannot  give  assistance  necessary;  stomach  lavage  in  them  means 
a  fight  and  consequently  much  danger  from  spread  of  infection.  Further, 
the  omentum  in  children  is  small  and  can  do  little  to  wall  off  the  focus  of  infec- 
tion. The  aged  bear  confinement  in  bed  badly  and  as  a  rule  the  whole  treat- 
ment outlined  is  inapplicable  to  them.  In  these  cases  the  surgeon  should  either 
operate  at  once  or  watch  the  case  carefully  and  if  improvement  does  not  set 
in  promptly  or  if  the  symptoms  get  worse,  he  should  operate. 

3.  After  the  subsidence  of  the  acute  attack,  where  the  temperature  and  pulse 
have  become  normal,  when  pain,  tenderness,  and  muscular  rigidity  have  dis- 
appeared and  the  bowels  are  acting  well,  without  causing  disturbance,  then  the 
interval  operation  ought  to  be  performed.  Many  surgeons  advise  that  a  cer- 
tain definite  time  be  allowed  to  elapse  between  the  attack  and  the  interval 
operation,  e.g.,  four  weeks,  to  permit  of  complete  restitution  of  the  normal 
conditions.  This  is  a  safe  precaution,  but  a  careful  observer  is  able  to  form  an 
opinion  of  his  patient's  condition  and  operate  when  he  thinks  right  without  ad- 
hering to  any  such  strict  rule  as  to  lapse  of  time. 

4.  When  the  case  is  seen  too  late  for  the  early  operation,  and  tumor  is  pres- 
ent and  the  pulse,  temperature,  and  general  condition  of  the  patient  indicate  a 
dangerous  amount  of  absorption;  if  the  tumor  is  increasing  markedly  and  there 
are  signs  of  the  infection  spreading,  no  surgeon  would  hesitate  as  to  operation. 
Interference  is  imperative.  When,  however,  the  tumor  is  not  increasing  or  is 
decreasing  and  the  temperature  and  pulse  are  moderate  and  in  proper  relation 
to  each  other,  there  is,  on  the  whole,  less  danger  in  delay  than  in  immediate 
operation.  Such  cases  almost  always  improve  under  the  Ochsner  regimen  to 
such  an  extent  that  a  safe  interval  operation  becomes  possible.  The  most  rigid 
adherence  to  the  regimen  and  to  rest  is  essential,  otherwise  a  catastrophe  may 
happen.  The  danger  of  immediate  operation  is  not  merely  that  of  shock  and 
of  general  peritoneal  infection,  but  the  manipulations  necessary  for  the  evacua- 
tion of  the  encapsulated  pus  inevitably  open  by  channels  by  which  toxins  are 
absorbed  in  quantities  which  may  be  fatal.  Nature,  when  aided  by  rest,  can 
safely  encapsulate,  and  ultimately  remove,  even  considerable  quantities  of  pus 
in  the  peritoneum.  If  at  any  time  during  the  course  of  the  disease  it  becomes 
apparent  that  the  encapsulation  is  incomplete  and  that  dangerous  amounts  of 
toxins  are  being  thrown  into  the  circulation,  then  immediate  operation  becomes 
imperative.  The  author  is  perfectly  aware  that  this  advice  violates  the  great 
law  "w&i  pus  ibi  evacuo,"  and  will  not  meet  with  the  approval  of  the  majority  of 
surgeons,  but  its  importance  has  been  impressed  on  him  by  experience. " 

5.  In  cases  of  appendicitis  with  generalized  peritonitis  the  general  rule  is  to 
operate  at  once  and  thoroughly.  Very  excellent  results  have  been  obtained  in 
this  way  by  many  thoroughly  reliable  surgeons.  The  author  is  compelled  to 
admit  that  his  recoveries  have  been  few  in  the  cases  on  which  he  has  operated 
under  these  conditions,  while  of  the  cases  which  refused  operation  a  considerable 
number  (too  many  to  be  all  examples  of  mistaken  diagnosis)  have  recovered 
most  unexpectedly.     Since  adopting  the  Fowler  or,  better,  the  exaggerated 


REMARKS  479 

Fowler   position  during  after-treatment,  the   writer's  results  have  improved 
immensely. 

Remarks. — (The  following  remarks  seem  to  the  author  logical  but  must  be 
taken"  with  a  grain  of  salt"  as  the  whole  subject  discussed  is  at  present  in  a  state 
not  remote  from  chaos.)  On  page  470  a  reasonably  large  incision  is  strongly 
advised  in  operations  for  chronic  appendicitis  because  the  symptoms  are  so  often 
due  to  other  troubles  unrelated  to  the  appendix  as  evidenced  by  their  persistence 
after  the  appendix  is  removed.  Some  of  the  anatomical  conditions  which  may 
be  found  and  which  ought  to  attract  the  surgeon's  attention  are  as  follows: 

1.  Caecum  mobile  with  the  neighboring  ileum  also  mobile.  This  is  perfectly 
normal  and  causes  no  trouble  unless  volvulus  should  develop  as  it  may  in  the 
similarly  mobile  sigmoid  loop. 

2.  Caecum  fixed;  ileum  mobile.     Normal. 

3.  Caecum  mobile;  ileum  fixed  by  adhesions  or  by  an  ileo-pelvic  band  (Lane's 
ileal  kink).  There  may  be  intermittent  or  partial  intestinal  obstruction. 
Treatment:  (a)  Mobilization  of  the  ileum  by  division  of  the  band  and  repair 
of  the  resulting  wound  in  the  peritoneum;  (b)  caecopexy;  (c)  ileal  mobilization 
plus  caecopexy;  (d)  ileo-sigmoidostomy  (Lane). 

4.  Caecum  fixed;  ileum  fixed,  the  ileum  between  its  point  of  fixation  and  the 
caecum  is  angulated.     There  may  be  partial  or  intermittent  obstruction. 
Treatment:  (a)  Mobilize  ileum;  (b)  ileo-sigmoidostomy  (Lane.) 

5.  Caecum  mobile;  ileum  fixed;  band  across  the  ascending  colon.  Inter- 
mittent obstruction  possible  but  unlikely.  Treatment  if  required:  Mobilize 
ileum;  caecopexy  after  placing  the  caecum  in  proper  relation  to  the  ascending 
colon  and  the  ileum. 

6.  Caecum  mobile  and  sunk  down  into  true  pelvis.  Ileo-transversostomy 
(Wilms). 

7.  Caecum  mobile,  much  distended  and  atonic.  Ileo-transversostomy 
(Wilms).     Caecoplication  plus  caecopexy  (Roeder). 

8.  Caecum  mobile;  ileum  mobile;  band  across  ascending  colon  (Jackson's 
membrane).  Possible  obstruction  by  caecum  bending  over  the  band  or  being 
pushed  over  it,  e.g.,  by  pregnant  uterus  (?)  (Fromme).  Treatment  if  required: 
Division  of  the  band  or  caecopexy  (Travel), 

9.  Band  over  ascending  colon  causing  obstruction  by  compression.  Treat- 
ment: Divide  membrane  or  "dodge"  the  obstruction  by  ileo-transversostomy 
or  ileo-sigmoidostomy. 

10.  Kinking  at  hepatic  or  splenic  flexures  with  union  of  the  ascending  or 
descending  colon  to  the  corresponding  portions  of  the  transverse  colon.  Partial 
or  intermittent  obstruction.  Treatment  if  necessary — short  circuit  by  suitable 
anastomosis,  e.g.,  ileo-sigmoidostomy. 

11.  Kinking  by  so-called  meso-sigmoiditis  or  deposits  of  scar  tissue  on  the 
external  surface  of  the  meso-sigmoid,  may  give  rise  to  volvulus  requiring  resec- 
tion of  the  involved  gut  or  anastomosis  between  the  afferent  and  efferent  loops. 
After  ileo-sigmoidostomy  Lane  thinks  a  "kink"  above  the  site  of  anastomosis 
is  valuable  in  preventing  reflux  of  faeces  into  the  descending  colon  and  he  some- 
times creates  such  a  kink  by  sutures. 

12.  No  anatomic  conditions  may  be  found  to  account  for  the  symptoms 


480  VERMIFORM    APPENDIX    AND    PERITONEUM 

which  may  be  due  to  faulty  habits  of  life  leading  to  auto-intoxication  with  its 
sequelae.  For  such  patients  medical  treatment  alone  is  indicated  unless  such 
treatment  may  be  aided  by  Hushing  the  colon  by  means  of  ca^costomy  or  appen- 
dicostomy  or  possibly  by  Lane's  ileo-sigmoidostomy. 

TUBERCULOUS   PERITONITIS 

When  tuberculous  peritonitis  is  not  a  mere  phase  in  the  history  of  a  general 
tuberculosis,  it  is  usually  a  reaction  against  infection  coming  from  a  tubercu- 
lous Fallopian  tube;  from  a  tuberculous  stenosing  ulcer  of  the  ileum;  from  a 
tuberculous  tumor  of  the  ileum  and  caecum;  from  a  tuberculous  vermiform 
appendix.  Tuberculous  peritonitis  is  much  more  common  in  the  female,  as  the 
Fallopian  tubes  are  the  favorite  sites  for  primary  intraabdominal  lesions. 

Accidentally  it  was  found  that  mere  abdominal  incision  and  evacuation  of 
any  ascitic  fluid  present,  with  or  without  subsequent  drainage,  led  to  recovery 
in  many  cases.  Veit  believes  that  50  per  cent,  of  the  cases  are  cured  and  25 
per  cent,  improved  after  the  above  treatment,  the  curative  agent  being  serum, 
effused  as  a  result  of  the  operative  interference,  acting  as  an  antitoxin. 

The  most  favorable  cases  are  those  in  which  ascitic  fluid  was  removed  during 
the  operation,  hence  it  is  difficult  to  imagine  the  above  theory  correct.  J.  B. 
Murphy  observed  that  where  the  end  of  the  diseased  Fallopian  tube  was  patent, 
peritonitis  was  progressive,  and  where  the  ostium  was  closed  by  adhesions, 
etc.,  the  peritonitis  became  stationary  or  was  cured.  Mayo  came  to  the  con- 
clusion that  in  the  presence  of  ascites  the  fimbriated  extremity  of  the  tube 
was  mechanically  kept  patent,  the  fimbriae  being  kept  from  adhering  to  each 
other  and  to  neighboring  structures,  and  hence  the  infective  contents  of  the 
tube  could  constantly  or  intermittently  leak  into  the  peritoneal  cavity.  This 
gives  a  feasible  explanation  as  to  why  simple  laparotomy  with  removal  of 
ascitic  fluid  often  results  in  the  cure  of  tuberculous  peritonitis;  the  end  of  the 
tube,  no  longer  buoyed  up  by  the  fluid,  becomes  closed,  either  by  the  fimbrise 
adhering  to  each  other  or  to  neighboring  structures.  The  primary  lesion  thus 
becomes  encapsulated,  and  the  peritoneum,  being  very  resistant  to  tubercu- 
losis, recovers.  It  has  long  been  known  that  the  cases  accompanied  by  ascites 
are  the  ones  most  benefited  by  surgical  interference. 

Primary  tuberculous  lesions  in  the  ileum  have  a  great  tendency  towards 
spontaneous  recovery;  in  these,  when  operation  is  demanded,  it  is  to  overcome 
resultant  stenosis. 

The  tumor-like  tuberculosis  of  the  ileo-caecal  region  has  likewise  a  predis- 
position to  cure.  Both  in  the  case  of  disease  of  the  ileum  and  of  the  ileo-caecal 
region  the  presence  of  ascites  is  well  calculated  to  prevent  the  formation  of 
protective  adhesions  around  the  focus  of  disease,  hence  the  simple  removal  of  the 
fluid  may  result  in  efficient  encapsulation  of  the  primary  focus. 

Baisch  ("Munch,  med.  Woch.,"  20  Aug.,  1907)  reports  the  results  in  one 
hundred  and  ten  cases  of  tuberculous  peritonitis  observed  from  four  to  ten  years 
in  the  Tiibingan  gynecological  clinic. 

I .  Pure  Exudative  Form.— Thirty-eight  cases ;  thirty-four  submitted  to  opera- 
tion, twenty-two  cured,  twelve  of  those  operated  on  died  in  from  three  months 
to  four  years. 


TUBERCULOUS   PERITONITIS  48 1 

2.  Dry  Adhesive  Form.- — Twenly-two  cases;  eleven  submitted  to  operation, 
eight  of  whom  remained  well,  a  few  of  these  recovered  only  after  a  long  illness 
and  two  had  fajcal  fistula  which  closed  after  some  months. 

3.  Tuberculous  Adnexae. — Forty-five  cases;  thirty- two  submitted  to  opera- 
tion with  good  results  (eighteen  cured;  five  in  which  one  tube  was  left  required 
a  secondary  operation).  Do  not  leave  an  apparently  healthy  Fallopian  tube. 
Leave  the  uterus  and  if  an  ovary  appears  healthy  it  may  safely  be  left. 

Operative  Treatment. — It  is  presumed  that  the  diagnosis  of  tuberculous  peri- 
tonitis has  been  made,  but  the  site  of  the  primary  lesion  is  unknown. 

Step  I. — Open  the  abdomen,  in  the  female,  by  median,  in  the  male,  by 
the  right  rectus,  incision.     Evacuate  any  fluid  which  may  be  present. 

Step  2. — If  in  the  female,  examine  the  Fallopian  tubes.  This  must  be 
done  with  enormous  caution  in  the  presence  of  many  adhesions,  as  it  is  easy 
to  tear  into  a  gut.  If  the  necessary  manipulations  are  very  diflacult,  the  dan- 
gers from  injury  to  the  gut  outweigh  the  advantages  of  a  radical  removal  of 
the  primary  focus,  and  it  will  be  wise  for  most  surgeons  to  trust  to  the  encap- 
sulation of  the  disease  which  is  likely  to  result. 

If  safe,  removal  of  the  tubes  is  of  course  the  procedure  of  choice.  In  any 
case  examine  the  favorite  sites  of  tuberculous  lesions.  Remember  that  what 
may  appear  a  simple  chronic  appendicitis  may  be  tuberculous,  and  that  with 
the  appendix  any  enlarged  glands  in  the  mesenteriolum  ought  to  be  removed. 
When  there  is  a  stenosing  ulcer  of  the  ileum,  an  anastomosis  between  the 
aflFerent  and  efferent  segments  of  gut  is  all  that  is  commonly  required.  If 
the  diseased  segment  of  gut  is  limited  in  extent  and  easily  excised,  its  removal 
is  proper,  though  not  imperative. 

The  tumor-like  tuberculous  lesion  of  the  ileo-caecal  region  ought  to  be  ex- 
cised if  this  is  fairly  easy;  if  difiicult,  then  that  segment  of  the  gut  may  be 
"segregated"  or  left  to  the  curative  powers  of  nature,  assisted  by  the  abdominal 
incision. 

M.  H.  Richardson  writes:  "When,  therefore,  I  have  found  a  tuberculosis 
limited  to  a  single  coil  of  intestine,  rather  than  excise  that  coil,  except  when 
stricture  is  present,  I  have  contented  myself  with  the  exploration  and  demon- 
stration of  the  disease.  If  the  area  affected  has  been  one  that  could  be  easily 
and  safely  removed,  I  have  removed  it,  as  in  tuberculosis  limited  to  the  appen- 
dix or  to  the  Fallopian  tubes." 

In  one  case  operated  on  by  the  author  three  enlarged  lymph  nodes,  one 
the  size  of  a  hen  egg,  existed  in  the  mesentery  of  the  ileum.  There  was  no 
evident  disease  of  the  gut.  Incision  through  the  superficial  layer  of  the  mes- 
entry  permitted  the  easy  enucleation  of  the  diseased  structures,  after  which 
the  mesenteric  wound  was  sutured.     Recovery. 

Any  tuberculous  abscesses  encountered  should  be  evacuated,  dried,  iodo- 
formized,  and  not  drained. 

The  end  results  after  enterectomy  by  Goullioud  for  ileo-caecal  tuberculosis  were 
published  by  Perreve  (These  de  Lyons  1919-1920,  Ref.  La  Pr.  Med.  June  9,  1920). 
Of  15  patients  followed,  10  were  cured.  Three  for  17  years,  i  for  16  years,  2  for  10 
years,  i  seven  years,  3  from  2  to  5  years.  Among  the  5  deaths  following  operation 
there  was  active  tuberculosis,  death  occurring  some  months  after  operation  from 

31 


482  THE    RECTUM 

pulmonan-  or  meninglUc  tuberculosis.  Two  other  patients  siu-vived  9  years,  one 
dying  from  obscure  gastric  disturbance,  the  other  from  acute  peritonitis  follow- 
ing a  secondary'  enterectomy. 

Step  3. — Close   the  abdomen,  preferably  without  drainage.     The  use  of  a 
drain  is  liable  to  lead  to  secondary  infection  and  faecal  fistula. 


CIL\PTER   XXXVI 
THE  RECTUM 

Imperforate  Anus. — There  are  two  forms  of  imperforate  anus,  (A)  No  anal 
depression  is  present;  (B)  an  anal  depression  is  present,  but  does  not  open  into 
the  rectum. 

(A)  The  anal  depression  is  absent. 

The  Operation. — Place  the  child  in  the  lithotomy  position.  Draw  off  the 
urine  with  a  catheter.  Do  not  keep  the  patient  deeply  anesthetized,  as  its  at- 
tempts at  cn,'ing  and  struggling  press  the  gut  dowmwards  and  aid  the  surgeon 
in  recognizing  the  gut  when  he  approaches  it.  Of  course,  enough  anesthetic 
should  be  given  to  prevent  suffering. 

Step  I. — Make  an  incision  in  the  median  line  from  the  middle  of  the  peri- 
neum to  the  tip  of  the  coccyx.  Penetrate  the  skin  and  the  musculo-aponeurotic 
floor  of  the  pelvis.  Frequently  the  gut  will  now  present  and  be  recognized 
from  the  dark  blue  color  given  it  by  the  contained  meconium.  If  the  gut  is 
not  found,  retract  the  walls  of  the  wound.  Note  the  position  of  the  bladder — 
if  necessary,  introducing  a  sound  into  the  bladder  for  this  purpose.  Deepen 
the  wound  by  blunt  dissection,  following  the  concavity  of  the  sacrum  to  its 
promontory.  If  the  external  wound  is  too  small  to  permit  of  such  deep  dis- 
section, continue  the  original  incision  backwards  over  the  lower  end  of  the 
sacrum  and  excise  the  coccyx  and  lowest  segment  of  the  sacrum.  When  the 
neighborhood  of  the  gut  is  reached,  if  the  child  cries,  an  impulse  will  be  com- 
municated to  the  palpating  finger.  If  the  child  is  too  deeply  anesthetized  to 
cry,  intermittent  firm  pressure  on  the  abdomen  may  give  the  same  result.  The 
gut  having  been  found,  separate  its  lower  end  as  freely  as  possible  from  its 
surroundings. 

Step  2. — When  the  gut  is  found  to  be  superficial,  seize  it  with  a  couple  of 
small  volsellae  or  pass  a  suture  through  it  for  purposes  of  traction  and  pull 
it  downwards  to  the  skin,  separating  its  lateral  adhesions  as  traction  is 
being  made.  With  a  knife  cut  into  the  gut.  Meconium  at  once  escapes 
and  must  be  washed  away  by  a  stream  of  warm  water.  Clean  out  the  gut 
by  means  of  injections  of  warm  water  until  the  water  returns  clear.  Cleanse 
the  wound  with  a  mild  antiseptic  solution. 

Step  3. — Carefully  and  accurately  suture  the  opening  in  the  gut  to  the 
skin  with  interrupted  sutures.  Close  the  remainder  of  the  wound  with  such 
deep  and  superficial  sutures  as  may  be  required. 

Wlien  the  gut  is  more  deeply  situated,  the  technic  is  rendered  much  more 
difficult.  It  may  be  impossible  to  bring  the  gut  down  to  the  skin  before  evacu- 
ating its  contents.  In  such  a  case,  fix  the  gut  with  sharp  hooks  or  forceps,  open 
it  with  a  knife,  and  by  means  of  a  catheter  douche  out  its  contents.     When  the 


PROLAPSUS    RECTI  483 

gut  has  been  emptied,  it  is  often  possible  to  separate  it  from  its  lateral  connec- 
tions and  bring  it  down  to  or  near  to  the  skin.  When  possible,  the  edges  of  the 
opening  in  the  gut  must  be  accurately  sutured  to  the  skin,  as  already 
described. 

Should  the  rectum  be  entirely  absent,  the  peritoneal  cavity  may  be  opened 
through  the  perineal  wound  and  the  first  loop  of  gut  which  presents  (generally 
the  sigmoid)  brought  down,  opened,  and  sutured  to  the  skin  (Stromeyer).  In 
cases  of  failure  to  find  the  lower  end  of  the  rectum  through  the  perineal  route 
Macleod  recommends  that  the  abdomen  be  opened,  the  lower  end  of  the  blind 
rectum  found,  rendered  mobile,  and  pushed  downwards  into  the  perineal  wound, 
where  it  is  treated  in  the  manner  already  described. 

(B)  The  anal  portion  of  the  gut  is  present,  but  is  not  joined  to  the  rectum. 

By  palpation  and  inspection  find  if  there  is  only  a  thin  diaphragm  separating 
the  rectum  from  the  anal  gut  or  depression.  If  this  is  so,  perforate  or  excise 
the  diaphragm.  If,  as  is  often  the  case,  much  tissue  is  interposed,  make  an 
incision  in  the  middle  line  from  the  anal  depression  or  gut  to  the  coccyx,  deepen 
the  incision  as  may  be  required,  and  proceed  as  if  no  anal  gut  were  present, 
except  tfiat  after  the  rectum  has  been  opened  and  evacuated,  its  opening  should 
be  sutured  to  the  anal  gut  instead  of  to  the  skin. 

When  none  of  the  methods  described  is  successful,  or  if  the  condition  of  the 
patient  is  such  as  to  render  the  operation  hazardous,  it  is  proper  to  make  a 
permanent  or  temporary  artificial  anus  in  the  inguinal  or  lumbar  region. 
Should  it  seem  advisable,  the  perineal  operation  may  be  attempted  on  a  later  date. 

Prolapsus  Recti. — Rectal  prolapse  may  be  of  two  forms:  in  one  form  the 
rectal  mucous  membrane  alone  is  protruded  through  the  anus;  in  another, 
the  rectal  walls  are  more  or  less  prolapsed.  The  prolapsed  tissue  may  be 
reducible  or  irreducible;  in  the  latter  case  it  generally  shows  evidences  of  past 
and  present  inflammation.  The  prolapse  may  be  due  to  atony  or  dilatation 
of  the  sphincter,  or  to  a  lack  of  support  to  the  gut  from  above.  Relaxation  of 
the  levator  ani  muscles  seems  to  act  by  destroying  the  ano-rectal  angle.  Nor- 
mally the  rectum  forms  with  the  anus  nearly  a  right  angle  opening  downwards 
and  backwards.  When  the  levator  ani  muscles  are  deficient  the  upper  (rectal) 
orifice  of  the  anal  canal  moves  backwards  while  the  inferior  orifice  moves  for- 
wards and  it  is  easy  for  the  rectum  to  push  its  way  through  the  anus  during 
coughing  or  strain.  Prolapse  may  be  an  accidental  concomitant  of  a  rectal 
tumor,  the  weight  of  the  tumor  dragging  the  gut  down.  Comparatively  re- 
cently the  main  active  treatment  of  rectal  prolapse  consisted  in  chemical  or 
thermal  destruction  of  protruding  mucous  membrane  orof  portions  of  the  dilated 
anus,  the  scar  contraction  incident  to  healing  leading  to  narrowing  of  the  anus 
and  support  of  the  gut.  Strangulation  of  the  protruding  tissues  by  means  of 
ligatures  was  also  recommended  and  often  gave  good  results.  All  such  meas- 
ures ought  to  be  discarded,  as  chemical  and  thermal  action  is  difficult  to  regu- 
late and  the  strangulation  by  ligature  is  distinctly  dangerous. 

There  are  three  distinct  principles,  each  of  which  is  the  base  of  a  modern 
method  of  operative  treatment. 

I.  When  the  prolapse  is  due  to  sphincteric  atony  or  looseness,  the  principle 
of  treatment  is  to  overcome  this  condition  by  narrowing  the  sphincter. 


484  THE    RECTUM 

2.  When  the  prolapse  is  due  to  obliteration  of  the  recto-anal  angle,  this 
angle  should  be  reconstituted. 

3.  When  the  prolapse  is  due  to  want  of  superior  support,  such  support  must 
be  provided. 

4.  When  there  is  excess  of  rectum  and  much  tissue  is  prolapsed,  the  pro- 
truded mass  should  be  excised.  Generally  this  excision  must  be  supplemented 
by  narrowing  the  sphincter. 

It  must  be  remembered  that  very  many  cases  of  prolapse,  and  in  children 
even  severe  cases,  may  be  cured  without  operative  interference. 

Plastic  Operation  on  the  Sphincter  Ani. — I.  Buret's  Operation. — From  the 
posterior  surface  of  the  rectum  remove  a  triangle  of  mucous  membrane.  The 
base  of  the  triangle  is  at  the  muco-cutaneous  junction;  the  apex  is  directed 
up  to  the  gut.  From  the  skin  behind  the  anus  remove  a  similar  triangle  having 
the  same  base  as  the  former,  but  having  its  apex  directed  towards  the  coccyx. 
A  lozenge-shaped  raw  surface  is  thus  formed  partly  involving  the  skin  and 
partly  the  mucosa.  By  deep  dissection  cut  away  a  wedge  of  the  tissues  ex- 
posed by  the  removal  of  the  skin  and  mucous  membrane.  With  the  wedge 
of  tissue  a  portion  of  the  sphincter  is  excised.  Insert  deep  and  superficial 
sutures  and  close  the  wound.  It  is  a  wise  precaution  to  unite  the  divided 
ends  of  the  sphincter  by  one  or  more  interrupted  buried  catgut  sutures.  In 
one  case  of  particularly  flaccid  anus  Duret  has  performed  the  above  operation 
both  posteriorly  and  anteriorly.  The  operation  must  be  done  under  the  most 
painstaking  aseptic  technic.  This  is  of  great  moment  in  all  the  plastic  opera- 
tions above  the  rectum  and  anus. 

II.  Buret's  operation  may  be  modified  as  follows:  Make  a  curved  trans- 
verse incision  following  more  or  less  closely  the  muco-cutaneous  junction  at 
the  posterior  side  of  the  anus.  Through  this  incision,  with  scissors  or  knife 
dissect  the  mucous  membrane  from  the  posterior  anal  wall  until  a  point  is 
reached  above  the  sphincter.  Excise  a  sufficiency  of  the  sphincter  and  with 
catgut  sew  the  divided  ends  together.  If  necessary,  excise  a  portion  of  the 
reflected  flap  of  mucous  membrane.  Close  the  superficial  wound.  This  opera- 
tion is  only  feasible  if  the  prolapse  can  be  reduced. 

Operation  to  Restore  the  Recto-anal  Angle.  Brechot's  Operation  (Paris Med., 
March  15,  1919). — i.  From  a  point  ^  inch  (2  cm.)  above  the  tip  of  the  coccyx 
make  a  median  incision  upwards  for  4-5  in.  (12  cm.).  Expose  the  posterior 
surfaces  of  the  coccyx  and  lower  portion  of  the  sacrum. 

2.  On  each  side  of  the  sacrum  make  an  opening  through  the  great  sacro- 
sciatic  ligament.  Through  these  openings  denude  the  anterior  surface  of  the 
sacrum  to  the  necessary  extent. 

3.  Divide  the  sacrum  transversely  at  the  level  of  the  coccygeal  cornua  and 
at  a  point  two  finger-breadths  higher  up.  Remove  the  segment  of  sacrum 
between  the  two  fines  of  section. 

4.  Unite  the  lower  segment  of  sacrum  (and  coccyx)  to  the  upper  segment 
by  a  wire  or  chromic  gut  suture  and  by  suture  of  the  lateral  aponeurotic  planes. 

5.  Close  the  wound. 

Brechot's  operation  may  be  combined  with  myorrhaphy  of  the  fibres  of  the 
levatores  ani  in  front  of  the  anus. 


RECTOPEXY  485 

Operations  to  Narrow  the  Rectal  Lumen  and  thus  Prevent  Prolapse.- — Lange^s 
Operation  {Transverse  Rectorrhaphy). — Make  an  incision  in  the  middle  line 
from  a  point  immediately  behind  the  anus  to  the  base  of  the  coccyx.  Do  not 
injure  the  sphincter.  Resect  the  coccyx.  By  dissection  expose  the  posterior 
surface  of  the  rectum.  Introduce  a  number  of  sutures  into  the  gut  wall  in 
the  Lembert  fashion,  transversely,  as  if  closing  a  longitudinal  tear  in  the  rectal 
wall.  The  sutures  must  not  penetrate  the  mucosa.  Tie  the  sutures.  The 
result  is  to  narrow  the  gut  by  throwing  its  posterior  wall  into  a  longitudi- 
nal fold.     Close  the  external  wound  by  deep  and  superficial  sutures. 

Rectopexy. — (A)  Mummery's  Operation. — Prepare  the  patient  carefully  as 
it  is  essential  to  insure  against  action  of  the  bowels  for  at  least  four  or  five  days 
after  operation.  Note  the  extent  of  the  prolapse  and  return  it.  Thoroughly 
swab  the  lower  rectum  with  spirit-soap  and  water.  Douche  with  Lysol  (i 
drachm  to  the  pint)  and  remove  excess  of  solution  with  dry  gauze.  Clean  the 
field  of  operation. 

Step  I. — Midway  between  the  tip  of  the  coccyx  and  the  anus  make  a  two 
inch  transverse  incision.  Deepen  the  incision,  slightly  backwards  and  divide 
the  attachment  of  the  external  sphincter  to  the  coccyx.  Open  the  posterior 
rectal  space.  Guided  by  the  finger  enlarge  the  opening  thoroughly  to  each  side 
of  the  rectum  and  separate  the  bowel  from  the  concavity  of  the  sacrum.  This 
can  be  done  by  blunt  dissection  aided  by  a  few  snips  of  the  scissors.  A  gloved 
finger  in  the  rectum  serves  as  a  useful  guide.  The  dissection  should  be  carried 
upwards  for  a  distance  about  equal  to  the  length  of  the  prolapse  when  it  was 
down,  and  ought  to  be  carried  round  the  sides  of  the  rectum  as  well  as  up  its 
posterior  wall.  When  the  prolapse  is  large  and  of  long  standing  carry  the 
separation  into  the  space  above  the  levator  ani  and  between  this  muscle  and 
the  rectal  wall  on  each  side. 

Step  2.— Pack  the  whole  cavity  with  tapes  of  selvedged  gauze  (Bismuth  or 
Iodoform)  to  prevent  primary  union,  but  the  packing  must  not  be  tight  enough 
to  run  any  risk  of  causing  pressure  necrosis. 

Step  3. — ^Just  within  the  anus  apply  forceps  to  a  fold  of  the  mucous  mem- 
brane of  the  anterior  wall  of  the  rectum.  Replace  the  forceps  by  a  ligature. 
This  prevents  any  tendency  to  prolapse  of  this  membrane  into  the  patulous 
anus  after  the  posterior  wall  has  been  fixed. 

After  Treatment. — Keep  the  patient  flat  in  bed.  Do  not  let  him  sit  up  for 
any  purpose  for  about  30  days.  After  six  days  remove  parts  of  the  gauze  day 
by  day  replacing  them  with  light  packing.  After  this  dress  daily  until  the 
wound  is  healed  (not  less  than  three  weeks).  The  diet  should  be  very  light 
until  the  bowels  are  moved  by  oil  enema ta  on  the  sixth  or  seventh  day. 

In  Mummery's  operation  not  only  is  a  rectopexy  secured  but  division  of  the 
attachments  of  the  external  sphincter  to  the  coccyx  allows  the  anus  to  move 
forward  which  in  itself  tends  to  prevent  further  prolapse.  The  author  has 
found  the  operation  excellent. 

(B)  VerneuiVs  Operation. — With  a  knife  trace  a  triangle  having  its  base  at 
the  anus,  its  apex  at  the  tip  of  the  coccyx.  Excise  this  triangle  of  tissue  and 
with  it  the  whole  segment  of  sphincter  corresponding  to  its  base.  Pass  a  long 
suture  transversely  through  the  posterior  wall  of  the  exposed  rectum,  without 


486  THE    RFXTUM 

penetrating  the  mucosa.  Arm  each  end  of  the  suture  with  a  needle.  Push 
the  needles  through  the  tissues  of  the  back,  from  within  outwards,  to  emerge 
through  the  skin,  one  on  each  side  of  the  sacrococcygeal  articulation.  At 
lower  levels  introduce  three  other  sutures  in  a  similar  manner.  Tie  the  sutures. 
This  narrows  the  anus  and  pulls  the  lower  rectum  backwards  and  upwards. 

(C)  Marchant's  Operation. — Expose  the  posterior  surface  of  the  rectum  by 
means  of  a  median  incision  from  behind  the  anus  to  the  tip  of  the  coccyx. 
Introduce  several  rows  of  sutures  in  the  long  axis  of  the  gut  after  the  Lembert 
method,  as  if  to  close  a  series  of  transverse  ruptures  of  the  gut.  The  sutures 
must  not  penetrate  the  mucosa.  As  each  row  of  longitudinally  placed  sutures 
is  tied  the  posterior  wall  of  the  gut  is  thrown  into  a  series  of  transverse  folds, 
which  shortens  it.  With  catgut  unite  the  lowermost  fold  to  the  tissues  imme- 
diately in  front  of  the  coccyx.  Give  additional  support  by  introducing  one 
or  more  sutures  after  the  method  of  Verneuil  described  above.  Close  the 
wound  completely. 

Colopexotomy  (Jeannel's  Operation). — The  object  of  this  operation  is  to  at- 
tach the  sigmoid  flexure  to  the  abdominal  wall  and  so  give  superior  support  to 
the  rectum.  The  scope  of  the  operation  must  be  limited.  In  Carre's  clinic 
59  per  cent,  of  relapses  followed  the  operation  or  some  modification  of  it. 
(Pachnio,  "Beitrage  z.  klin.  Chir.,"  xlv,  300.) 

The  Operation. — Open  the  belly  as  in  left  inguinal  colostomy.  Seize  the 
sigmoid  flexure  and  pull  it  up  until  the  rectal  prolapse  is  reduced.  Suture 
to  the  abdominal  wound  the  lowest  portion  of  the  gut  which  can  conveniently 
be  brought  into  it  after  reduction  of  the  prolapse.  Make  an  artificial  anus. 
After  the  gut  is  securely  attached  to  the  abdominal  wall,  and  the  rectum, 
irritated  and  inflamed  because  of  having  been  prolapsed,  is  healed,  the  arti- 
ficial anus  may  be  closed. 

McArthur's  Operation. — Abdominal  rectopexy.  Principles  of  operation: 
(i)  Obliterate  the  dilatation  of  Douglas' pouch  which  is  always  present.  (2) 
Perform  a  rectopexy  by  uniting  the  rectum  to  a  fixed  portion  of  the  sigmoid. 
(3)  Avoid  dangers  from  recto-sigmoid  kinking  by  making  an  anastomosis  be- 
tween the  rectum  and  sigmoid.  The  anastomosis  should  be  made  with  three 
lines  of  suture  so  as  to  assure  unusually  thorough  union.  (4)  If  necessary 
repair  the  pelvic  floor,  e.g.,  by  Marchant's  method. 

Step  I. — Trendelenburg  position.  Open  the  abdomen  in  the  middle  line 
below  the  umbilicus. 

Step  2. — Seize  the  rectum  and  pull  it  upwards  until  the  prolapse  is  com- 
pletely reduced.  Note  that  the  lower  part  of  the  peritoneum  of  Douglas'  pouch 
cannot  be  put  on  the  stretch  no  matter  how  strongly  one  may  pull  up  the  gut. 
Obliterate  the  relaxed  lower  segment  of  Douglas'  pouch  by  suturing  its  walls 
together.     This  is  as  important  as  obliterating  the  sac  of  a  hernia. 

Step  3. — To  the  upper  portion  of  the  rectum  apply  an  intestinal  clamp. 
Choose  a  portion  of  the  upper  sigmoid,  or  of  the  junction  of  the  descending 
colon  and  the  upper  sigmoid,  which  is  well  fixed  to  the  posterior  abdominal  wall 
(i.e.,  which  is  well  supported  superiorly)  and  yet  which  can  be  easily  brought 
into  apposition  with  the  chosen  portion  of  rectum.     Apply  an  intestinal  clamp 


PKOLAPSlfS    RECTI 


487 


here.  Make  a  large  lateral  anastomosis  between  the  chosen  segments  of  rec- 
tum and  sigmoid.     Remove  the  clamps. 

Step  4. — Close  the  abdomen.  If  necessary  the  anal  opening  may  be  nar- 
rowed at  a  subsequent  operation. 

Quenu  and  Duval  ("Rev.  de  Chir.,"  Feb.,  1910)  describe  a  very  elaborate 
means  of  obliterating  Douglas'  pouch;  suturing  the  lower  pelvic  colon  trans- 
versely to  the  back  of  the  broad  ligaments  and  vaginal  dome  (to  the  back  of 
the  bladder  in  the  male) ;  the  upper  part  of  the  colon  to  the  exposed  tendon  of 
the  psoas  parvus.     Fig.  637  explains  the  operation. 

Excision  of  the  Prolapsed  Gut. — A  considerable  number  of  methods  have 
been  devised  for  the  removal  of  the  prolapsed  mass.     Several  of  the  methods 


Fig.  637. — {Quenu  and  Duval.) 

fail  to  recognize  the  existence  of  a  peritoneal  pouch  between  the  inner  and 
outer  tube  of  the  intussuscepted  gut  and  that  a  loop  of  small  intestine  may 
be  present  in  that  pouch.  This  failure  renders  all  such  methods  too  danger- 
ous to  be  justifiable,  and  they  will  not  be  here  described.  Excision  should  be 
reserved  for  gangrenous,  irreducible  or  ulcerated  cases  as  it  has  a  death  rate 
of  10  per  cent,  and  there  are  at  least  7  per  cent,  of  recurrences. 

Mikulicz's  Operation. — Place  the  patient  in  the  lithotomy  position  at  the 
edge  of  the  table.  Make  a  horizontal  incision  through  the  anterior  half  of 
the  external  tube  or  cylinder  of  gut,  i.e.,  into  the  peritoneal  pouch.  Explore 
the  pouch  with  the  finger  and  reduce  its  contents  if  there  are  any.  Suture, 
by  the  Lembert  method,  the  peritoneal  surface  of  the  outer  tube  to  that  of  the 
inner  tube  (Fig.  638).  Cut  away  the  gut  corresponding  and  peripheral  to  the 
line  of  suture.  Cover  the  line  of  suture  by  a  row  of  stitches  uniting  the  mucous 
membrane  of  the  outer  to  that  of  the  inner  tube.     The  posterior  half  of  the 


488  THE   RECTUM 

prolapsed  gut  must  now  be  attacked  in  the  same  manner  and  the  outer  and 
inner  tubes  united  by  a  row  of  Lembert  sutures  protected  from  contamination 
by  some  stitches  which  involve  the  mucosa  alone. 

To  be  successful  the  above  operation  must  often  be  supplemented  by  a 
plastic  operation  on  the  sphincter  such  as  has  already  been  described. 

Stricture  of  Rectum. — I.  When  a  rectal  stricture  is  soft  and  can  be  reached 
through  the  anus,  treatment  by  gradual  dilatation  should  be  attempted. 

Introduction  of  Rectal  Bougies. — Place  the  patient  on  his  left  side  with  the 

right  thigh  partially  flexed.     Introduce  the  index  finger  through  the  anus  and 

^^-g^  'f   /  /  locate  the  opening  through  the  stricture.     If  the 

^^^^^^^^^ss-  /  /  (^3^      stricture  is  large  enough  to  permit  the  passage  of 

(if      *  ..^^^^^      ^^^  finger  without  force  being  employed,  the  finger 

^^^^  ^-^i^^^^^^^^       ^^^  ^^  ^^^^  ^^  ^  bougie.     If  the  stricture  is  either 

p^^^^^fi. '  narrower  or  much  wider  than  the  finger,  use  the 

l^^^    '     -'-  finger  as  a  guide  and  pass  a  well-oiled  soft-rubber 

'^    ^^^^^^^^^^\     rectal  bougie  through  the  constriction.     iVo  appre- 

y^^  \^^     ciahle  force  must  he  used.    Leave  the  bougie  in  place 

for  two  or  three  minutes  and  withdraw  it.  Repeat 
^'"V,  638.- Prolapsus  of  rectum.  ^^    operation  after  the  lapse  of  from  one  to  four 

O.  T.  Outer  tube  of  gut.     I.  T.  -^  ^ 

Inner  tube  of  gut.    P.  Peritoneum,  days,  i.e.,  after  any  imtation  produced  by  the  oper- 

S.  Sphincter  am.     X.  Suture.  J    i  i  J  f  j  f 

ation  has  subsided.  At  each  operation  it  may  be 
necessary  to  pass  several  instruments  of  different  sizes,  the  last  one  being  the 
largest  which  it  is  possible  to  introduce  through  the  constriction  without  force. 
The  principle  of  treatment  is  identical  with  that  of  gradual  dilatation  of  urethral 
stricture.  As  in  the  case  of  the  urethra,  some  rectal  strictures  are  too  irritable 
to  permit  of  gradual  dilatation.  When  suitable,  the  treatment  is  safe,  but  it 
is  only  palliative,  as  the  contraction  recurs  when  dilatation  is  discontinued. 

II.  Crede's  Operation. — If  the  stricture  is  firm  and  resistant  to  gradual  dila- 
tation, Crede's  operation  may  be  useful.  Administer  an  anesthetic.  Guided 
by  the  finger,  pass  a  probe-pointed  knife  through  the  stricture  and  with  it 
make  a  number  of  small  cuts  or  "nicks"  in  the  protruding  edge  or  ring  of  the 
stricture.  SLx  or  eight  of  these  cuts  may  be  made,  none  of  them  deep  enough 
to  endanger  the  peritoneum.  Remove  the  knife  and  gently  introduce  a  bougie. 
The  rest  of  the  treatment  is  that  of  gradual  dilatation. 

Forcible  dilatation  has  been  practised,  but  has  proven  too  brutal  and  dan- 
gerous.    It  is  unjustifiable. 

III.  Posterior  Rectotomy. — Place  the  patient  in  the  lithotomy  position. 
Guided  by  the  finger,  pass  a  probe-pointed  bistoury  through  the  stricture  and 
divide  it  completely  in  the  middle  line  posteriorly.  Continue  the  incision  down- 
wards and  backwards  so  as  to  divide  the  sphincter  ani.  The  result  of  this  cut 
is  the  division  of  the  stricture,  the  rectal  wall  below  the  stricture,  and  the 
sphincter,  in  the  posterior  median  line.  Attend  to  hemostasis.  Pack  the 
wound.  The  after-treatment  consists  in  frequent  changes  of  dressings,  in  care- 
ful cleansings,  and  subsequently  in  the  use  of  rectal  bougies. 

IV.  Pean's  Modification  of  Posterior  Rectotomy. — Make  an  incision  in  the 
middle  line  of  the  posterior  wall  of  the  rectum  from  a  point  three-fourths  of  an 
inch  above  the  stricture  to  and  including  the  sphincter  Contani.     inue  the  inci- 


EXCISION    OF    RECTUM  489 

sion  backwards  in  the  middle  line  until  the  incision  through  the  skin  equals  in 
length  that  through  the  mucous  membrane  of  the  rectum.  Pull  the  mucous 
membrane  at  the  upper  angle  of  the  wound  downwards  and  suture  it  to  the 
skin.  To  render  the  mucous  membrane  movable,  it  may  be  necessary  to  under- 
mine it  slightly.  The  principle  of  the  operation  is  to  convert  the  original  ver- 
tical wound  into  a  transverse  one  and  so  gain  room. 

V.  Sonncnbiirgs  Operation. — Expose  the  gut  by  Kraske's  method  (page  491). 
Divide  the  stricture,  vertically,  taking  care  to  avoid  injuring  the  sphincter. 
Pack  the  wound.  Healing  takes  place  very  slowly;  fistulae  are  almost  certain 
to  persist,  and  after-treatment  with  bougies  is  necessary. 

VI.  Sokolofs  Operation. — This  operation  is  the  same  as  Sonnenburg's,  but 
instead  of  packing  the  wound,  the  vertical  incision  is  converted  into  a  transverse 
one  by  means  of  sutures.  In  suitable  cases  this  operation  is  one  of  much 
promise,  but  cases  suitable  for  it  must  be  exceedingly  rare. 

VII.  Excision  of  the  Stricture. — The  stricture  may  be  excised  in  various 
ways.  The  methods  of  rectal  excision  are  described  elsewhere.  It  was  hoped 
that  excision,  though  dangerous,  might  prove  an  entirely  reliable  means  of 
treatment.  Experience  seems  to  show  that  it  is  little  better  than  a  means  of 
palliation. 

VIII.  Colo-rectostomy. — When  the  stricture  is  seated  high  up  in  the  rectum, 
an  anastomosis  may  be  made  between  the  colon  and  the  rectum  so  that  the 
intestinal  contents  may  pass  around  the  stricture. 

IX.  Colostomy  may  be  used  in  the  treatment  of  rectal  stricture  for  two  pur- 
poses: {a)  To  give  relief  from  the  obstruction;  (Jb)  to  give  rest  to  the  rectum 
and  to  permit  of  local  operations  or  treatment  being  carried  out  without  inter- 
ruption from  faeces.  In  this  case  after  the  rectal  disease  has  been  cured  the 
artificial  anus  may  be  closed. 

The  methods  of  performing  colostomy  are  described  elsewhere. 

Excision  of  Rectum. — Excision  of  the  rectum  is  most  commonly  indicated 
in  cases  of  malignant  tumors.  When  performed  for  the  relief  of  rectal  stricture 
(non-malignant),  the  operation  is  identical,  except  that  in  this  case  it  is  not 
necessary  to  excise  the  disease  so  extensively. 

Preliminary  Treatment. — Two  main  indications  must  be  observed,  viz.:  (i) 
Improve  the  general  condition  of  the  patient;  (2)  diminish  the  septicity  of  the 
intestine. 

The  general  condition  may  be  improved  by  means  of  proper  regulation  of 
the  organs  of  elimination  and  of  proper  regulation  of  the  diet.  A  diet  of  eggs 
and  milk  is  highly  to  be  recommended.  How  may  the  septicity  of  the  gut  be 
diminished?  The  only  efficient  medicinal  means  of  cleansing  the  rectum  is 
purgation.  But  it  is  easy  to  carry  this  means  too  far  and  weaken  the  patient. 
The  moderate  use  of  salines  or  of  calomel  is  highly  proper.  For  Tuttle's 
method  of  cleaning  the  rectum  see  page  515.  Various  antiseptics  have  been 
administered  by  the  mouth,  in  the  hope  of  lessening  the  filthiness  of  the  rectum 
(resorcin,  salol,  etc.),  but  in  the  opinion  of  the  writer  such  endeavors  must  be 
as  futile  as  an  attempt  to  antisepticize  the  Mississippi  River  at  New  Orleans 
by  pouring  a  barrel  of  corrosive  sublimate  into  its  current  at  St.  Paul. 


4QO  THK    RECTUM 

Apart  from  moderate  purgation,  the  only  possible  means  to  approximate 
cleanliness  in  the  lower  bowel  is  flushing  and  scraping. 

Flushing  the  Rectum. — Pass  a  long,  soft,  flexible  rubber  tube  into  the  rectum 
and  through  the  stricture.  Through  a  funnel  on  the  proximal  end  of  the  tube 
pour  warm  water  or  boracic  acid  solution  into  the  gut  until  the  patient  experi- 
ences a  feeling  of  discomfort.  Lower  the  funnel  and  tube,  and  permit  the  water 
to  flow  into  a  receptacle  on  the  floor.  Repeat  the  operation.  Carry  out  these 
rectal  flushings  every  morning  and  evening  for  four  or  five  days  before  the 
operation. 

Scraping  the  Rectum. — Immediately  before  the  operation  dUate  the  anus  and 
scrape  away  all  the  friable  surface  of  the  cancerous  growth  with  a  sharp  spoon, 
preferably  with  a  flushing  curette.  The  bleeding  is  trivial  and  soon  stops. 
Should  the  hemorrhage  not  cease  spontaneously  and  quickly,  touch  the  bleed- 
ing points  with  a  thermo-cautery  or  with  liquid  carbolic  acid,  preferably  the 
former.  Removal  of  the  abominably  foul  surface  of  the  cancer  with  a  curette 
and  thorough  flushing  of  the  rectum  are  undoubtedly  the  best  means  of  dimin- 
ishing the  septicity  of  the  bowel,  but  however  thoroughly  these  means  are  used, 
the  cleanliness  obtained  is  only  relative,  though  none  the  less  important. 

I.  Vaginal  Route. — In  the  female,  when  the  anterior  rectal  waU  alone  is  dis- 
eased, one  may  make  a  vertical  incision  through  the  posterior  vaginal  wall, 
expose  the  growth,  excise  it,  suture  the  opening  left  in  the  rectum,  and  then 
separately  suture  the  vaginal  wound.     Such  an  operation  is  not  often  suitable. 

II.  Anal  Route. — (A)  The  anus  is  involved  in  the  disease.  Place  the  patient 
in  the  lithotomy  position.  Make  an  incision  all  around  the  anus.  With  blunt 
and  sharp  dissection  separate  the  diseased  anus  and  the  rectum  from  their  sur- 
roundings untU  a  point  in  the  rectum  is  reached  about  one  and  one-half  inches 
above  the  disease.  Divide  the  rectum  at  this  point  and  remove  the  disease. 
Attend  to  hemostasis.  Pull  the  edge  of  the  divided  rectum  downwards  and 
suture  it  to  the  skin,  if  possible.  If  the  incision  surrounding  the  anus  does  not 
give  sufficient  room  for  the  next  steps  of  the  operation,  one  may  supplement  it 
by  a  median  incision  running  backwards  to  the  coccyx  or  one  may  even  excise 
the  coccyx.  If  it  is  impossible  to  bring  the  divided  end  of  the  rectum  down  to 
the  skin  at  the  site  of  the  natural  anus,  it  may  be  sutured  to  the  skin  at  the  level 
of  the  coccyx. 

The  operation  as  described  is  permissible  only  if  the  anus  is  diseased.  The 
sphincter  is  sacrificed.  Incontinence  of  faeces  results.  Delbet  writes:  "To 
avoid  these  inconveniences  Witzel,  on  the  advice  of  Willems,  passes  the  end 
of  the  rectum  through  the  fibres  of  the  gluteus  maximus.  Rydygier  through 
the  pyriformis  and  gluteus  maximus.  Gersuny,  before  fixing  the  rectum,  so 
twists  it  on  its  axis  that  its  longitudinal  muscular  fibres  play  the  role  of  sphincter, 
or  at  least  offer  some  mechanical  opposition  to  the  escape  of  intestinal  contents." 

(B)  The  anus  is  not  involved  in  the  disease. 

I.  The  disease  is  freely  movable  and  only  involves  a  small  part  of  the  rectal 
wall.  Place  the  patient  in  the  lithotomy  position.  Dilate  the  anus  fully. 
Seize  the  tumor  with  a  volsella  and  pull  it  downward  into  a  freely  accessible 
position.  On  each  side  of  and  a  little  above  the  tumor  seize  the  rectum  with 
forceps  or  sharp  hooks.     The  object  of  this  is  to  prevent  the  wound  being  re- 


EXCISION    OF   KECTUM  49 1 

tracted  out  of  easy  reach  after  the  tumor  is  removed.  Freely  excise  the  tumor. 
Close  the  wound  with  sutures  after  attending  to  hemostasis.  When  possible,  it 
is  wise  to  insert  the  sutures  in  the  long  axis  of  the  gut  so  that  the  resulting  scar 
is  transverse  and  danger  of  subsequent  stricture  is  lessened. 

2.  The  disease  is  freely  movable,  is  very  low  down  in  the  rectum,  but  involves 
all  or  nearly  all  the  circumference  of  the  gut.  Place  the  patient  in  the  lithotomy 
position.  Dilate  the  anus  fully.  Seize  the  tumor  with  volsellae  and  pull 
it  downwards  into  a  freely  accessible  position.  Make  an  incision  completely 
around  the  anus  at  the  muco-cutaneous  junction.  Separate  the  anal  mucous 
membrane  from  the  sphincter.  When  the  upper  edge  of  the  sphincter  is  passed, 
divide  the  whole  thickness  of  the  rectal  wall  and  separate  the  rectum  from  its 
surroundings  until  a  point  is  reached  well  above  the  disease.  In  cancer  remove 
too  much  rather  than  too  little.  Attend  to  hemostasis.  Divide  the  rectum 
above  the  disease  and  remove  it.  Pull  down  the  divided  end  of  healthy  rectum 
and  suture  it  to  the  skin. 

III.  The  Perineal  Route. — ^^Place  the  patient  in  the  lithotomy  position. 
Make  an  incision  in  the  middle  line  from  the  anus  to  the  point  of  the  coccyx. 
This  incision  divides  the  sphincter.  Dieflfenbach  supplements  the  above  cut  by 
one  placed  in  the  middle  line  anteriorly  which  also  divides  the  sphincter  and 
reaches  to  the  bulb  of  the  urethra.  Retract  the  edges  of  the  wound.  Separate 
the  anal  mucous  membrane  from  the  sphincter  and  proceed  to  remove  the 
disease  as  described  in  the  preceding  paragraph.  In  dissecting  the  rectum  free 
from  its  surroundings  take  special  care  not  to  injure  the  prostate  or  the  base 
of  the  bladder;  for  this  purpose  it  is  wise  to  do  most  of  the  dissection  with  the 
finger  or  some  blunt  instrument.  Should  the  bladder  be  torn,  its  wound  must  be 
closed  at  once  by  a  few  sutures. 

The  (iisease  having  been  removed,  pull  down  the  divided  end  of  the  healthy 
rectum  and  suture  it  to  the  anal  skin.  Close  the  rest  of  the  wound  with  deep 
and  superficial  sutures.  The  stitches  should  restore  the  integrity  of  the  sphinc- 
ter and  do  away  with  the  presence  of  dead  spaces  in  the  depth  of  the  extensive 
wound.  If  it  is  impossible  to  avoid  the  presence  of  dead  spaces,  such  must  be 
drained. 

If,  in  order  freely  to  excise  the  tumor  it  is  necessary  to  open  the  peritoneum, 
do  so,  but  before  penetrating  that  cavity  carefully  wash  the  wound  with  an 
antiseptic  solution  and  close  the  peritoneal  wound  with  sutures  at  as  early  a 
stage  in  the  operation  as  possible. 

IV.  Sacral  Route. — Every  method  by  which  the  rectum  is  removed  via  the 
sacral  route  is  based  upon  the  Kraske  operation. 

Kraske's  Operation. — Place  the  patient  on  his  right  side  with  the  thighs 
slightly  flexed. 

Step  I. — Make  an  incision  in  the  middle  line  from  the  middle  of  the  sacrum 
to  the  anal  margin.  This  cut  penetrates  to  the  bone  but  does  not  cut  through 
the  anal  sphincter. 

Step  2. — Detach  the  gluteus  maximus  on  the  left  side  from  its  sacral  and 
coccygeal  origins. 

Step  3.- — Excise  the  coccyx. 


492 


THE    RECTUM 


Step  4. — Close  to  the  sacrum,  cut  through  the  lower  part  of  the  left  sacro- 
sciatic  ligament. 

Step  5. — With  chisel  or  strong  bone  forceps  excise  the  left  half  of  that  part 
of  the  sacrum  lying  below  the  level  of  the  third  posterior  sacral  foramen*  (A, 
B,  C,  Fig.  639). 

Step  6. — Expose  the  rectum  by  dividing  the  soft  structures  lying  between 
it  and  the  sacrum.     Do  not  open  the  gut. 

Step  7. — Separate  the  gut  from  its  surroundings  by  blunt  dissection.  The 
rectal  mesentery  having  been  loosened  (bluntly),  pull  the  gut  downwards  to 
such  an  extent  that  after  the  diseased  section  has  been  freely  removed  the  con- 
tinuity of  rectum  may  be  restored  by  sutures  on  which  no  unnecessary  tension 


Fig.  639. 

A,  B,  C.  Kraske's  line  of  section.     H.  K.  Heineke  and  Kocher's  line  of  section. 

may  be  exerted.  It  is  important  not  to  have  opened  the  gut,  as  in  this  step  of 
the  operation  the  peritoneum  is  frequently  opened  either  by  accident  or  design. 
If  the  gut  is  not  opened  and  the  tumor  not  invaded,  the  peritoneum  must  be 
closed  by  sutures  or  packing  (preferably  by  sutures)  after  the  rectum  has  been 
pulled  downwards  to  the  desired  extent.  If  the  peritoneal  w^ound  has  become 
soiled,  owing  to  escape  of  intestinal  contents  from  an  accidental  tear  in  the 
gut,  it  must  be  cleansed  and  drained  with  iodoform  gauze. 

Step  8. — At  a  point  about  one  and  one-quarter  inches  above  the  disease 
(if  it  is  malignant;  closer,  if  non-malignant)  divide  the  gut  transversely  and 
remove  it  to  a  point  the  same  distance  below  the  disease.  Suture  the  upper 
segment  of  gut  to  the  lower. 

*  Step  5  of  Kraske's  operation  is  frequently  modified.  It  is  found  that  much  more  of  the 
sacrum  may  be  removed,  when  necessary,  than  has  been  described  above.  The  left  half  of 
the  sacrum  up  to  the  second  foramen  has  been  excised,  the  spinal  canal  opened,  and  the  lower 
fibres  of  the  cauda  equina  removed  without  evil  resulting. 


KRASKE  S    OPERATION 


493 


Step  9. — Cleanse  the  whole  wound  carefully.  Diminish  the  size  of  the 
wound  by  a  few  stitches  so  applied  as  to  avoid  interfering  with  the  freest  pos- 
sible drainage.  Pack  the  rest  of  the  wound  loosely  with  iodoform  gauze.  The 
wound  closes  by  granulation.  A  faecal  fistula  frequently  results,  as  the  intes- 
tinal sutures,  especially  the  posterior  ones,  commonly  give  way. 

Kraske  ("German  Surg.  Congress,"  1906)  thinks  that  laparotomy  ought 
always  to  be  practised  as  an  immediate  preliminary  to  the  sacral  operation  in 
cases  of  extensive  disease  in  order  to  permit  removal  of  lymphatic  nodes.  He 
divides  the  gut  with  the  cautery  between  two  ligatures  and  thus  renders  the 
lower  segment  mobile  and  easy  of  excision  through  the  sacral  route. 

Rehn's  Modification  of  Kraske' s  Operation. — Instead  of  Kraske's  median  in- 
cision make  a  cut  along  the  left  side  of  the  sacrum  and  coccyx  and  continue 


Fig.  640. — Rehn's  operation. 


it  towards  the  anus  (A  B,  Fig.  640).  If  sufficient  space  is  obtained  by  this 
incision,  proceed  with  the  other  steps  of  the  operation.  If  more  room  is  re- 
quired, make  a  transverse  incision  (B  C,  Fig.  640)  over  the  sacrum  between 
the  third  and  fourth  sacral  foramina.  Separate  the  sacrum  from  the  soft  parts 
in  front  of  it  and  divide  the  bone  along  the  line  of  the  transverse  incision. 
Reflect  the  newly  formed  flap,  consisting  of  sacrum,  coccyx,  and  soft  struc- 
tures covering  them,  to  the  right. 

The  rest  of  the  operation  is  practically  identical  with  Kraske's,  except 
that  after  the  rectum  is  loosened  from  its  connections  and  pulled  down  so  far 
that  the  suture  of  the  divided  ends  (without  tension)  will  be  possible  after  the 
tumor  is  removed,  the  whole  wound  is  loosely  packed  with  iodoform  gauze 
and  the  rectum  left  unopened  and  not  relieved  of  the  tumor.  During  the  after- 
treatment  the  patient  must  lie  on  his  side.  Keep  the  bowels  locked  up  for 
five  days  with  opium.     On  the  fifth  day  move  the  bowels  with  castor  oil  and 


494 


THE    RECTUM 


enemata.  After  the  lapse  of  about  ten  days  from  the  primary  operation,  excise 
the  tumor  and  suture  the  ends  of  the  gut  together.  In  doing  so,  first  stitch 
the  mucosa  with  catgut  and  then  unite  the  other  coats  with  silk.  It  strengthens 
the  line  of  sutures  if  the  silk  stitches  include  in  their  bite  some  of  the  neigh- 
boring soft  parts. 

It  is  claimed  that,  among  other  advantages,  the  operation  in  two  stages 
lessens  the  immediate  mortality  of  a  very  serious  procedure — (a)  because  the 
shock  is  lessened,  (b)  because  the  huge  wound  cavity  is  well  covered  by 
granulations  before  there  is  much  chance  of  its  becoming  soiled  by  intestinal 
contents. 


Fig.  641. — Schlange's  operation. 

A  distinct  disadvantage  of  Kraske's  operation  is  that  the  levator  and  the 
sphincter  ani  muscles  lose  the  support  which  they  normally  obtain  from  the 
sacrum  and  coccyx.  This  is  important  for  the  future  comfort  of  the  patient. 
In  order  to  save  the  sacrum  and  coccyx  Heineke  and  Kocher  (Fig.  639)  have 
divided  the  coccyx  and  lower  end  of  the  sacrum  longitudinally  in  the  middle 
line  and  retracted  the  fragments  to  either  side,  replacing  them  when  the  opera- 
tion was  completed.  Schlange  has  attained  the  same  object  by  a  method  which 
affords  much  room  and  has  given  excellent  results  in  his  hands. 

Schlange's  Operation. — Step  1. — Make  a  transverse  incision  down  to  the 
bone  across  the  lower  part  of  the  sacrum. 

Step  2. — From  the  above  incision  make  two  others  (one  on  each  side  of  the 
coccyx)  which  diverge  from  each  other  slightly  and  end  near  the  level  of  the 
anus.  Near  the  anus  these  two  cuts  merely  penetrate  the  skin,  but  where  they 
skirt  the  coccyx  and  lower  end  of  the  sacrum  they  divide  the  muscles  and  liga- 
ments inserted  into  these  bones. 

Step  3. — With  a  Gigli  wire  saw  divide  the  sacrum  transversely  along  the 
line  of  the  original  skin-incision  (Step  i).     Reflect  downwards  the  flap  of  bone 


KRASKE  S    OPERATION  495 

and  superjacent  soft  parts  formed  by  the  preceding  steps  (Fig.  641).  The 
rectum  is  isolated,  tumor  excised,  and  intestinal  wound  closed  as  in  Kraske's 
operation.  After  attending  to  hemostasis  the  wound  is  loosely  packed  with 
iodoform  gauze  and  the  sacro-coccygeal  bone-flap  is  partially  replaced.  The 
patient  is  kept  on  his  side  for  a  few  weeks  to  avoid  injury  to  the  flap;  the  wound 
heals  by  granulation  and  the  flap  gradually  assumes  its  normal  position. 
Schlange  was  able  to  exhibit  to  the  Berlin  Medical  Society  a  patient  on  whom 
he  had  performed  the  above  operation  six  weeks  previously  with  a  result  per- 
fect as  regards  both  comfort  and  function. 

Kijmmel  no  longer  (1906)  excises  much  bone,  nor  does  he  use  large  bone- 
flaps.  He  excises  no  more  than  the  coccyx.  Rotter  does  the  same,  but  leaves 
the  point  of  the  coccyx  with  its  muscular  attachments.  After  dissecting  free 
the  diseased  segment  of  gut  Rotter,  if  possible,  resects  this  segment  and  re- 
establishes the  intestinal  continuity.  If  resection  is  impossible  he  amputates 
the  diseased  and  distal  portions  of  the  gut,  and  pulling  the  upper  segment  of 
gut  through  a  tunnel  bored  through  the  glutei  muscles,  establishes  a  gluteal 
anus  away  from  the  large  coccygeal  wourfd.  This  little  modification  (estab- 
lishment of  gluteal  anus)  has  been  very  life-saving. 

Rotter's  death  rate  has  fallen  from  32  per  cent,  before  1903  to  4^  per 
cent,  since  that  date.  His  late  results  have  been  very  encouraging.  (See 
" Centralblatt  fur  Chir.,"  July  14,  1906,  or  "La  Presse  Medicale,'^  July  21, 
1906.) 

W.  J.  Mayo's  Modification  of  Kraske's  Operation. — Place  the  patient  in  the 
Trendelenburg  position,  but  on  his  face  instead  of  on  his  back.  The  pelvis 
must  be  supported  at  the  end  of  the  table  and  the  hips  more  or  less  flexed. 
The  posture  might  be  called  the  reversed  lithotomy  position. 

Step  I . — Make  a  median  incision  from  near  the  anus  up  to  a  point  between 
the  middle  and  base  of  the  sacrum.  Reflect  the  soft  parts  from  the  coccyx 
and  the  lower  half  of  the  sacrum.  Divide  the  soft  parts  attached  to  the  sides 
of  sacrum  and  coccyx  all  the  way  around  these  bones  from  one  sacro-sciatic 
notch  to  the  other. 

Step  2.— With  a  chisel  divide  the  sacrum  transversely  at  the  second  foramen; 
i.e.,  at  the  level  of  the  sacro-sciatic  notch.  Excise  the  lower  part  of  the  sacrum 
and  the  coccyx.     The  mid-sacral  artery  will  require  ligation. 

Step  3. — Divide  the  levatores  ani  in  the  middle  line.  With  a  pledget  of 
gauze  wipe  downwards  the  external  and  at  least  part  of  the  internal  sphincter 
to  the  anus,  separating  these  structures  from  the  mucosa  of  the  gut.  (It  is 
assumed  that  the  mucosa  here  is  not  involved  in  the  disease.) 

Step  4. — Mobilize  the  rectum  above  the  disease.  Open  the  peritoneum 
and  pack  it  with  gauze.  Pull  the  sigmoid  (pelvic  colon)  downwards.  Ligate 
and  divide  the  inferior  mesenteric  artery.  Open  the  two  folds  of  meso-rectum 
and  wipe  downwards  all  the  fat  and  lymph  tissue  behind  the  rectum  in  the 
cavity  of  the  sacrum.  All  the  diseased  gut  now  lies  loose  except  at  its  upper 
and  lower  ends. 

Step  5. — Pull  the  rectum  upwards  so  that  the  anus  is  pulled  inwards  (or 
upwards).  This  is  possible  because  the  sphincters  have  already  been  separated 
from  the  anal  mucosa.     Clamp  and  divide  the  gut  at  the  muco-cutaneous 


496  THE   RECTUM 

junction.  The  loosened  sphincters  lie  below  the  clamp.  Clamp  and  divide 
the  gut  well  above  the  disease.     Remove  the  diseased  segment. 

Step  6. — Bring  the  rectal  stump  downwards;  pull  it  through  the  anus  until 
it  protrudes  one  inch.  Fix  it  in  position  with  safety  pins.  If  there  is  tension  on 
the  gut,  incise  the  peritoneum  more  freely  at  the  sides  as  this  is  the  support- 
ing force. 

Step  7. — For  a  distance  of  three  inches  upwards  from  the  anus  suture  the 
levatores  ani  muscles  together  and  to  the  posterior  surface  of  the  gut.  (If  the 
internal  sphincter  has  been  divided  and  preserved,  suture  it  along  with  the 
levatores. 

Remove  the  peritoneal  packs.  Attach  the  peritoneum  to  the  gut  with 
interrupted  sutures.  Provide  ample  drainage  by  means  of  split  rubber  tubes 
containing  strips  of  gauze.     Partly  close  the  external  wound. 

After  forty-eight  hours  remove  part  of  the  drains  (all  of  them  if  the  wound 
seems  clean).  Fill  the  wound  with  Van  Arsdale's  fluid  (5  per  cent,  balsam  of 
Peru  in  castor  oil).  The  Carrel  Dakin  treatment  of  the  wound  is  good.  Do 
not  repack  except  to  keep  the  exte^al  wound  open. 

Mummery s  Method  ("Brit.  Med.  Journ.,"  June  i,  1907). — ^Lithotomy  posi- 
tion with  pelvis  raised  on  small  hard  cushion.  (Combined  lithotomy  and  Tren- 
delenburg postures). 

Step  I. — Dissect  a  cufif  of  mucosa  from  the  anal  canal  for  about  2  inches, 
as  in  the  Whitehead  operation  for  piles.  With  sutures  or  clamp  completely 
close  this  tube  of  mucosa  so  that  nothing  can  escape  from  the  rectum.  With 
cautery  or  pure  carbolic  sterilize  the  stump.  Change  gloves  and  discard  all 
instruments  used.     Once  more  cleanse  the  parts. 

Step  2. — Make  a  median  incision  through  the  sphincters  backwards  to  and  a 
little  beyond  the  base  of  the  coccyx.  Remove  the  coccyx.  Open  the  posterior 
rectal  space  and  separate  from  the  sacrum  by  gauze  dissection  all  the  glands, 
fat,  etc.,  there  present  and  push  these  structures  forward  in  one  piece  along 
with  the  rectum. 

Step  3. — Pull  down  the  levator  ani  on  each  side  with  the  finger.  Divide 
the  muscle  close  to  the  rectum.  Separate  the  rectum  from  the  prostate  and 
urethra  (or  from  the  vagina).     This  requires  much  care. 

Step  4. — Open  the  peritoneal  cul-de-sac  and  divide  the  attachments  of  the 
peritoneum  to  the  rectum  first  on  one  side  and  then  on  the  other,  keeping  close 
to  the  rectum  to  avoid  the  ureters.  This  leaves  the  rectum  free  except  for  the 
meso-rectum. 

Step  5. — Divide  the  meso-rectum  as  near  the  sacrum  as  possible  after 
applying  clamps  or  better  suture  ligatures.  The  rectum  now  comes  down  freely 
and  the  sigmoid  presents.  The  lowest  portion  of  the  sigmoid  is  often  provided 
with  such  a  short  meson  that  it  cannot  be  brought  to  the  anus  without  tension. 
Divide  the  meso-sigmoid,  after  applying  clamps  or  ligatures  until  a  portion  of 
the  gut  is  reached  with  mesentery  long  enough  to  permit  easy  union  of  gut  to 
skin  (see  Fig.  642). 

The  tumor  and  all  the  rectum  are  now  outside  the  wound.  Do  not  yet 
divide  the  gut. 

Step  6. — Attend  to  hemostasis  in  a  painstaking  manner.     Suture  the  peri- 


Proust's  operation 


497 


toneum  to  the  sides  and  front  of  the  sigmoid.  Close  the  wound  after  providing 
for  "cigarette"  drainage.  Be  specially  careful  to  suture  the  sphincters 
accurately. 

Step  7. — Divide  the  gut  about  ^"i  to  i  inch  distal  to  the  sphincter.  ¥\x 
the  edges  of  the  divided  gut  by  a  few  stitches  not  to  the  margin  of  the  skin- 
wound  but  to  the  skin  itself  about  i  inch  away  from  the  wound.  This  greatly 
protects  the  wound  against  fouling.  Later  the  excess  of  mucosa  can  be  cut 
away.  Introduce  a  short  rubber  tube  into  the  bowel  to  permit  passage  of  gas. 
Apply  dressings. 


Fig.  642. — {Mummery,  ''Brit.  Med.  Jour.") 


Proust's  Modification  of  Kraske's  Operation. — Proust's  account  of  this  opera- 
tion ("La  Presse  Med.,"  December  28,  1907)  is  so  clear  and  so  well  illustrated 
that  it  would  be  unjust  to  that  surgeon  and  to  the  profession  not  to  give  a 
short  description  of  it  here.  For  two  weeks  before  operation  give  repeated 
purgatives  and  enemata.  Give  a  final  purgative  forty-eight  hours  before  opera- 
tion. Give  opium  sufficient  to  thoroughly  constipate  twenty-four  hours  prior 
to  operation. 

Place  the  patient  on  his  left  side,  thighs  slightly  flexed  and  buttocks  slightly 
over  the  edge  of  the  table.     The  ventral  position  may  be  used. 

Temporarily  close  the  anus  with  a  purse-string  suture. 

Step  I. — Same  as  in  Mayo's  method. 

Step  2. — Divide  the  sacrum  transversely,  four  fingers'  breadth  above  the 
point  of  the  coccyx,  i.e.,  on  a  line  just  below  the  third  foramen.  Remove  the 
lower  part  of  the  sacrum  and  the  coccyx.  Ligate  the  mid-sacral  artery  which 
lies  on  the  anterior  surface  of  the  bone.  Apply  moist,  hot  pads  to  the  cut  sur- 
face of  bone  to  stop  bleeding. 

Step  3. — The  retro-rectal  cavity  with  walls  smooth  as  a  serous  bursa,  is 
now  open.  Carefully  tear  a  hole  in  the  anterior  wall  of  this  cavity,  i.e.,  in  the 
aponeurotic  sheath,  and  expose  the  posterior  surface  of  the  rectum,  high  up 
on  which  lie  the  superior  hemorrhoidal  vessels.    Ligate  these  (Fig.  643).     En- 

32 


498 


THE    RECTUM 


Fig.  643.— Ligation  of  superior  and  middle  hemorrhoidal  vessels.     {Proust.) 


Fig.  644. — Ligation  of  branches  of  inferior  mesenteric  vessels.     (Proust. 


PROUST  S    OPERATION 


499 


large  the  opening  in  the  sheath  downwards  to  expose  the  middle  hemorrhoidal 
vessels.    Ligate  these  (Fig.  ^H.:?)- 

Step  4. — Bit  by  bit  separate  the  rectum  from  its  sheath  and  push  it  to  the 
left  until  the  peritoneum  appears  at  the  upper  part  of  the  field.  Open  the 
peritoneum  by  a  vertical  cut  in  the  middle  line.  Introduce  the  finger  and  hook 
it  round  the  gut  so  that  the  point  of  the  finger  raises  the  peritoneum  on  the 
opposite  side  of  the  gut.  Open  the  peritoneum  here  also.  Pass  a  loop  of  gauze 
round  the  gut  like  a  scarf  for  purposes  of  traction.  Pack  the  peritoneum  with 
gauze. 

Step  5. — Pull  the  rectum,  and  with  it  the  sigmoid,  downwards.  Successively 
ligate  and  divide  the  terminal  branches  of  the  inferior  mesenteric  vessels 
in  the  meso-sigmoid  (Fig.  644).  This  dissection  makes  the  descent  of  the 
sigmoid  easy.     Continue  the  dissection  until  the  neoplasm  and  an  ample  suffi- 


FiG.  645. — Closure  of  peritoneum  and  fixation  of  gut.     {Proust.) 


ciency  of  healthy  gut  is  delivered  and  until  healthy  gut  above  the  neoplasm 
can  be  brought  easily  and  without  tension  to  lie  against  healthy  gut  below 
the  neoplasm.  With  the  gut  bring  away  all  the  suspected  lymphatic  tissue  of 
the  meson. 

Step  6. — Partially  close  with  transverse  sutures  the  vertical  wound  in  the 
peritoneum.  Make  each  suture  pass  through  the  meso-sigmoid  above  the  part 
which  has  been  ligated  and  divided  but  do  not  include  any  vessels  within  the 
sutures.  Tie  the  sutures.  This  partly  closes  the  peritoneum  and  it  fixes  the 
gut  so  that  it  cannot  retract  upwards  (Fig.  645). 


500 


THE    RECTUM 


Step  7. — Apply  rubber-covered  intestinal  clamps  to  the  gut  above  and 
below  the  lines  chosen  for  division  of  the  intestine.  Lay  the  clamps  along  side 
each  other  and  unite  the  anterior  surfaces  of  the  two  loops  of  gut  by  a  row 
of  continuous  Lembert  sutures  on  the  tumor  side  of  the  clamps.  Apply  crush- 
ing clamps  to  the  two  loops  of  gut  between  the  line  of  Lembert  suture  and 
the  neoplasm.  Divide  the  gut  and  remove  the  neoplasm.  The  crushing  clamps 
prevent  escape  of  contents  from  the  gut  being  removed.  Complete  the  end- 
to-end  anastomosis  of  the  gut  (circular  enterorrhaphy)  (Fig.  646).  The  an- 
terior and  part  of  the  lateral  surfaces  of  the  gut  are  usually  covered  by  peri- 
toneum if  the  tumor  is  fairly  highly  placed  and  hence  good  serous  apposition 


Fig.  646. — .Vnastomosis  of  gut.     (Frousi.) 


can  be  attained.  The  posterior  surface  is  devoid  of  serosa  and  hence  union  is  less 
accurate.  Proust  therefore  recommends  that  no  attempt  be  made  to  cover 
this  portion  of  the  intestinal  wound  by  gliding  flaps  of  parietal  peritoneum 
over  it,  but  that  the  parietal  peritoneum  should  be  stitched  to  the  gut  in  such 
fashion  as  to  close  the  peritoneal  cavity  and  leave  the  doubtful  portion  of 
the  intestinal  wound  entirely  extraperitoneal.  If  the  tumor  is  found  at  too 
low  a  level  to  permit  of  safe  end-to-end  anastomosis  the  operation  may  be 
finished  by  Mayo's  method. 

Step  8. — Bring  the  edges  of  the  skin  wound  together  with  stitches  deep 
enough  to  catch  up  the  subjacent  tissues.  Drain  all  dead  spaces  with  loose 
gauze  packing.  Remove  the  purse-string  suture  which  closed  the  anus  tem- 
porarily.    Apply  dressings.     Keep  the  patient  constipated  during  one  week. 


PRELIMINARY   COLOSTOMY  50I 

Inguinal  Colotomy  as  a  Preliminary  to  Excision  oj  the  Rectum. — Should  ingui- 
nal colotomy  be  performed  as  a  preliminary  to  excision  of  the  rectum?  Quenu 
seems  to  consider  that  such  is  always  advisable;  other  surgeons  seem  to  consider 
that  it  is  always  needless.     Probably  the  truth  lies  between  these  extremes. 

Mummery  considers  colotomy  unnecessary  if  it  is  possible  to  thoroughly 
empty  the  bowel  of  all  retained  fjcces  before  operation  so  that  one  can  be 
morally  certain  no  faecal  material  will  find  its  way  into  the  lower  bowel  for 
some  days  after  the  operation  and  the  bowels  can  be  prevented  from  acting 
for  six  or  seven  days.  When  the  above  cannot  be  accomplished  preliminary 
colotomy  is  advisable. 

The  disadvantages  of  a  preliminary  colotomy  are  mainly  the  following: 

(a)  The  annoyance  of  an  operation  performed  some  days  before  the  main 
intervention. 

{h)  The  risk  and  annoyance  of  an  operation  performed  to  close  the  inguinal 
anus  some  weeks  after  the  main  intervention. 

(c)  Adhesion  of  the  sigmoid  flexure  to  the  abdominal  wall  at  the  site  of 
the  artificial  anus,  interfering  with  the  pulling  down  of  the  rectum  necessary 
to  excise  the  tumor  and  approximate  the  divided  ends  of  the  gut. 

.  This  is  the  real  objection  to  the  operation,  but  it  may  be  overcome  either 
by  exercising  care  in  choosing  the  part  of  the  colon  to  be  united  to  the  abdomi- 
nal wall  or  by  making  the  artificial  anus  on  the  right  side  of  the  abdomen. 

The  main  advantages  of  preliminary  colotomy  are  as  follows: 

(a)  Through  the  abdominal  cavity  one  can  explore  the  upper  limits  of  an 
extensive  cancer  and  observe  the  presence  of  serious  lymphatic  extension. 

{h)  One  prevents  the  passage  of  faeces  into  the  diseased  rectum  and  can 
thoroughly  irrigate  it  with  solutions  introduced  either  through  the  anus  or 
through  the  colotomy  wound.  During  the  after-treatment  one  is  not  depend- 
ent upon  opium  as  a  means  of  keeping  the  wound  free  from  faecal  contamina- 
tion. With  the  aid  of  a  preliminary  colotomy  it  is  easy  at  least  to  approximate 
cleanliness  in  an  excision  of  the  rectum. 

What  are  the  indications  for  radical  operation  in  rectal  cancer? 

Whenever  cancer  of  the  rectum  is  diagnosed,  it  should  be  removed  at  once. 
Too  much  should  be  removed  rather  than  too  little.  This  should  be  the  in- 
variable rule  except  when  the  patient's  local  or  general  condition  is  such  that 
the  operation  affords  no  hope  of  recovery,  in  which  case  palliative  treatment, 
e.g.,  by  colotomy,  must  be  initiated. 

From  careful  examination  of  a  rectum  excised  for  cancer  Sampson  Hardley 
comes  to  certain  conclusions  which  may  be  epitomized  as  follows  ("Brit.  Med. 
Journ.,"  April  16,  1910): 

(a)  That  permeation  of  the  growth  may  extend  very  widely  in  the  mucous 
plexus  upwards  and  downwards,  reaching  in  a  comparatively  early  stage  of 
the  disease  a  point  at  least  5  inches  from  the  edge  of  the  primary  disease.  The 
affected  section  of  the  bowel  may  appear  quite  healthy  to  ordinary  macro-  and 
microscopic  examination  (mucicarmine  is  a  specific  stain  for  cancer  cells  under- 
going mucoid  degeneration)  because  the  permeating  cells  have  undergone 
myxomatous  degeneration. 

{h)  Permeation  of  the  mucous  lymphatic  plexus  as  a  factor  in  dissemination 


so 2  THE   RECTUM 

is  probably  limited  in  effectiveness  by  the  habitual  degeneration  of  the  cancer 
cells  in  this  situation. 

(c)  Cancerous  infiltration  in  the  muscular  and  peritoneal  coats  does  not 
extend  far  from  the  primary  growth. 

(d)  Effective  dissemination  probably  occurs  as  a  rule  through  the  meso- 
rectum  or  peri-rectal  tissue  opposite  the  primary  growth  and  hence  this  tissue 
must  be  removed, 

(e)  Because  of  the  permeation  referred  to  in  (a)  a  great  length  of  bowel 
should  be  removed  including  the  sphincters. 

A  few  years  ago  cancer  of  the  rectum  was  considered  beyond  remedy  by 
operation  if  the  upper  limits  of  the  tumor  could  not  be  reached  by  the  finger 
passed  through  the  anus.  Mere  extent  of  tumor  along  the  gut  no  longer 
contraindicates  operation.  Extension  of  the  tumor  through  the  intestinal 
walls  and  involvement  of  neighboring  tissues  is  a  matter  of  great  import.  As 
a  general  rule,  it  may  be  said  that  when  the  tumor  has  become  absolutely 
immobile,  the  disease  is  so  widespread  that  operation  is  worse  than  useless; 
that  when  the  immobility  is  only  partial  it  may  possibly  be  due  to  simple  in- 
flammatory adhesions,  and  operations  may  be  justifiable,  though  exceedingly 
dangerous.  Esmarch  does  not  consider  involvement  of  the  base  of  the  bladder 
in  the  cancerous  process  a  contraindication  to  operation — he  boldly  excises  the 
diseased  bladder-wall  and  sutures  the  defect.  Extensive  involvement  of  the 
pelvic  lymphatic  glands  is  a  contraindication  to  operation  which  can  rarely 
be  utilized  unless  the  abdomen  is  explored.  If  one  practises  preliminary  colo- 
tomy,  one  has  the  opportunity  to  examine  the  pelvis  before  fixing  the  colon 
to  the  belly-wall. 

Choice  of  Operation. — In  most  cases  where  the  tumor  is  well  within  the  reach 
and  its  uppermost  extension  can  be  easily  palpated  by  the  finger  introduced 
through  the  anus,  the  operation  through  the  anus  or  perineum  may  be  chosen. 
In  such  localized  and  easily  surmounted  tumors  the  results  are  excellent. 

Kelsey  writes:  "The  advantages  of  the  sacral  incision  may  be  briefly 
enumerated  as  follows: 

"i.  To  dissect  methodically  cancers  situated  high  up,  and  preserve  the 
sphincters. 

"2.  To  completely  remove  cancers  distinctly  circumscribed,  but  which 
would  be  inoperable  by  the  older  methods,  their  upper  limit  being  beyond  the 
reach  of  the  knife. 

"3.  To  preserve,  in  whole  or  in  part,  the  external  sphincter,  even  when 
the  rectum  is  involved  low  down. 

"4.  To  avoid  the  formation  of  a  cloaca,  even  when  the  rectovaginal  septum 
is  invaded  by  the  disease. 

"5.  To  attack  recurrent  growths  while  yet  limited,  and  give  to  the  sufferers 
one  more  chance  of  health. 

"  6.  Finally,  to  render  more  easy  and  precise  the  extirpation  of  non-malignant 
strictures." 

Combined  Abdominal  and  Perineal  Rectectomy.—  Qu cnu's  Method. — Step 
I. — Place  the  patient  in  Trendelenburg's  position.  Open  the  abdomen  in  the 
middle  line  below  the  umbilicus. 


QUENU'S    OPERATION 


503 


Step  2. — Ligature  of  both  internal  iliac  arteries.  (This  is  for  the  control  of 
the  middle  and  inferior  hemorrhoidals.)  Note  the  inferior  border  of  the  prom- 
ontory of  the  sacrum;  on  each  side  of  this  can  be  felt  the  pulsation  of  the 
internal  iliac  arteries  or  of  the  common  iliac  if  the  division  has  not  yet  taken 
place.  At  this  level,  i}/i  inches  (3  cm.)  from  the  middle  line  and  a  trifle  to  the 
inner  side  of  the  pulsating  artery,  place  the  middle  of  a  2-inch  incision  through 
the  peritoneum  alone.  By  blunt  dissection  retract  the  outer  lip  of  the  peri- 
toneal wound  and  with  it  the  ureter.  Expose  the  common  and  the  external 
iliac  arteries.  A  little  downwards  and  inwards  expose  the  internal  iliac  and 
ligate  it  at  a  point  a  little  more  than  ^^  inch  below  the  bifurcation  (Fig.  647). 
On  the  left  side  the  ligation  is  not  so  easy  as  on  the  right,  because  the  origin 
of  the  meso-sigmoid  hides  the  vessels.  Two  methods  are  possible:  ia)  Pref- 
erable when  the  meso-sigmoid  is  short.    Lay  the  sigmoid  flexure  against  the  iliac 


Fig.  647. — Ligation  internal  iliac  artery.     {Monod  and  Vanverts  ) 

fossa;  make  an  incision,  symmetrical  to  that  on  the  right  side,  so  as  to  get 
through  the  meson  and  expose  the  parietal  peritoneum.  Incise  the  exposed 
peritoneum,  retract  the  outer  lip  of  the  peritoneal  wound,  and  proceed  to  the 
ligation  as  on  the  right  side,  {b)  If  the  meso-sigmoid  is  very  long,  pull  the 
sigmoid  upwards,  incise  the  parietal  peritoneum  immediately  below  the  origin 
of  the  meson,  and  thus  reach  the  vessels  directly.  When  it  is  evident  that  the 
ligation  of  the  left  iliac  will  be  difficult,  it  is  simpler  to  put  this  step  off  until 
after  the  sigmoid  has  been  divided  and  the  field  of  operation  has  been  made 
easier  of  access.  While  the  iliac  vessels  are  exposed,  examine  this  region  for 
enlarged  lymphatic  glands.  Close  the  wounds  made  in  the  peritoneum  over  the 
arteries. 

Step  3. — At  a  point  free  from  blood-vessels  tear  a  hole  in  the  meso-sigmoid 
and  pass  a  large  strip  of  gauze  through  it  (Fig.  648).  Protect  the  abdominal 
cavity  with  gauze  pads.  With  the  fingers  empty  the  contents  from  that  portion 
of  the  sigmoid  opposite  the  tear  in  the  meson.  Doubly  ligate  the  gut  and 
divide  it  between  the  ligatures,  preferably  with  the  thermocautery.  Cover 
the  divided  ends  of  gut  with  gauze  and  rubber  caps  held  in  place  by  a  thread  or 


504 


THE   RECTUM 


a  rubber  band.  This  to  prevent  soiling.  Working  downwards  from  the  tear  in 
the  meso-sigmoid,  divide  that  structure  between  forceps  or  ligatures  and  push 
aside   temporarily  the  lower  segment  of  gut.      Sudeck's  illustration  (Fig.  649), 


-^    %>    '-^  %^ 
Fig.  648. — Quenu's  operation.     {Monod  and  Vanverls.) 


Fig.  649. — Inferior  mesenteric  arter3\     (Sitdeck.) 

("Muench.  med.  Woch.,"  July  2,  1907)  gives  a  very  clear  idea  of  the  inferior 
mesenteric  artery.  It  is  best,  if  possible,  to  ligate  the  artery  after  it  gives  off 
its  last  important  anastomotic  branch,  i.e.,  when  the  ligation  is  for  hemostasis 
and  not  for  mobilization. 

Step  4. — Make  an  incision  in  the  left  iliac  region  through  the  parietes  (Fig. 


QUENU  S   OPERATION 


505 


650)  and  pull  the  divided  end  of  the  upper  segment  of  gut  through  this.*  Fix 
the  gut  in  position  by  a  few  sutures.  A  permanent  artificial  anus  is  thus  pro- 
vided.    For  Handley's  modification  see  p.  518. 

Step  5. — Pull  the  lower  segment  of  gut  (viz.,  that  to  be  removed)  forwards 
and  upwards  against  the  pubis.  Divide  the  meso-rectum  and  ligate  the  hem- 
orrhoidal vessels.  When  the  posterior  connections  of  the  rectum  have  been 
separated,  proceed  to  incise  the  recto-vesical  cul-de-sac  if  this  is  possible  of  access. 
Lay  the  whole  lower  segment  of  gut,  well  covered  with  gauze  pads,  in  the  deepest 
part  of  the  pelvic  fossa.  Completely  close  the  abdominal  wound,  after  as 
far  as  possible  diminishing  the  peritoneal  laceration  by  means  of  sutures  applied 
to  the  remnants  of  the  meso-rectum.  ' 

Step  6. — Place  the  patient  in  the  lithotomy  position  and  complete  the  opera- 
tion by  removing  the  loosened  rectum  and  its  protecting  pads  of  gauze  by  the 
perineal  route,  if  necessary  excising  the  coccyx  and  portions  of  the  sacrum. 
Provide  for  perineal  drainage  and  close  the  perineal  wound  with  sutures. 

Step  7. — According  to  circumstances,  either  leave  the  portion  of  gut  which 
has  been  fixed  in  the  left  iliac  region  untouched  for  two  or  three  days  or  open 
it  immediately  so  as  to  empty  the  bowels.  In  the  formation  of  the  artificial 
anus  the  use  of  Paul's  tube  will  aid  in  pre- 
venting soiling  of  the  dressings.! 

Modified  Quenu  Operation. — Step  i. — 
Place  the  patient  in  the  high  Trendelenburg 
position.  Open  the  abdomen  in  the  middle 
line  below  the  umbilicus.  Examine  as  to  the 
possibility  of  removing  the  disease.  Protect 
all  the  intestines  with  gauze  pads,  leaving  the 
sigmoid  and  rectum  free. 

Step  2. — Apply  two  clamps  to  the  gut  well 
above  the  disease  and  divide  the  gut  between 
them.  Close  each  end  of  gut  by  a  row  of 
through-and-through  sutures.  Invaginate 
the  stumps  into  the  lumen  of  the  gut  by  a 
purse-string  suture  as  in  appendectomy. 
Leave  uncut  the  suture  attached  to  the  upper 
segment  of  gut;  apply  a  hemostat  to  the  end 
of  the  suture;  the  suture  will  act  as  a  guide 
to  the  gut  later. 

Step  3. — Pull  the  end  of  the  lower  segment  of  gut  up  into  the  wound.  On 
each  side  of  the  gut  make  a  cut  through  the  peritoneum  of  the  meson  parallel 
to  the  gut  and  strip  back  the  peritoneum.  If  the  lower  part  of  the  sigmoid 
forms  a  part  of  the  lower  or  rectal  segment  of  gut,  ligate  its  vessels  which  are 
easily  seen.  Continue  the  incisions  in  the  meson  downwards  on  each  side  of  the 
rectum,  stripping  the  peritoneum  off  the  meso-rectum.  Divide  the  peritoneum 
anteriorly  so  as  to  separate  the  rectum  from  the  uterus,  or  from  the  bladder, 
prostate,  etc. 

*  This  incision  is  best  made  in  exactly  the  same  way  as  in  McBurney's  muscle-splitting 
operation  of  appendectomy. 

t  The  above  description  has  been  taken,  practically  completely,  from  Monod  and  Van- 
verts'  "Traite  de  Technique  Operatoire." 


Fig 


.  650. — Quenu's  operation. 
{Monod  and  Vanverts.) 


5o6 


THK   kkchm 


Step  4. — Find  and  ligate  the  inferior  mesenteric  artery  just  to  the  left  of  the 
promontory  of  the  sacrum.  With  gauze  wipe  downwards  all  the  fat  and  lym- 
phatic tissue  posterior  to  the  rectum;  this  is  rendered  possible  by  the  incision  and 
reflection  of  the  peritoneal  surfaces  of  the  meson.  While  wiping  the  fat  down- 
wards expose  and  ligate  the  middle  sacral  artery  as  high  as  possible.     Continue 


Fig.  652. 
Figs.  651,  652  and  653. 


Fio.  653. 
-{Weir,  "Jour.  Am.  Med.  Assoc.'") 


the  gauze  dissection,  laying  bare  the  internal  iliac  vessels  and  the  ureters.  Find 
and  ligate  the  middle  hemorrhoidal  arteries  which  arise,  one  on  each  side,  from 
the  anterior  divisions  of  the  internal  iliac  arteries  and  run  inward  to  the  middle 
portion  of  the  rectum. 

Step  5. — If  sufficient  gut  above  the  anus  is  healthy,  complete  the  operation 


WEIR  S    OPERATION 


^"/ 


by  Weir's  method.  If  restoration  of  the  continuity  of  the  intestinal  canal 
is  impossible  or  too  dangerous,  complete  as  in  Quenu's  operation. 

R.  F.  Weirs  Operation. — This  operation  is  suitable  in  cases  of  cancer  situ- 
ated high  up  iu  the  rectum. 

Step  I. — Open  the  abdomen  in  the  middle  line  or  through  the  left  rectus 
muscle. 

Step  2. — Free  the  rectum  from  its  connections  to  a  point  near  the  tip  of  the 
coccy.x  posteriorly  and  to  the  edge  of  the  prostate  anteriorly. 

Step  3. — Divide  the  gut  between  two  ligatures  above  the  tumor  (Fig.  651). 

Step  4. — By  means  of  forceps  passed  up  through  the  anus  seize  the  upper 
end  to  the  lower  segment  of  gut  and  pull  it  out  through  the  anus,  thus  inverting 
the  gut.     Cut  away  the  tumor. 


Fig.  654. — (Weir,  "Jour.  Am.  Med.  Assoc") 


Step  5. — Pull  the  distal  end  of  the  proximal  segment  through  the  inverted 
lower  segment.  The  serous  surfaces  of  the  two  segments  lie  in  apposition. 
Unite  the  two  segments  by  means  of  Maunsell's  method  of  suturing  (Figs. 
652  and  653). 

Step  6. — Reduce  the  prolapsed  gut.  Suture  the  pelvic  peritoneum  divided 
when  freeing  the  rectum  from  its  connections  (Fig.  654).  This  suture  shuts 
off  the  general  peritoneal  cavity  from  the  deep  portion  of  the  pelvis. 
Drain  the  lower  portion  of  the  pelvis  through  an  incision  made  behind  the  anus 
(Fig.  654;). 

Maunsell  and  Trendelenburg  have  performed  a  very  similar  operation,  but 
drain  the  deep  pelvis  with  gauze  brought  out  through  the  abdominal  wound. 


5o8 


THE    RECTUM 


Miles  Operation  (Brit.  J.  Surg.,  Oct.,  1914). — Step  i.— Place  the  patient  in 
the  high  Trendelenburg  position.  Make  an  incision  just  to  the  left  of  the  linea 
alba  from  the  symphysis  pubis  to  or  beyond  the  umbilicus.  Examine  the  liver  for 
metastases.  Examine  the  pelvic  mesocolon  for  nodules  or  plaques  of  growth, 
if  such  are  present  or  if  the  bladder  or  vagina  are  involved  in  the  disease  the 
case  is  inoperable.  It  is  important  to  have  the  pelvis  cleared  of  all  the  small 
intestines  and  if  it  is  impossible  to  keep  them  out  of  the  way  in  the  upper 
abdomen  Miles  does  not  hesitate  to  pull  them  out  of  the  wound  and  let  them 
hang  down  outside  the  abdomen  protected  by  an  abdominal  swab  wrung  out  of 
warm  salt  solution. 

Step  2. — Draw  the  pelvic  colon  through  the  wound,  if  necessary,  mobilizing 
it  by  incising  the  outer  side  of  its  mesocolon.     This  mobilization  exposes  the 

colonic  vessels  and  permits  of  the  proximal 
segment  of  colon  being  subsequently  used 
for  colostomy  without  undue  tension. 
Choose  a  point  on  the  bowel  between  the 
anastomotic  loops  of  the  first  and  second 
sigmoidal  branches  of  the  inferior  mesen- 
teric artery  and  apply  to  the  bowel  a 
powerful  crushing  forceps  for  about  two 
minutes.  Miles  clamp  has  a  blade  i 
inch  wide.  Remove  the  clamp  and  pass 
a  stout  thread  through  the  meson  at  each 
extremity  of  the  crushed  area  and  tie 
firmly  (Fig.  655).  Divide  the  bowel  be- 
tween the  ligatures  and  also  divide  a  por- 
tion of  the  mesocolon  which  has  also  been 
crushed.  Invaginate  the  ligated  ends  of 
the  bowel  by  means  of  purse-string 
sutures. 

Step  3. — Make  an  incision  through 
the  peritoneum  on  the  outer  aspect  of  the 
pelvic  mesocolon  along  its  parietal  border  at  the  level  of  the  left  sacro-iliac  syn- 
chondrosis. Note  and  avoid  the  left  ureter  as  it  crosses  the  common  iliac  artery 
(Fig.  656).  This  is  important  because  the  ureter  is  parallel  and  close  to  the 
inferior  mesenteric  vessels  and  might  easily  be  ligated  with  them.  Ligate  the 
inferior  mesenteric  artery  immediately  below  the  origin  of  the  first  sigmoid 
branch.  If  the  first  and  second  sigmoid  arteries  arise  by  a  common  trunk  do 
not  ligate  the  trunk  but  tie  the  first  sigmoid  below  the  trunk  and  the  second 
when  the  mesentery  is  divided.  Divide  the  remainder  of  the  pelvic  meso- 
colon, the  inferior  mesenteric  vessels  as  they  lie  in  its  parietal  border  being 
also  divided  below  the  point  of  ligature.  Drop  the  proximal  end  of  the  colon 
temporarily  into  the  abdominal  cavity. 

Step  4. — Beginning  at  the  point  where  the  pelvic  mesocolon  has  been  cut 
across,  make  an  incision  on  either  side  of  the  attachment  of  the  lower  portion 
of  the  pelvic  mesocolon  at  a  distance  of  about  i  inch  from  it.  Carry  these 
incisions  downwards  parallel  to  the  mesocolon  to  the  level  of  the  peritoneal 


Fig.  655. — Showing  the  crushed  area  of  the 
bowel  after  removal  of  the  clamp. 

A  ligature  is  passed  through  the  mesocolon 
close  to  the  bowel  on  either  side  of  the  crushed 
area,  and  tied  firmly.  The  interrupted  line  in- 
dicates the  incision  to  be  made  through  the 
crushed  bowel  and  adjacent  portion  of  the 
mesocolon.  (Illustration  taken  from  Mr.  Ernest 
Miles'  paper  in  the  British  Journal  of  Surgery, 
October,  1914.) , 


MILES    OPERATION 


509 


reflexion  in  the  pelvis.  These  incisions  are  in  the  posterior  parietal  peritoneum 
on  each  side  of  the  meson  and  i  inch  from  it.  This  gives  access  to  lymphatics 
which  extend  under  the  peritoneum  to  each  side  of  the  meson.     Pull  the  distal 


^K-^tKiVf^  • 


Fig.  656. — Showing  complete  division  of  the  pelvic  mesocolon  and_ligature  of  the  inferior 
mesenteric  artery  at  the  seat  of  election. 
The  portion  of  the  bowel  on  the  left-hand  side  is  that  from  which  the  colostomy  is  eventually  made. 
The  incision  in  the  peritoneum,  carried  forward  on  the  left  side,  exposes  the  left  ureter  as  it  crosses  the 
left  common  iliac  vessels.  The  ureter  is  drawn  aside  while  the  ligature  is  placed  around  the  inferior  mesen- 
teric vessels.  (Illustration  taken  from  Mr.  Ernest  Miles'  paper  in  the  British  Journal  of  Surgery,  October, 
1914.) 

segment  of  colon  forwards  and  open  the  connective-tissue  space  in  front  of  the 
concavity  of  the  sacrum.  By  finger  and  gauze  dissection,  from  above  down- 
wards, detach  the  rectum  (ensheathed  in  the  fascia  propria  recti)  along  with  its 


;io 


THE    RECTUM 


meson,  blood-vessels  and  lymphatic  glands  from  the  ligamentous  structures 
in  front  of  the  sacrum  (Fig.  657). 

Carry  this  separation  down  to  the  level  of  the  sacro-coccygeal  articulation 
which  may  be  recognized  by  the  firm  attachment  of  the  fascia  propria  recti 
to  the  end  of  the  sacrum.     Do  not  injure  the  median  sacral  veins. 


-.--■  /;«\n*: 


>tti. 


Fig.  657. — Showing  the  rectum  and  the  retrorectal  tissues  separate  from  the  hollow  of   the 
sacrum  as  far  as  the  sacrococcygeal  articulation. 

After  ligature  of  the  inferior  mesenteric  vessels,  the  remains  of  the  pelvic  mesocolon  are  divided  below 
the  ligature,  and  the  incisions  in  the  pelvic  peritoneum  are  carried  forwards  on  either  side  along  the  lateral 
wall  of  the  pelvis.  The  cellular  space  in  front  of  the  sacrum  is  opened  up  as  far  as  the  coccyx.  (Illustration 
taken  from  Mr.  Ernest  Miles'  paper  in  the  British  Journal  of  Surgery,  October,  1914.) 


Step  5. — Bring  the  two  peritoneal  incisions  forward  around  the  rectum  to 
meet  behind  the  base  of  the  bladder  in  the  male  or  the  upper  portion  of  the 
vagina  in  the  female.  Look  out  for  the  ureters  which  are  adherent  to  the 
parietal  peritoneum  as  they  skirt  the  lateral  wall  of  the  pelvis  on  their  way  to 
the  bladder. 

Bluntly  separate  the  anterior  wall  of  the  rectum  from  the  bladder  and  seminal 
vesicles  as  far  as  the  upper  border  of  the  prostate,  in  the  male  looking  out  for 
and  avoiding  the  vasa  deferentia,  and  from  the  vagina  in  the  female. 


MILES    OPERATION 


511 


Step  6. — The  lateral  ligaments  of  the  rectum  are  two  strong  bands  of  con- 
nective tissue,  each  about  i^-^  or  2  inches  deep,  extending  from  the  sides  of  the 
rectum  forwards  and  outwards  towards  the  base  of  the  bladder  (Fig.  658). 


Fig.  658. — Showing  the  separation  of  the  anterior  connections  of  the  rectum  as  far  as  the 
upper  border  of  the  prostate,  and  division  of  the  lateral  ligaments. 

The' lateral  incisions  in  the  peritoneum  have  been  extended  on  either  side  so  as  to  meet  in  front  behind 
the  base  of  the  bladder.     The  lateral  ligaments  have  been  defined  as  far  as  the  upper  surface  of  the  levator 
ani  on  either  side.     These  ligaments  are  then  completely  divided  with  scissors,  the  ureter  on  the  left  side 
having  been  drawn  aside.     (Illustration  taken  from  Mr.  Ernest  Miles'  paper  in  the  British  Journal  o 
Surgery,  October,  1914.) 


Separate  the  rectum  from  its  lateral  attachments.  On  the  left  side  never  lose 
sight  of  the  ureter  as  it  lies  close  to  the  rectum  and  is  easily  injured.  On  the 
right  the  ureter  is  more  remote  and  ought  to  be  left  undisturbed  in  its  attach- 
ment to  the  parietal  peritoneum. 


512 


THE    RECTUM 


Divide  the  lateral  ligaments  completely.  Failure  in  completeness  of  this 
section  renders  the  perineal  portion  of  the  operation  difficult.  When  dividing 
the  left  lateral  ligament  do  not  forget  the  ureter.  The  middle  hemorrhoidal 
arteries  lie  in  the  lateral  ligaments  but  are  small  and  rarely  require  ligation. 

Miles  remarks  that  these  are  the  only  branches  of  the  internal  iliac  arteries 
divided  during  the  abdominal  part  of  the  operation  and  hence  there  is  no  use  in 
preliminary  ligation  of  the  internal  iliacs  as  is  sometimes  advised. 


Fig.  659. — Showing  method  of  restoring  the  pelvic  floor  of  the  male. 

A  flap  of  peritoneum  has  been  dissected  up  from  the  bladder  and  drawn  backwards  until  it  meets  the 
cut  edge  of  the  pelvic  mesocolon,  to  which  it  is  sutured.  On  the  right  side  the  distal  portion  of  the  pelvic 
colon  can  be  seen  lying  in  the  pelvic  cavity  below  the  new  pelvic  floor.  (Illustration  taken  from  Mr 
Ernest  Miles'  paper  in  the  British  Journal  of  Surgery,  October,  1914.) 


Step  7. — The  rectum  having  been  freed  in  all  directions,  anteriorly  as  far 
as  the  upper  border  of  the  prostate  or  half  way  down  the  posterior  vaginal  wall, 
posteriorly  as  far  as  the  sacro-coccygeal  articulation,  and  laterally  down  to  the 
levatores  ani,  push  it  down  into  the  cavity  of  the  pelvis.  The  peritoneum  on 
each  side  of  the  pelvic  mesocolon  has  been  widely  excised  (this  incision  is  fimda- 


MILES     OPERATION 


513 


mentally  important  to  prevent  recurrence) ;  therefore  a  large  gap  remains  which 
must  be  closed.  Dissect  the  peritoneum  freely  up  from  the  lateral  walls  of  the 
pelvis  (avoiding  injury  to  the  ureters)  until  the  posterior  margins  can  be  brought 
together  in  front  of  the  promontory  of  the  sacrum,  without  undue  tension,  and 
sutured  to  the  stump  of  the  pelvic  mesocolon  where  the  inferior  mesenteric 
vessels  have  been  tied.  A  large  pear-shaped  gap  still  remains.  In  the  male 
dissect  up  a  flap  of  peritoneum  from  the  bladder,  lay  it  across  the  gap  and  suture. 
In  the  female  dissect  up  the  innermost  layers  of  the  broad  ligaments  and  use  the 
flaps  to  fill  the  defect  (Fig.  659).  It  is  tempting  to  use  the  uterus  to  cover  the 
gap  but  Miles  found  that  menstrual  troubles  resulted.  Omental  grafts  may  be 
required  to  supplement  the  peritoneal  flaps. 


■"SS^^E^w: 


Fig.  660. — Showing  the  reflection  of  the  skin  flaps  and  opening  of  the  sacrococcygeal  joint. 

_  When  the  surface  incisions  around  the  anus  are  deepened,  as  much  as  possible  of  the  ischiorectal  fat 
is  included.  (Illustration  taken  from  Mr.  Ernest  Miles'  paper  in  the  British  Journal  of  Surgery,  October, 
19x4.) 


Step  8. — Pull  the  proximal  segment  of  colon  through  a  small  incision  about 
I  inch  internal  to  the  left  anterior  superior  iliac  spine  and  establish  an  artificial 
anus  (it  is  well  not  to  open  the  new  anus  for  some  time). 

Step  9. — Attend  to  the  toilet  of  the  peritoneum.  Introduce  two  or  three 
pints  of  warm  saline  solution  into  the  abdomen.  Close  the  wound.  Apply 
dressings. 

Step  10. — Place  the  patient  in  the  right  dorsal  semiprone  position.  Close 
the  anus  by  a  purse-string  suture.  Make  the  incision  shown  in  Fig.  660. 
Open  the  sacro-coccygeal  articulation  and  remove  the  coccyx.  Make  a  small 
33 


5^4 


THE    RECTUM 


transverse  incision  into  the  dense  connective  tissue  immediately  below  the 
sacrum,  where  the  attachment  of  the  fascia  propria  recti  can  readily  be  detached 
from  the  front  of  the  lowermost  piece  of  the  sacrum.  Thrust  the  index  finger 
into  this  and  so  into  the  space  containing  the  isolated  bowel.  Divide  the 
coccygei  muscles  transversely  on  each  side,  extending  the  cuts  outwards  as  far 
as  the  sacro-sciatic  ligaments  (Fig.  66i).  Pull  the  bowel  out  through  this 
wound.  If  in  the  earlier  stages  of  the  operation  the  anterior  connections  of 
the  rectum  have  been  separated  down  to  the  prostate,  the  base  of  the  bladder. 


Fig.  66 1. — Showing  the  pelvic  colon  and  the  isolated  upper  part  of  the  rectum  withdrawn 

from  the  cavity  of  the  pelvis. 

If  the  isolation  of  the  rectum  has  been  efficiently  carried  out  anteriorly,  posteriorly,  and  laterally,  the 
bowel  can  be  readily  withdrawn,  in  the  manner  shown,  and  the  base  of  the  bladder,  the  vesiculae  seminales, 
with  the  vasa  deferentia  and  the  prostate  gland,  are  clearly  exposed  to  view.  The  levatores  ani  are  then 
divided  close  to  their  origin  from  the  pelvic  wall.  (Illustration  taken  from  Mr.  Ernest  Miles'  paper  in 
the  British  Journal  of  Surgery,  October,  1914-) 


the  vesiculae  seminales,  the  vasa  deferentia  and  the  upper  part  of  the  prostate, 
come  into  view.  In  the  female,  the  uterus  and  upper  half  of  the  vagina  are 
exposed.  Pull  upon  the  bowel  and  thus  put  the  levatores  ani  on  the  stretch. 
Divide  them  close  to  the  lateral  wall  of  the  pelvis.  If  these  muscles  do  not  come 
into  view  on  traction  being  made  it  is  because  the  lateral  ligaments  of  the  rectum 
have  not  been  sufficiently  divided  in  step  6.  Until  these  ligaments  have  been 
completely  divided,  delivery  of  the  bowel  is  difficult  and  the  levatores  cannot  be 
divided. 


TUTTLE  S    OPERATION  515 

If  the  growth  is  situated  on  the  anterior  wall  of  the  ampulla,  Miles  always 
removes  the  prostatic  capsule  with  the  rectum. 

Dissect  the  anal  canal  from  the  perineum  avoiding  injuring  the  membraneous 
urethra. 

Step  II. — -Pack  the  huge  cavity  with  strips  of  gauze  to  support  the  pelvic 
floor  which  is  formed  only  of  peritoneum,  but  place  a  sheet  of  protective  or 
rubber  dam  between  the  gauze  and  the  walls  of  the  cavity  to  prevent  adhesion. 
Adhesion  of  the  gauze  to  the  peritoneum  has  caused  serious  trouble.  Close 
most  of  the  wound  with  sutures.     Apply  dressings. 

Tuttle's  Operation. — ("Amer.  Journ.  Surg.,"  June,  1910.)  Prepare  the 
patient  during  several  days  by  diet,  purges,  irrigations,  etc.  Immediately 
before  operation  irrigate  the  rectum  with  a  3  per  cent,  solution  of  formalin, 
wiping  this  out  and  then  injecting  two  or  three  ounces  of  pure  peroxide  of 
hydrogen  up  into  the  rectum  and  above  the  tumor  if  possible. 

Step  I. — Put  the  patient  in  the  Trendelenburg  position.  Freely  open  the 
abdomen  by  a  longitudinal  ircision  just  outside  the  left  rectus  muscle.  Ex- 
amine for  adhesions,  metastasis,  etc. 

Step  2. — Treatment  oi  meso-sigmoid.  Select  "a  point  on  the  sigmoid 
two  inches  further  above  the  tumor  than  the  latter  is  above  the  anus."  Make 
a  small  incision  in  the  peritoneal  layer  of  the  meso-sigmoid,  one-half  inch 
from  the  margin  of  the  gut;  introduce  through  the  incision  a  thin  spatula-like 
director  and  on  this  as  a  guide  incise  the  peritoneum  parallel  with  the  gut 
down  to  the  tumor.  Turn  the  gut  over  and  repeat  the  process  on  the  other 
side  of  the  meso-sigmoid.  Strip  the  peritoneum  back  on  both  sides  of  the 
meson  to  its  origin  on  the  posterior  abdominal  wall.  Division  of  the  peritoneum 
as  described  permits  the  gut  to  be  pulled  further  out  of  the  wound  and  facilitates 
tying  the  blood-vessels  and  removing  the  glands. 

Step  3. — The  gut  being  pulled  upwards  through  the  wound,  begin  near 
the  origin  of  the  visible  vessels  to  brush  all  fat  and  glands  from  them  by  gauze 
dissection,  towards  the  intestine  until  the  lower  sigmoidal  artery  is  found  and 
traced  to  its  origin  in  the  superior  hemorrhoidal.  Doubly  tie  and  divide  the 
superior  hemorrhoidal  artery  just  above  the  origin  of  the  lower  sigmoidal, 
which  point  is  usually  just  below  the  promontory  of  the  sacrum  and  in  the 
angle  of  the  iliac  vessels. 

A  glance  at  Fig.  662  shows  that  if  the  ligation  is  made  as  directed  (XX') 
the  anastomosis  between  the  colonic  and  hemorrhoidal  vessels  is  ample  to 
keep  up  the  circulation  in  the  latter.  An  extra  amount  of  mobilization  may  be 
obtained  by  double  ligation  and  division  of  another  anastomotic  trunk  at  YY' 
without  interference  with  the  rectal  nutrition. 

Step  4. — Split  the  deep  fascia  behind  the  lower  stump  of  the  ligated  vessels 
and  peel  the  rectum,  fat  and  glands  out  of  the  sacral  cavity  down  to  the  tip  of 
the  coccyx  posteriorly  and  to  the  upper  surface  of  the  levatores  ani  on  the  sides. 
Pack  the  cavity  with  hot  moist  gauze  to  control  oozing. 

Step  5. — Carry  the  peritoneal  incision  ''across  the  gut  one  inch  above  the 
tumor  and  through  the  cul-de-sac  between  the  gut  and  the  bladder  or  the  uterus 
as  the  case  may  be." 


:i6 


THE    RECTUM 


Fig.  662. — Mobilization  of  sigmoid  by- 
division  of  vessek. 


Separate  the  gut  from  the  anterior  organs  by  blunt  dissection  as  far  down  as 
possible  without  too  great  traumatism,  usually  as  far  as  the  prostate  at  least. 

Step  6. — Remove  the  gauze  from  the  sacral  cavity.  Examine  the  sigmoid 
and  on  it  choose  the  lowest  portion  (well  above  the  tumor)  where  the  nutrition 
is  above  reproach.  Carry  this  part  of  the  sigmoid  down  to  the  tip  of  the  coccyx 
to  measure  whether  it  can  be  brought  out  of  the  anus  without  tension.     If 

it  cannot,  study  whether  it  is  the  blood- 
vessels or  the  peritoneal  covering  of  the 
meso-sigmoid  which  holds  it.  If  the 
peritoneum,  then  increase  the  incision 
made  in  Step  2;  if  the  vessels,  feel  which 
one  is  at  fault  and  divide  it  between  two 
ligatures  (Fig.  662,  YY')  in  such  a  man- 
ner as  not  to  interfere  with  anastomosis. 

Step  7. — Method  A. — The  tumor  is  of 
moderate  size  and  is  three  inches  or  more 
from  the  anus.  Tie  a  narrow  tape  with 
long  ends  around  the  gut  just  above  the 
tumor.  Have  an  assistant  dilate  the 
anus  and  pass  through  it  a  long  dressing 
forceps  to  a  point  just  below  the  tumor. 
Protect  the  abdomen  with  pads.  Make  the  points  of  the  forceps  perforate  the 
gut  just  below  the  tumor;  seize  the  ends  of  the  tape  with  the  forceps  and  pull 
them  into  the  gut  and  out  through  the  anus.  By  pulling  on  the  tapes  and  push- 
ing the  tumor  downwards,  the  tumor  is  invaginated  into  the  lower  segment  of 
gut  and  out  through  the  anus  dragging  after  it  the  lower  segment  of  mobilized 
sigmoid  to  the  desired  extent.  Replace  all  reflected  flaps  of  peritoneum  and 
repair  all  peritoneal  wounds  with  sutures  until  the  floor  of  the  pelvis  and  the 
meso-sigmoid  are  entirely  restored.  Close  the  abdomen.  Put  the  patient  in  the 
lithotomy  position.  Cut  through  the  rectum  or  surrounding  tube  (intussus- 
cipiens)  all  around,  catch  the  edges  with  forceps.  Through  this  circular  wound 
note  the  intussuscepting  sigmoid  (intussusceptum)  and  find  the  lowest  point 
in  it  where  the  circulation  is  good  (prove  that  the  circulation  is  good  by  punctur- 
ing with  a  needle)  and  yet  which  is  high  enough  above  the  tumor.  Suture  this 
portion  of  sigmoid  to  the  wall  of  the  everted  rectum.  Cut  away  the  gut  below 
the  line  of  suture  and  stitch  the  mucous  membrane  of  the  sigmoid  to  that  of  the 
rectum.  Pass  a  large  rubber  tube  into  the  rectum.  With  four  sutures  passed 
through  the  margin  of  the  gut  and  the  skin  outside  the  anus  prevent  retraction 
inwards  of  the  line  of  suture  until  union  has  taken  place.  Mayo  uses  safetji  pins 
instead  of  sutures.  Drainage  is  secured  by  a  tube  or  cigarette  drain  introduced 
into  the  hollow  of  the  sacrum  through  a  cut  made  alongside  the  coccyx. 

Method  B. — The  tumor  is  high  up  and  too  large  to  be  evaginated  through 
the  anus.  Have  the  assistant  make  an  incision  alongside  the  coccyx  and 
through  this  pull  out  the  tapes  and  with  them  the  sigmoid.  Repair  the  peri- 
toneum and  close  the  abdomen.  Excise  the  tumor  through  the  parasacral 
incision,  enlarging  this  if  necessary.     Unite  the  ends  of  the  gut  by  circular 


Balfour's  operation 


517 


sutures  or  evaginate  them  through  the  anus  and  treat  them  after  the  manner 
described  in  Weir's  operation,  page  507. 

Balfour's  Operation. — ("Annals  of  Surg.,"  Feb.,  1910.)  Suitable  for  tumors 
near  the  junction  of  the  rectum  and  sigmoid. 

Step  I. — Place  the  patient  in  the  high  Trendelenburg  position.  Excise 
the  tumor  in  the  usual  manner,  through  an  abdominal  incision. 

Step  2. — Provide  a  rubber  tube  about  ^  inch  in  diameter  similar  in  stiffness 
to  those  used  for  colonic  lavage.  The  tube  should  have  a  lateral  eye  near  its 
end  to  permit  the  escape  of  gas  should  the  end  become  obstructed.  Pass  the 
tube  from  the  abdomen  through  the  lower  segment  of  gut  so  as  to  protrude 
through  the  anus.     Pass  the  "eyed"  end  of  the  tube  into  the  proximal  segment 


mT 


Fig.  663.  Fig.  664.  Fig,  665. 

Figs.  663,  664  and  665. — Balfour's  operation. 

of  sigmoid  for  about  3  inches  having  previously  prevented  accidental  extrusion 
of  faecal  matter  by  the  application  of  a  guarded  clamp  placed  sufficiently  high 
above  the  line  of  section.  One-half  inch  above  the  cut  end  of  the  sigmoid  fix 
the  tube  to  the  intestine  by  a  transverse  stitch  of  catgut  (Fig.  663). 

Step  3. — Have  an  assistant  pull  upon  the  tube  projecting  from  the  anus 
until  the  cut  ends  of  the  proximal  and  distal  segments  of  intestine  are  in  ap- 
position. Unite  the  upper  to  the  lower  segment  of  intestine  by  carefully  applied, 
interrupted,  through-and-through  sutures  of  chromicized  catgut.  Be  careful 
to  coapt  the  mucous  membranes  (Fig.  664). 

Step  4. — Have  the  assistant  once  more  pull  upon  the  protruding  tube  so  as  to 
produce  an  invagination  of  the  proximal  for  about  }^  inch  into  the  distal  seg- 
ment of  gut.  Assist  this  invagination  by  steadying  the  lower  segment  of  the 
intestine  with  a  few  forceps.  Insert  sero-muscular  sutures  around  the  invagina- 
tion to  prevent  the  withdrawal  of  the  intussusceptum  (Fig.  665).     (Occasion- 


510  THE    RECTUM         » 

ally  it  has  been  impossible  to  insert  the  second  row  of  sutures  and  yet  good  re- 
sults have  been  obtained.) 

Step  5. — Repair  the  peritoneal  wound  behind  the  anastomosis  by  sliding 
the  peritoneum  and  suturing  it.  Pull  the  omentum  down  over  the  site  of  an- 
astomosis and,  if  necessary,  secure  it  there  by  a  catgut  suture. 

Step  6. — Close  the  abdomen  after  providing  for  drainage. 

The  rubber  rectal  tube  remains  in  situ  until  the  catgut  suture  is  absorbed 
(about  six  days).  Do  not  remove  the  abdominal  drain  for  one  week  because 
a  temporary  fsecal  fistula  sometimes  occurs. 

Rotter  ("Handbuch  der  praktischen  Chirurgie")  writes:  "The  tendency 
of  the  French  to  make  a  permanent  iliac  anus  in  every  case  is  not  approved 
in  Germany.  Whenever  practicable,  we  endeavor  to  preserve  the  sphincter 
ani,  and  consequently  continence.  This,  as  a  rule,  can  be  attained.  The 
danger  of  infection  is  very  slight,  as  the  gut  is  only  opened  at  the  end  of  the 
operation.  If  union  of  the  divided  ends  of  the  gut  is  impossible  owing  to  the 
shortness  of  the  upper  segment,  we  prefer  to  make  a  sacral  rather  than  an  iliac 
anus." 

German  surgeons,  as  a  rule,  make  use  of  an  abdomino-dorsal  instead  of  an 
abdomino-perineal  operation.  By  the  sacral  (dorsal)  route  they  expose  and 
free  the  rectum  as  far  as  conditions  permit,  and  then,  if  they  meet  with  diffi- 
culties, open  the  abdomen,  mobilize  the  gut  to  the  necessary  extent,  close  the 
abdominal  wound,  and  pull  the  gut  (rectum  and,  if  necessary,  sigmoid)  out 
of  the  sacral  wound,  when  the  neoplasm  is  excised  and  the  divided  ends  of  gut 
united  by  circular  enterorrhaphy  or  by  the  invagination  method. 

W.  E.  Miles  has  had  a  large  experience  in  both  the  perineal  and  sacral 
operations  and  found  the  ultimate  results  to  be  atrocious;  in  fact  there  was  re- 
currence in  55  out  of  58  patients.  He  operates  by  the  combined  method  (p.  508) 
removing  nearly  the  whole  of  the  pelvic  colon,  the  whole  of  the  corresponding 
meso-colon,  the  whole  of  the  levatores  ani,  the  whole  of  the  rectum  and  anus  and 
ischio-rectal  tissues,  making  a  permanent  inguinal  colostomy.  His  patients 
have  practically  complete  sphincteric  control  of  the  abdominal  anus  which  is 
neither  unsightly,  uncleanly  nor  a  source  of  discomfort.  He  writes:  "The 
operation  is  a  severe  one.  I  do  not  think  that  it  should  be  performed  on  those 
over  60  years  of  age;  of  10  such  cases  all  died.  With  regard  to  the  remainder, 
of  whom  there  were  36,  8  died  from  the  effects  of  the  operation,  4  have  had 
recurrence,  2  died  of  intercurrent  disease,  while  22  are  to-day  alive  and  well 
after  periods  varying  from  six  months  to  six  years"  ("Brit.  Med.  Journ.,"  Jan, 

25,  1913)- 

Handley  ("Universal  Med.  Record,"  1912,  385)  has  improved  on  the  method 
of  performing  the  combined  operation  as  follows:  When  the  gut  has  been  divided 
above  the  disease  (Step  4,  Quenu's  operation,  page  463),  completely  close  the  end 
of  the  bowel  which  is  to  form  the  future  artificial  anus  and  bring  it  out  through 
a  stab  incision  just  within  the  left  anterior  superior  spine  (possibly  better  control 
may  be  obtained  by  making  the  incision  through  the  left  rectus  muscle).  At  the 
end  of  the  operation  make  a  small  stab  into  the  blind  protruding  end  of  the  bowel, 
introduce  a  rubber  catheter  and  tie  it  in  with  a  purse-string  suture.  Use  the 
catheter  for  the  exhibition  of  salt  solution  by  the  drop  method  or  when  the  solu- 


HAEMORRHOIDS  519 

tion  is  not  being  given  permit  flatus  to  escape  by  it.  About  the  fifth  day  excise 
the  protruding  bowel  and  form  the  artificial  anus.  Handley  advises  the  use  of 
anti-streptococcic  serum  and  of  mixed  staphylococcic  vaccine  as  a  preliminary 
to  operation. 


CHAPTER  XXXVII 
HEMORRHOIDS  AND   FISTUL^E 

External  Haemorrhoids. — External  haemorrhoids  are  practically  never 
operated  on  except  when  inflamed.  It  is  well  to  snip  away  with  scissors  any 
tags  of  skin  around  the  anus  at  the  same  time  as  the  pile  is  attacked;  this  to 
avoid  subsequent  trouble. 

Hold  the  inflamed  pile  between  the  finger  and  thumb  of  the  left  hand. 
Transfix  the  base  of  the  pile  with  a  knife  in  the  direction  of  the  radiating  anal 
folds.  Cut  outwards  between  the  finger  and  thumb,  thus  splitting  the  pile. 
By  squeezing  or  with  a  forceps  or  curette  evacuate  the  contained  blood-clot. 
Remove  with  scissors  redundant  tissues.  Sutures  are  unnecessary.  Apply 
a  little  simple  ointment  and  a  pad  of  cotton.  The  after-treatment  consists  in 
keeping  the  bowels  open,  occasional  washing  of  the  parts,  reapplication  of 
ointment  and  pad  and  the  exercise  of  moderate  patience  for  a  few  days. 

Internal  Haemorrhoids. — Preparatory  Treatment. — Evacuate  the  bowels 
thoroughly.  Allingham  advised  giving  two  pills  each  containing  blue  mass  gr. 
j.  with  gr.  V.  of  pil.  colocynth.  et  hyoscyami  thirty-six  hours  before  operation 
and  using  an  enema  of  soap  and  water  a  few  hours  prior  to  operating.  This 
method  is  as  good  as  any. 

Methods  of  Operating. — I.  Excision. — (a)  Place  in  lithotomy  position. 
Dilate  anus  completely  with  thumbs  or  bivalve  speculum.  Catch  each  pile 
to  be  removed  in  a  forceps.  The  removal  of  three  pile  masses  is  all  that  is  usually 
necessary;  if  more  are  removed  stricture  may  result.  Cut  away  the  lowermost 
pile  with  scissors.  Pick  up  and  ligate  all  bleeding  vessels.  Suture  the  wound. 
The  operation  is  easy  on  paper,  but  it  is  not  easy  to  pick  up  the  vessels  and  to 
apply  the  suture  neatly.  Before  it  was  customary  to  dilate  the  anus  com- 
pletely, excision  was  dangerous  because  of  concealed  haemorrhage  into  the  rec- 
tum.    This  danger  no  longer  exists. 

ib)  Thelwell  Thomas'  method  is  a  type  of  operation  devised  by  many 
surgeons. 

Lithotomy  position:  Completely  dilate  anus.*  Catch  the  pile  masses  in 
forceps.  Grasp  the  base  of  one  pile  in  a  forceps  having  a  blade  about  2)-'^ 
inches  long  and  not  too  thick.  Be  careful  not  to  include  any  of  the  skin  in  the 
forceps.  Cut  away  the  pile  about  %  inch  distal  to  the  forceps.  Arm  a  stout 
catgut  suture  about  ten  inches  long  with  a  rounded  needle  at  each  end.  Pass 
the  suture  through  the  upper  end  of  the  stump  distal  to  the  clamp  and  tie 
firmly.     Do  not  cut  the  suture,  but  pass  the  needles  one  from  one  side,  the  other 

*  Many  surgeons  avoid  dilating  the  anus  claiming  that  recovery  is  more  perfect  than 
where  it  is  dilated. 


;2o 


HEMORRHOIDS   AND   FISTULiE 


from  the  other  side  through  the  stump  about  ^y  inch  away  from  the  first  stitch 
and  tie  firmly  over  the  stump.  Repeat  the  stitch  (Fig.  666)  as  often  as  neces- 
sary to  completely  suture  the  stump.  Remove  the  clamp.  There  may  be  a 
little  oozing  from  the  mucous  membrane  where  crushed  by  the  clamp.  Treat 
the  other  tumors  in  the  same  way.  It  is  usually  only  necessary  to  remove  three 
pile  masses.  If  more  tumors  must  be  removed  and  stricture  is  feared,  Thomas 
advises  to  apply  the  clamp  to  one  or  more  of  the  tumors  transversely  to  the  axis 
of  the  gut  and  suture  in  the  same  direction,  the  resulting  scar  being  transverse 
also. 

After-treatment. — On  completion  of  the  operation  introduce  two  supposi- 
tories, one  containing  3  grs.  of  iodoform,  the  other  l-i,  gr.  of  morphine.     Apply 
a  pad  of  gauze  or  cotton  and  some  simple  ointment  to 
the  anus. 

On  the  fifth  day  give  a  laxative.  After  the  bowels 
move,  introduce  an  iodoform  suppository.  The  author 
finds  that  there  is  little  use  in  keeping  the  bowels  locked 
up;  if  they  show  a  tendency  to  move  it  is  satisfactory  to 
give  an  enema  of  a  few  ounces  of  warmed  oil.  A 
favorite  dressing  with  some  surgeons  is  to  introduce  into 
the  rectum  a  tube  surrounded  by  gauze:  the  tube  per- 
mits the  exit  of  gas;  the  gauze  is  supposed  to  keep  the 
wound  clean  and  prevent  bleeding.  This  dressing  ought 
to  be  reserved  for  personal  enemies  and  malefactors  as 
it  does  no  good  and  can  cause  much  suffering.  After 
excision  the  patient  is  generally  well  by  about  the 
seventh  day. 

II.  Ligation. — (a)  Lithotomy  position:  Dilate  the 
anus  completely.  Catch  the  piles  to  be  removed  with 
forceps.  Pull  the  lowermost  pile  downwards  by  the  forceps  attached  to  it. 
Note  the  white  line  at  the  junction  of  the  skin  and  mucous  membrane;  begin- 
ning at  this  line  immediately  below  the  pile,  with  scissors  separate  the  pile  from 
the  subjacent  submucous  and  muscular  tissues  on  which  it  rests.  Continue 
the  separation  upwards  until  the  pile  remains  hanging  by  a  small  pedicle  of 
vessels  and  mucous  membrane.  This  is  possible  and  safe  because  all  the 
vessels  enter  or  leave  the  tumor  above,  immediately  under  the  mucous  mem- 
brane. Tie  the  pedicle  tightly  with  a  strong  but  not  thick  silk  ligature.  Cut 
away  the  tumor  distal  to  the  ligature.  Before  applying  the  ligature  it  may  be 
convenient  to  crush  a  groove  in  the  pedicle  with  a  strong  forceps.  This  permits 
the  use  of  a  lighter  ligature.     Treat  the  other  piles  in  the  same  manner. 

{h)  Modified  ligation:  Separate  the  pile  as  for  ligation.  Divide  the  mucous 
membrane  above  the  pedicle  so  that  the  pedicle  comes  to  consist  of  vessels  alone. 
Ligate  the  vessels  with  catgut.  Suture  the  mucosa.  This  operation  is  prac- 
tically an  excision. 

III.  Clamp  and  Cautery  Operation. — Many  clamps  have  been  devised. 
The  simplest  are  Langenbeck's,  Smith's  or  Gant's.  Some  have  ivory  on  the 
under  side  to  keep  the  heat  from  burning  the  skin.     A  piece  of  asbestos  paper 


Fig.  666. — Excision  of 
piles. 


WHITEHEAD  S    OPERATION  52 1 

placed  between  the  clamp  and  the  skin  is  a  cheap  and  effective  substitute  for  the 
ivory. 

Lithotomy  position:  Dilate  the  anus  completely.  Seize  with  forceps  each 
pile  to  be  removed.  (The  removal  of  three  pile  masses  usually  suffices.) 
Seize  the  base  of  the  lowermost  pile  in  a  clamp.  Arrange  asbestos  paper  between 
the  clamp  and  the  skin.  Burn  away  the  protruding  pile  completely  with  the 
cautery.  Some  surgeons  cut  away  the  pile,  leaving  a  stump  ^  inch  long  pro- 
truding from  the  clamp  and  cauterize  this  stump.  Paquelin's  cautery  is  useful 
in  this  operation;  so  is  an  electro-cautery,  but  both  these  instruments  are  fairly 
expensive  and  often  out  of  order.  Ordinary  soldering  irons  are  cheap,  easily 
heated  in  a  lamp  and  are  always  reliable.  They  should  be  heated  to  a  dull  red 
color  and  allowed  to  cool  slightly  before  being  used. 

IV.  Excision  of  the  Pile-bearing  Area. — {a)  Whitehead's  operation. — ^Lithot- 
omy position:  Dilate  anus  completely.  Make  an  incision  all  around  the  anus 
at  the  junction  of  the  skin  and  mucous  membrane.  Separate  the  mucous 
membrane  by  blunt  and  occasional  sharp  dissection  from  the  external  and 
internal  sphincter.  Attend  to  hsemostasis.  The  whole  pile-bearing  area  (there 
are  exceptions  to  this  rule)  now  hangs  separated  from  the  subjacent  tissues. 
Divide  the  mucous  membrane  transversely  above  the  pile  area  in  successive 
stages.  As  each  segment  of  mucosa  is  divided  bring  its  free  margin  down  and 
suture  it  to  the  corresponding  edge  of  skin.  This  is  much  easier  than  cutting 
off  the  whole  loosened  segment  of  gut  at  once. 

{b)  Vercesco's  Method  (Potarca,  "Rev.  de  Chir.,"  May,  1902). — Prepare  a 
champagne  cork  by  providing  its  narrow  end  with  a  handle  (a  loop  of  stout  wire 
is  satisfactory).     Have  a  number  of  fine  tacks  ready. 

Lithotomy  position:  Fully  dilate  anus.  Reduce  the  piles.  Pass  the 
champagne  cork,  thick  end  first,  into  the  bowel.  Make  a  short  incision  through 
the  muco-cutaneous  junction.  Tack  the  separated  mucosa  to  the  cork.  Repeat 
this  until  the  incision  runs  completely  round  the  anus  and  the  whole  circumfer- 
ence of  the  mucosa  is  tacked  to  the  cork.  By  means  of  the  handle  on  the  cork 
pull  the  cork  and  with  it  the  gut  downwards  and  separate,  as  in  Whitehead's 
operation,  the  pile  area  from  the  subjacent  structures.  Attend  to  hsemostasis. 
Suture  the  free  edge  of  skin  to  the  raw  surface  of  the  mucosa  (on  the  cork)  all 
around  the  anus.  With  a  knife  divide  the  mucous  membrane  immediately  distal 
to  the  line  of  suture  and  remove  the  cork  and  with  it  the  pile-bearing  tissues. 
Instead  of  suturing  as  above  one  may  make  a  short  incision  through  the  mucosa, 
suture  it  to  the  corresponding  free  edge  of  skin  and  repeat  this  alternate  cutting 
and  suturing  until  the  operation  is  completed.  The  advantage  of  this  method 
over  the  Whitehead's  consists  in  the  avoidance  of  soiling  the  deep  wound  with 
intestinal  discharge  during  the  operation. 

Choice  of  Operation. — Excision  of  the  pile-bearing  area  depends  for  success 
on  healing  by  first  intention.  This  does  not  always  take  place;  if  it  does  not, 
then  healing  must  be  by  granulation  and  stricture  results.  Wetherill  has  seen 
cases  where  after  perfect  union  was  obtained  the  sensitiveness  of  the  anus 
was  so  obtunded  that  the  normal  impulses  which  precede  and  call  for  the  act 
of  defaecation  were  absent  and  a  condition  of  persistent  constipation  was  estab- 


\22 


HEMORRHOIDS    AND    FlSTUL.l;; 


lished.  The  same  cause  may  lead  to  incontinence  of  gas  and  faeces.  The  other 
methods  of  operating  all  give  good  results.  Each  surgeon  knows  that  the  method 
he  uses  gives  better  results  than  any  other.  The  author's  preference  is  for  the 
Thelwell  Thomas  operation. 

Pruritus  Ani. — In  long-standing  cases  of  pruritus  where  medical  treatment 
has  failed  to  give  relief  and  where  no  evident  removable  cause  for  the  itching  can 
be  found,  a  cure  may  be  cfifected  by  one  of  two  operations: 

I.  Cauterization. — Administer  a  general  anesthetic.  Thoroughly  dilate  the 
anus.     Remove  any  tags  of  skin  or  small  polypi  which  may  present.     Apply 

lightly  the  flat  side  of  a  Paquelin  cau- 
igl'.  'Vj  tery,  at  a  white  heat,  to  every  part  of 

the  affected  anal  skin.  Only  the  super- 
ficial epithelium  ought  to  be  destroyed 
and  on  recovery  there  should  be  no  scar 
formation. 

II.  Ball's  Operation. — Division  of 
the  terminal  branches  of  the  nerves 
supplying  the  affected  skin. 

Step  I.- — The  patient  being  in  the 
lithotomy  position,  make  the  incision 
A  B  (Fig.  667)  on  one  side  of  the  anus 
and  reflect  the  flap  X,  consisting  of  skin 
and  subcutaneous  tissue.  The  fibres 
of  the  external  sphincter  should  be  ex- 
posed and  the  dissection  continued  up 
to  and  beyond  the  muco-cutaneous 
junction.  With  scissors  undermine  for 
a  short  distance  the  skin  to  the  outer  side  of  the  incision  A  B. 

Step  2. — On  the  opposite  side  of  the  anus  make  the  incision  C  D  and  reflect 
the  flap  Y  as  in  Step  i.  Be  careful  that  the  distance  between  A  and  C  and  be- 
tween B  and  D  is  fully  one  inch. 

Step  3. — With  scissors,  undermine  the  bridges  of  skin  A  C,  B  D.  Attend  to 
haemostasis. 

Step  4. — Replace  the  flaps  X  and  Y  and  suture  the  wounds  A  B  and  C  D. 
Apply  dressings.     Sensation  gradually  returns  in  the  area  of  operation. 

Lockhart-Mummery  (Brit.  Med.  Jour.,  Aug.  21,  1915)  very  strongly  en- 
dorses Ball's  operation. 

III.  Lynch's  operation  (Med.  Record,  June  13,  1914)  is  almost  identical  with 
Ball's  except  that  the  incision  is  only  about  3^^  inch  in  length,  and  from  it  the 
skin  is  undermined  from  the  anterior  raphe  to  the  posterior  commissure  within 
a  radius  of  11-2  inches  from  the  anus.  Bleeding  is  controlled  by  pressure 
and  the  wound  is  drained  for  twelve  hours  by  a  small  piece  of  rubber  tissue. 
As  a  rule  no  sutures  are  required  and  the  wound  is  healed  in  about  forty- 
eight  hours. 


Fig.  667. — Operation  for  pruritus  ani. 


FISTULA  IN  ANO 


523 


FISTULA   IN  ANO 

Before  describing  the  operative  treatment  of  anal  fistula  it  is  important  to 
consider  the  anatomy  of  the  disease  and  the  principles  on  which  proper  opera- 
tions must  be  based. 

If  a  line  is  drawn  transversely  through  the  middle  of  the  anus,  all  fistulas 
lying  anterior  to  this  line  will  be  found  to  pass  directly  from  the  cutaneous 
openings  to  that  in  the  anal  canal,  whereas  all  fistulas  posterior  to  this  line 
have  their  internal  opening  in  the  posterior  midline  of  the  anal  canal  no  matter 
how  many  external  openings  there  may  be  and  no  matter  where  these  external 
openings  are  situated.  Thus  practically  all  complicated  horseshoe  fistulas  are 
posterior. 


Fig.  668. 


It  is  commonly  believed  that  all  except  the  most  superficial  fistulas  run 
from  the  skin  to  the  gut  external  to  the  internal  sphincter,  i.e.,  that  they 
penetrate  between  the  external  and  the  internal  sphincters.  It  is  generally 
believed  that  division  of  the  external  sphincter  is  necessary  to  effect  a  cure  not 
only  because  of  the  free  drainage  secured,  but  because  of  the  rest  given  to  the 
wound  while  the  muscle  is  hors  de  combat. 

Goodlee  found  at  autopsies  that  the  majority  of  fistulas  are  superficial  to 
the  external  sphincter  and  Mummery  corroborated  these  findings  by  careful 
observation  during  operations.  He  writes  "If,  when  operating  for  fistula,  one 
divides  the  track  to  the  internal  opening  by  cutting  down  on  to  the  director 
with  an  ordinary  scalpel,  instead  of,  as  is  more  usual,  transfixing  it,  it  is  quite 
easy  to  observe  whether  or  not  one  cuts  the  fibres  of  the  external  sphincter. 
I  have  been  surprised  to  find  in  how  few  cases  the  muscle  has  been  cut."     With 


524  HEMORRHOIDS    AND    FISTULA 

very  few  exceptions  the  internal  opening  of  any  fistula  is  situated  within  three 
fourths  inch  of  the  skin  margin.  "  The  fact  that  a  track,  can  be  detected  running 
up  the  bowel  for  some  considerable  distance  does  not  mean  that  the  internal 
opening  is  at  the  upper  end  of  this  track;  it  will  probably  be  found  low  down 
near  the  anus."     (Mummery,  Diseases  of  the  Rectum,  1914.) 

Prophylactic  Treatment. — As  fistula  in  ano  is  always  caused  by  an  abscess 
which  opens  into  the  rectum  or  discharges  through  the  skin  or  by  both  routes,  it 
follows  that  proper  treatment  of  ischio-rectal  abscess  is  the  best  preventative 
of  fistulas.  Whenever  the  existence  of  an  ischio-rectal  abscess  is  known  or 
even  believed  to  be  present,  make  a  free  incision  into  the  indurated  tissue 
through  the  skin  external  to  the  sphincter.  Do  not  injure  the  sphincter.  The 
incision  need  not  be  radial  to  the  anus.  It  should  be  placed  where  it  will  give 
the  best  drainage  and  be  free  enough  to  permit  the  easy  insertion  and  retention 
of  a  drainage  tube.  The  patient  is  to  be  congratulated  if  operation  is  performed 
before  the  indurated  mass  has  broken  down  into  frank  pus.  Do  not  pack  the 
cavity  with  gauze  as  such  acts  as  a  plug.  Apply  dressings.  Keep  the  parts 
clean.  Let  the  patient  sit  in  a  hot  bath  morning  and  evening.  During  the 
remainder  of  the  time  he  should  be  in  bed.  Do  not  irrigate  the  abscess 
cavity.  Sometimes  the  use  of  hj^^eremia  by  Bier's  cups  is  of  value.  If  drain- 
age is  insufficient  reopen  and  enlarge  the  opening.  Always  warn  the  patient 
of  the  possibility  of  subsequent  fistula. 

Operative  Treatment  of  Fistula  in  Ano. — Never  operate  for  the  cure  of 
fistula  in  the  presence  of  acute  inflammation  or  when  there  is  much  pus. 

Place  the  patient  in  the  lithotomy  position  after  he  has  been  prepared  as 
for  hemorrhoid  operation. 

(A)  Simple  complete  fistula  with  nearly  straight  track  between  the  external 
and  internal  openings. 

Pass  a  grooved  director  completely  through  the  fistula.  Pass  a  finger  into 
the  gut  and  with  it  bring  the  point  of  the  director  out  through  the  anus.  Guided 
by  the  director  divide  all  the  tissues  covering  it.  The  fistula  is  now  a  gutter. 
With  a  sharp  spoon  scrape  away  all  the  granulation  tissue  lining  the  fistulous 
track.  If  there  is  much  dense  scar  tissue  surrounding  the  track  incise  this 
tissue.  Such  an  incision  is  called  "Salmon's  back  cut"  and  is  very  useful. 
Pare  away  any  overhanging  edges  of  skin.  Attend  to  hemostasis.  Fill  the 
wound  with  a  not  too  tight  pack  of  gauze.  The  author  generally  employs 
gauze  moistened  with  Paraffin  or  vaseline.  Apply  dressings.  Keep  the 
bowels  locked  for  four  or  five  days  and  then  open  them  with  a  dose  of  castor  oil. 
After  the  bowels  are  allowed  to  move,  the  dressings  must  be  changed  frequently 
and  Sitz  baths  are  comforting. 

(B)  Complicated  Fistula.  Horseshoe  Fistula. — It  has  been  shown  that  most 
complicated  fistulas  are  situated  behind  the  anal  equator  and  that  no  matter 
how  many  external  openings  and  tracks  may  be  present  there  is  usually  but 
one  internal  opening  and  that  within  ^  inch  of  the  anus. 

Begin  the  operation  by  freely  opening  all  the  fistulous  tracks  except  that 
which  penetrates  the  gut.  Only  after  this  is  done  proceed  to  divide  the  track 
leading  to  the  internal  opening  exactly  as  in  simple  fistula.  Make  the  incision 
strictly  radial  to  the  anus.     Never  incise  the  anal  margin  obliquely  nor  in  more 


FISTULA    IN   ANO  525 

than  one  place,  otherwise  loss  of  control  may  result.  Treat  the  tracks  as  in 
the  simple  operation.  Pare  away  all  skin  and  tissue  likely  to  interfere  with 
drainage  and  healing  (Fig.  668). 

(C)  Fistula  ivith  a  Lateral  Internal  Opening  above  the  External  Sphincter. — 
Mummery  writes  "It  is  a  matter  for  serious  consideration  in  such  cases  whether 
it  is  not  better  to  avoid  dividing  the  external  sphincter  laterally,  even  at  the 
risk  of  the  fistula  not  healing;  a  second  operation  being  preferable  to  an  incon 
tinent  anus.  In  some  cases  it  is  a  good  plan  after  division  of  the  track  to  bring 
the  ends  of  the  sphincter  together  by  deep  traction  sutures  of  silkworm  gut 
or  silver  wire.  By  enlarging  the  opening  of  the  fistula  and  draining  the  deep 
part  of  the  track  with  drainage  tubes,  one  can  usually  obtain  healing  of  a  fistula 
with  a  high  lateral  internal  opening  without  laying  open  the  track  into  the 
bowel."  An  operation  in  two  stages  is  well 
calculated  to  overcome  the  difficulties  incident 
to  sphincteric  division. 

Pass  a  probe  or  director  through  the 
fistula.  Guided  by  the  probe  freely  incise 
the  fistulous  tract  but  do  not  divide  the 
sphincter  The  whole  tract  must  be  freely 
opened  by  division  of  the  mucosa,  etc.,  above 
the  anus  and  of  the  skin  external  to  the  anus,  2i'I)i'^i 
but  the  anus  itself  and  the  sphincters  are  left  '^■■" 
intact  (Fig.  669).     Pack   the  whole  wound.  p^^   ^^ 

If  everything  goes  well   the  whole  fistulous 

tract  will  heal  except  near  the  sphincter  where  a  small  sinus  will  be  left.  This 
small  residual  sinus  or  fistula  is  easily  cured  by  dividing  the  sphincter  which 
heals  so  quickly  that  no  mass  of  scar  tissue  forms  to  interfere  with  its  efficiency. 

When  tracks  exist  running  up  under  the  mucous  membrane  such  should  not 
be  divided  but  should  be  dilated  and  drained  with  tubing,  rubber  dam  or  strips 
of  gauze. 

Elting  ("Trans.  Am.  Surg.  Assoc,"  1912)  thinks  that  practically  all  anal 
fistulas  communicate  with  the  intestine  whether  the  point  of  communication 
be  discovered  or  not,  and  that  if  this  communication  be  destroyed  the  fistulae 
will  recover  under  almost  any  or  no  treatment. 

Elting' s  Method. — Demonstrate,  if  possible,  the  inner  opening  of  the  fistula. 
Dilate  the  anus.  Beginning  at  the  muco-cutaneous  junction  excise  the  mucous 
membrane,  exactly  as  in  the  Whitehead  operation,  to  a  point  above  the  fistulous 
orifice  or,  if  such  is  not  seen,  up  to  the  white  line  which  shows  where  the  levatores 
ani  join  the  gut.  Treat  the  wound  as  in  the  Whitehead  operation.  Curette  the 
fistulous  tracts  and  drain  them,  making  stab  wounds  for  drainage  if  necessary. 

Blind  external  fistulas  have  external  but  no  internal  openings.  Enlarge  the 
external  opening  by  free  incision  without  encroaching  upon  the  anal  margin. 
Scrape  away  granulation  tissue  and  excise  any  excess  of  scar  tissue.  Trim  the 
edges  of  the  wound.  Pack  with  gauze.  If  the  fistulous  track  reaches  to  the 
mucous  membrane,  that  may  be  punctured  with  a  director  and  the  lesion 
treated  as  a  simple  complete  fistula. 

Blind  internal  fistidas  have  internal  but  no  external  openings.     Expose  the 


526  HEMORRHOIDS   AND   FISTULA 

internal  opening.  A  speculum  may  be  necessary  for  this  purpose.  Introduce 
a  director  or  probe  through  the  fistula  towards  the  skin.  Using  the  probe  as  a 
guide  convert  the  incomplete  into  a  complete  fistula.  Complete  the  operation 
as  for  a  complete  fistula. 

4.  Excisivn  of  Fistula. — Incise  the  fistula  (complete  or  incomplete)  as 
already  described.  With  forceps,  scalpel  and  scissors  remove,  if  possible  en 
masse,  all  the  sclerosed  diseased  tissues  surrounding  the  fistula.  Attend  to 
hiemostasis.  With  sutures  close  the  whole  wound.  This  is  best  done  by 
suturing  in  layers  with  a  continuous  suture  of  fine  catgut.  The  first  series 
of  sutures  should  be  confined  to  the  deep  wound  and  not  touch  either  the 
mucosa  or  the  skin;  the  two  latter  structures  should  be  closed  by  separate 

superficial  sutures.  If  the  sutures  closing 
the  deep  wound  pass  through  the  mucous 
membrane  or  skin,  they  are  liable  to  con- 
duct infection  into  the  deep  structures. 

Thrailkill  excises  fistulae  as  follows:  Pass 
the  probe  of  the  "safety-pin  spring  probe" 
through  the  fistula  into  the  rectum;  catch 
the  end  of  the  probe  on  to  its  hook  (Fig. 
Fig.  670.— Thrailkill's  probe.          670).     Make  an  incision  through  the  anal 

mucosa  and  the  sphincter  down  to  but  not 
into  the  fistula.  By  taking  hold  of  the  handle  of  the  instrument,  the  fistulous 
tract  and  wall  can  be  firmly  held  while  the  diseased  tissue,  threaded  on  the 
probe,  is  dissected  out  in  one  piece. 

Kenneth  Mackenzie's  Operation. — -("Trans.  Am.  Surg.  Assoc,"  1911.) 
"i.  The  patient  is  prepared  in  the  most  careful  way  as  for  any  major 
surgical  operation  on  these  parts. 

"2.  The  sphincter  is  completely  dilated. 

"3.  The  internal  orifice  of  the  fistula  is  minutely  examined  and  with  a  proper 
instrument  is  very  cautiously  dilated.  After  dilatation  the  mucosa  is  uplifted 
and  pared  with  curved  scissors  in  the  direction  of  the  long  axis  of  the  bowel,  and 
with  a  small  knife  or  fine  scissors  the  circumference  of  the  muscular  layer  is 
then  trimmed  and  vivified.  If  need  be,  the  opening  may  be  incised  or  split  in 
the  direction  of  the  circumference  of  the  sphincter.  After  this  has  been 
done  a  few  interrupted  sutures  of  iodized  catgut  are  introduced  in  the 
muscular  layer  at  right  angles  with  the  sphincter,  tied  and  divided.  The 
mucous  membrane  is  then  sutured  with  interrupted  chromic  catgut  or  silk 
sutures,  properly  spaced.  If  more  than  one  orifice  exists,  of  course  the  same 
procedure  is  followed. 

"4.  A  flap  is  made  on  the  side  involved,  beginning  by  making  a  small 
semilunar  incision  just  beyond  the  border  of  the  external  sphincter,  dividing 
the  parts  down  to  the  fistulous  tract,  the  latter  being  divided  flush  at  its  point  of 
emergence  from  the  bowel  (Fig.  671).  The  incision  is  extended  from  both 
ends  of  the  first  incision  outward  and  made  large  and  deep  enough  to  include, 
if  possible,  under  the  eye  all  visible  and  accessible  branching  tracks.  The 
exigencies  of  the  case  may  require  sometimes  the  lifting  of  one  or  other  of  the 
buttocks  in  its  entirety.     In  one  case,  it  was  necessary  to  make  a  complete  flap 


MACKENZIE  S    OPERATION 


527 


and  partial  resection  of  both  buttocks  in  order  to  reach  the  deepest  and  most 
distant  branching  tracks. 

"5.  The  opposite  side  of  the  rectal  opening  is  now  attacked,  and  after  all 
doubtful  tissues  have  been  removed  the  rectal  walls  are  infolded  once  or  twice 
over  the  line  of  suture  within.  The  greatest  care  must  be  exercised  in  removing 
all  doubtful  tissues.  If  need  be  the  cautery  could  be  used  for  their  complete 
destruction,  or  substituted  entirely  for  the  suture  of  these  parts. 


Fig.  671. — {Kenneth  Mackenzie.) 


"6.  The  exposed  flap  is  next  attacked  with  knife  or  large  pointed  scissors, 
curved  on  the  fiat,  and  the  original  track,  its  branches  and  the  entire  fistulous 
zone  including  every  branching  track  resected.  Careful  search  will  be  made  in 
the  ischiorectal  fossa  and  perirectal  spaces  for  any  concealed  track. 

"7.  The  whole  field  is  then  carefully  flushed  with  normal  salt  solution  and, 
if  need  be,  antisepticized  and  the  fat  layers  sutured  with  buried  catgut  so  as  to 
close  all  dead  spaces.  In  many  cases  the  entire  wound  may  be  closed  as  in  the 
case  of  breast  amputation  or  a  small  drain  may  be  left  for  twenty-four  or  forty- 
eight  hours." 


528  ASCITES 

CHAPTER  XXXVIII 
ASCITES 

Ascites. — Ascites  may  be  due  to  many  causes,  notably  to  cirrhosis  of  the 
liver.  In  this  disease  interference  with  the  portal  circulation  is  supposed 
to  cause  the  ascites  by  damming  back  the  blood  coming  from  the  abdominal 
viscera  to  the  liver.  Rolleston  and  Turner  argue  that  ascites  does  not  occur 
when  the  blood  pressure  is  presumably  highest  in  the  portal  vein,  i.e.,  early  in 
the  disease;  that  ligation  of  the  portal  vein  does  not  necessarily  cause  ascites; 
that  ascites  is  probably  rather  a  result  of  a  toxaemia  than  a  mere  mechanical 
result  of  increased  blood  pressure.  These  observers  think  that  any  good 
obtained  by  omentopexy  is  due  (a)  to  a  diminution  of  the  blood  flowing  through 
the  liver,  permitting  the  liver  cells  to  purify  the  blood  passing  through  it  more 
satisfactorily;  (b)  to  an  increase  of  the  arterial  supply  of  the  liver,  through 
new-formed  adhesions,  this  increased  nutrition  to  the  liver  cells  favoring  their 
compensatory  hypertrophy. 

Operations  for  ascites  may  be  divided  into  two  classes:  I.  Operations 
aiming  at  the  prevention  of  the  effusion  of  the  fluid.  II.  Operations  aiming 
at  the  removal  of  the  effused  fluid. 

I.  Morison-Talma  Operation.     Omentopexy.     Epiplopexy. 

Long  ago  it  was  noted  that  after  repeated  removals  of  ascitic  fluid  by  means 
of  the  trocar  and  cannula,  recovery  occasionally  took  place.  This  recovery 
was  ascribed  to  the  passage  of  some  of  the  portal  blood  into  the  systemic  circula- 
tion through  adhesions  formed  between  the  intra-abdominal  viscera  and  the 
parietes.  Talma  and  Rutherford  Morison  (the  latter  aided  and  abetted  by 
Drummond)  each  independently  decided  to  open  the  abdomen  and  in  a  definite 
fashion  establish  adhesions  between  the  viscera  and  the  parietes. 

Step  I. — Open  the  abdomen  near  the  middle  line  above  the  umbilicus. 
Encourage  all  the  ascitic  fluid  to  escape.  Mop  out  the  fluid  from  the  pelvis 
and  the  renal  pouches  with  gauze. 

Step  2. — With  gauze  rub  the  upper  surface  of  the  liver  vigorously  enough  to 
favor  the  formation  of  adhesions  between  it  and  the  diaphragm.  Do  the 
same  to  the  spleen. 

Step  3. — Method  A. — Pull  the  omentum  into  the  wound  and  unite  it  to 
the  anterior  parietal  peritoneum  in  the  following  manner:  Evert  one  edge  of 
the  abdominal  wound  so  as  to  expose  the  anterior  parietal  peritoneum  to  a 
point  far  from  the  middle  line.  This  is  easy  because  the  belly-wall  which 
was  much  distended  by  the  ascites  is  now  quite  lax  after  the  removal  of  the 
fluid. 

Suture  the  edge  of  the  omentum  to  the  parietal  peritoneum  as  far  from  the 
middle  line  as  possible.  Continue  this  suture  until  the  middle  line  is  reached. 
Do  the  same  on  both  sides. 

Method  B. — After  everting  the  anterior  belly-wall  as  in  Method  A,  make 
a  transverse  incision  through  the  peritoneum  and  suture  the  edge  of  the  omen- 
tum into  this  transverse  wound. 

Step  4. — Close  the  abdomen  with  or  without  drainage. 


OMENTOPEXY 


529 


On  the  whole,  the  results  of  the  Morison-Talma  operation  have  been  very 
fair.  The  death  rate  has  been  high — approximately  20  per  cent. — but  one  must 
remember  that  any  patient  requiring  the  operation  is  at  best  "a  bad  risk." 
The  best  results  have  been  obtained  in  patients  operated  on  early;  some  of  the 
results  have  been  most  gratifying. 

In  the  "American  Journal  of  Surgery"  (June,  1909)  are  published  the 
following  statistics  of  omentopexy  and  its  modifications:  1565  cases;  30.4 
per  cent,  cured;  19.8  per  cent,  relieved;  39.2  per  cent,  not  relieved;  10.6  per  cent, 
died.  ''The  greatest  variation — 5  to  23  per  cent. — is  in  the  percentage  of 
deaths,  and  this  is  found  to  depend  on  the  variation  in  the  length  of  the  post- 
operative period  on  which  the  different  mortality  statistics  were  based." 

Bindi  thinks  that  omentopexy  not  only  produces  new  and  free  anatomical 
connections  between  the  portal  and  systemic  circulation,  but  that  it  awakens 
and  increases  the  absorbent  power  of  the  peritoneum. 

Maiochi  reported  seventeen  cases  of  operation  for  cirrhosis  (ascites)  without 
death  due  to  operation.  Some  of  the  cases  were  observed  for  five  years  and 
four  seemed  to  be  cured  of  their  symptoms. 

Schiassi's  Method. — "Schiassi  makes  a  vertical  incision  a  little  below  the 
left  costal  margin  opposite  the  middle  of  the  clavicle,  and  another  one  running 
outwards  from  the  upper  end  of  the  first  incision.  A  triangular  flap  consisting 
of  all  the  tissues  to  the  peritoneum  is  then  raised,  and  a  vertical  incision  made 
in  the  peritoneum.  The  spleen  and  the  great  omentum  are  withdrawn  suffi- 
ciently to  allow  the  surgeon  to  fix  them  in  the  wound  which  is  then  sutured" 
(Jacobson  and  Rowlands). 

Mayo's  Method. — Mayo  makes  an  "incision  on  the  right  side  over  the 
liver,  in  line  with  the  deep  epigastric  and  internal  mammary  vessels,  so  as  to 
explore  its  surface.  A  second  incision  is  made  four  inches  below  this  through 
the  rectus  muscle  but  not  through  it  posterior  sheath.  The  posterior  sheath 
is  extensively  separated  from  the  muscle  and  a  portion  of  the  omentum  drawn 
out  of  the  upper  incision  and,  with  a  pair  of  forceps,  pulled  down  into  the 
pocket,  bringing  it  directly  in  contact  with  the  larger  vessels.  This  can  be 
repeated  on  the  opposite  side  and  the  intervening  segment  attached  to  the 
whole  front  of  the  parietal  peritoneum  after  the  plan  of  Morison." 

Narath's  Method. — Narath  has  modified  the  Talma-Morison  operation  as 
follows  ("Zentralblatt  fiir  Chir.,"  1905,  No.  32) : 

1.  Under  local  anesthesia  open  the  abdomen  just  above  the  umbilicus  and 
to  the  left  of  the  round  ligament. 

2.  Thoroughly  drain  away  the  ascitic  fluid  from  all  dependent  parts  of  the 
abdomen. 

3.  Pick  up  and  pull  out  of  the  wound  a  large  segment  of  omentum.  This 
portion  of  omentum  should  be  well  provided  with  vessels  and  its  pedicle 
should  be  as  thick  or  thicker  than  a  finger.  The  tension  exerted  on  the 
omentum  must  not  be  so  great  as  to  disturb  the  position  or  motility  of  the 
transverse  colon. 

4.  With  sutures  partially  close  the  wound  in  the  peritoneum  and  abdominal 
fascia,  being  careful  not  to  cause  pressure  on  the  protruding  omentum.  With 
a  few  fine  sutures  anchor  the  pedicle  of  omentum  to  the  peritoneum. 

34 


530  ASCITES 

5.  By  blunt  dissection  form  a  subcutaneous  pocket  to  the  left  of  the  wound 
and  into  this  pocket  tuck  the  4  or  5  inches  of  omentum  which  protrude  through 
the  belly-wall. 

6.  Close  the  cutaneous  wound  and  apply  dressings  which  will  not  injuriously 
press  upon  the  omentum  in  its  subcutaneous  position. 

Corson  ("Annals  Surg.,"  Dec,  1907)  is  an  enthusiastic  advocate  of  Narath's 
method.  For  reasons  which  will  be  given  later  the  author  believes  this  modi- 
fication of  omentopexy  to  be  valuable. 

A  number  of  surgeons,  notably  Delageniere,  advocate  performing  cholecys- 
tostomy  in  addition  to  omentopexy,  //the  patient's  general  condition  justifies 
this  additional  step  it  is  calculated  to  be  of  some  value. 

Encouraged  by  the  success  following  omentopexy  and  believing  that  success 
to  be  due  to  the  passage  of  blood  from  the  portal  to  the  systemic  circulation 
through  the  omental  adhesions,  some  surgeons  sought  for  a  more  direct  method 
of  attaining  the  same  end.  The  experiments  of  Eck  showed  the  feasibility 
of  establishing  an  anastomosis  between  the  portal  vein  and  the  inferior  vena 
cava.  Tansini  proposed  applying  this  procedure  to  man  and  Vidal  was  the  first 
to  carry  it  out.  Unfortunately,  as  Guibe  writes,  "this  operation  ought  to  be 
abandoned  because,  however  efificient  it  may  be,  it  exposes  the  patient  to  too 
great  dangers — the  danger  of  alimentary  intoxication  which  might  possibly  be 
foreseen  and  avoided,  but  specially  the  danger  of  a  general  infection  of  intestinal 
origin,  since  the  intestinal  mucosa  does  not  always  oppose  a  sufficient  barrier  to 
microbic  invasion.  The  patient  operated  on  by  Vidal  died  after  four  months 
with  evident  signs  of  a  sudden  general  infection."  A  patient  operated  on  by 
Thierry  de  Martel  died  of  anuria  in  48  hours.  Villard  and  Tavernier  anas- 
tomosed a  mesenteric  vein  to  the  right  ovarian,  but  the  opening  became  occluded 
by  a  clot. 

II.  Operations  for  ascites  aiming  at  the  removal  of  the  effused  fluid. 

Paracentesis  Ahdominalis. — The  bowels  and  bladder  have  been  emptied. 
Thoroughly  cleanse  the  abdomen.  Place  the  patient  (unless  too  weak)  in  a 
sitting  posture.  Place  a  binder  around  the  abdomen  in  such  a  manner  that 
it  can  be  continuously  tightened  by  an  assistant  standing  behind  the  patient. 
The  binder  must  be  provided  with  an  opening  in  front  through  which  the 
operation  may  be  performed.  Percuss  the  abdomen  to  find  the  limits  of 
the  contained  fluid.  Choose  the  site  of  operation,  usually  in  the  linea  alba 
midway  between  the  umbilicus  and  pubis.  Anesthetize  the  skin  by  injecting 
a  few  drops  of  weak  novocaine  solution.  Puncture  the  skin  with  a  tenotome. 
Through  the  puncture  insert  a  trocar  and  cannula  of  medium  size.  Withdraw 
the  trocar.  Permit  the  fluid  to  escape  and  as  it  escapes  have  the  binder  tight- 
ened. Should  the  patient  show  signs  of  faintness  stop  the  flow  of  fluid  until  he 
recovers. 

When  all  the  fluid,  or  as  much  as  seems  proper,  has  been  withdrawn,  remove 
the  cannula.  A  stitch  to  close  the  puncture  may  be  necessary  occasionally. 
Apply  dressings.     Keep  a  snugly  fitting  binder  around  the  abdomen. 

The  author  has  prolonged  life  in  certain  cases  by  injecting  into  the  subcu- 
taneous tissues  some  of  the  fluid  withdrawn  exactly  as  in  hypodermoclysis. 


SUBCUTANEOUS   DRAINAGE  53 1 

Permanent  Abdominal  Drainage. 

Lamhotte's  Method. — Tie  a  large  knot  about  23^^  inches  from  the  end  of  a 
thick  silk  thread  about  18  inches  long.  Make  a  small  opening  into  the  abdo- 
men; introduce  the  knot  and  short  free  end  of  the  silk  into  the  peritoneal  cavity; 
close  the  deep  abdominal  wound  around  the  silk  thread.  (The  knot  in  the 
thread  is  to  prevent  the  thread  being  pulled  out  of  the  abdomen.)  With  a 
long  probe  push  or  pull  the  long  end  of  the  thread  subcutaneously  from  the 
abdominal  wound  to  about  the  middle  of  the  thigh.  In  Lambotte's  case  there 
was  great  improvement  by  the  fourth  day.  Marked  oedema  was  noted  along 
the  course  of  the  thread.  Unfortunately  the  thread,  becoming  imbedded 
in  the  abdominal  wall,  no  longer  reached  the  peritoneum  and  thus  the  ascites 
returned. 

.  Handley  has  operated  in  a  similar  fashion  ("Brit.  Med.  Journ.,"  April  16, 
1910).  The  abdomen  was  opened  in  the  left  semilunar  line;  "a  stout  needle 
threaded  double  with  lymphangioplasty  silk  was  now  passed  in  and  out  in  a 
series  of  loops  through  the  peritoneal  and  subperitoneal  tissues  of  the  right 
iliac  fossa  external  to  the  mesocolon.  Short  loops  of  the  silk  were  left  exposed 
within  the  peritoneal  cavity,  whence  they  could  suck  up  fluid  by  capillary  at- 
traction. The  process  was  repeated  with  two  other  threads.  The  four  threads 
were  conducted  in  the  manner  described  to  a  point  close  to  the  anterior  superior 
spine.  With  the  aid  of  a  long  probe  they  were  then  thrust  beneath  the  outer  end 
of  Poupart's  ligament  some  way  downwards  into  the  subcutaneous  tissues 
of  the  thigh.  The  abdominal  wound  was  now  closed  in  such  a  way  that  the 
sutures  used  proved  additional  permanent  channels  for  the  escape  of  fluid 
from  the  peritoneal  cavity.  A  number  of  thick  silk  ligatures  were  employed 
taking  up  the  peritoneum  and  the  muscular  layers  of  the  abdomen  but  leaving 
out  the  skin.  These  were  tied  and  the  skin  was  then  closed  over  them  with  a 
continuous  superficial  suture."  The  result  of  the  operation  was  excellent. 
CEdema  under  the  abdominal  skin  showed  that  the  silk  used  in  suturing  was 
acting  as  desired,  but  the  right  leg  and  thigh  so  far  from  being  oedematous  were 
slightly  smaller  than  the  left.  It  seemed  as  if  the  silk  threads  passed  into  the 
thigh  were  useless.  Seven  months  after  operation  a  condition  arose  which 
seemed  to  show  that  these  threads  were  useful  and  that  drainage  had  been  taking 
place  all  the  time  without  causing  evident  oedema,  and  further  that  if  the 
absorptive  power  of  the  tissues  is  normal  and  the  amount  of  fluid  led  into  them 
is  not  excessive,  then  oedema  need  not  be  expected. 

Henschen  ("Zent,  fiir  Chir.,"  Jan.  11,  1913)  operates  as  follows:  Make  a 
semilunar  incision  (convexity  posterior)  through  the  skin  above  and  external 
to  the  iliac  spine;  undermine  the  skin  towards  the  base  of  the  flap  outlined. 
Opposite  the  base  of  the  skin  flap  make  a  small  incision  through  the  aponeurosis 
and  muscles  at  right  angles  to  the  direction  of  their  fibers  and  thus  form  a  tunnel 
about  the  size  of  a  finger  through  the  parietes.  Open  the  peritoneum.  With 
fine  interrupted  silk  sutures  stitch  the  thickened  ring  at  the  base  of  a  rubber 
finger-cot  to  the  peritoneum  all  round  the  incision  in  it.  Cut  away  the  blind  end 
of  the  finger-cot  at  such  a  level  as  to  leave  the  attached  segment  protruding 
about  ^  inch  beyond  the  external  aponeurosis.  Suture  the  protruding  end  of 
the  finger-cot  circularly  to  the  wound  in  the  aponeurosis.  Close  the  skin 
wound. 


532  ASCITES 

Henschen  remarks  that  a  similar  method  might  be  used  to  conduct  ascitic 
into  the  loose  lumbar  retroperitoneal  cellular  tissue. 

Peter  Paterson  (Lancet,  Oct.  29,  1910)  makes  a  small  incision  through  the 
peritoneum  and  introduces  a  glass  button.  This  button  measures  about  i  inch 
across  the  flanges,  ^4  inch  between  the  flanges  and  has  a  canal  3'i2  irich  wide. 
The  flanges  are  about  ^f  g  iiich  thick.  The  length  of  the  cylindrical  part  should 
vary  in  different  buttons  as  this  part  must  pass  through  the  abdominal  muscles. 
When  in  place  one  flanged  surface  lies  inside  the  peritoneum  and  the  other  out- 
side the  muscles  in  the  subcutaneous  fat.  Before  placing  the  button  in  position 
any  of  the  omentum  which  might  plug  the  inner  end  of  the  button  must  be  excised. 

Drainage  through  the  Femoral  Canal. — Acting  on  a  suggestion  made  by 
Wynter,  Handley  has  opened  the  peritoneum  through  the  femoral  canal  and 
sutured  the  edges  of  the  peritoneal  wound  to  the  surrounding  tissues  in  such  a, 
manner  as  to  prevent  its  closure  if  possible.  The  skin  wound  is  of  course 
completely  closed.  The  object  of  the  operation  is  to  conduct  the  ascitic  fluid 
into  the  subcutaneous  tissues  of  the  thigh  whence  it  may  be  absorbed. 

Although  femoral  drainage  gave  at  least  one  brilliant  result,  yet  the  new 
formed  canal  usually  becomes  closed  or  plugged  and  failure  results. 

Direct  Drainage  into  Veins. — The  vein  suitable  for  use  in  this  operation 
is  the  internal  saphenous,  for  the  following  reasons:  (i)  It  is  conveniently 
situated;  (2)  it  is  large  enough  to  permit  of  easy  manipulation;  (3)  it  is  pro- 
vided with  eflScient  valves  near  its  mouth  (the  operation  is  contraindicated 
when  varicosity  of  the  vein  renders  the  valve  useless);  (4)  it  does  not  belong  to 
the  portal  system. 

As  a  preliminary  to  operation  always  make  sure,  by  culture  and  inoculation, 
that  the  ascitic  fluid  is  sterile.     This  is  of  great  hnportance. 

Step  I. — Make  an  incision  in  the  inguinal  region  along  the  course  of  the 
internal  saphenous  vein.  Expose  and  liberate  the  vein  from  its  junction 
with  the  femoral  downwards  for  about  4  inches,  i.e.,  free  enough  of  the  vein 
to  reach,  without  tension,  a  point  on  the  abdomen  just  above  Poupart's  ligament. 

Divide  the  vein  at  the  selected  point  and  ligate  the  peripheral  segment. 

Step  2. — Wash  away  blood  from  the  vein  with  warm  salt  solution.  Smear 
the  cut  end  of  the  vein  with  vaseline  and  protect  the  vein  from  drying. 

Step  3. — Open  the  abdomen  a  short  distance  above  Poupart's  ligament 
preferably  by  means  of  the  muscle-splitting  method.  With  closed  forceps 
make  a  subcutaneous  tunnel  from  the  incision  in  the  groin  to  the  abdominal 
incision.  Pass  the  mobilized  segment  of  vein  through  the  tunnel  and  suture 
its  open  end  to  the  opening  in  the  peritoneum.  This  suturing  ought  to  be  done 
after  the  Carrel  method  of  arteriorraphy,  with  vaselinized  silk. 

Step  4. — Close  the  wounds.  Before  closing  the  abdominal  wound  it  may  be 
necessary  to  divide  a  few  muscle  fibres  so  as  to  prevent  pinching  of  the  vein 
as  it  passes  through  the  parietes. 

Routte  ("Lyon  Chirurgical,"  March,  1910;  "La  Presse  Med.,"  June  25, 
1910)  performed  this  operation  in  January,  1907,  on  a  very  unfavorable  subject. 
For  a  month  everything  went  well  but  after  that  time  Routte  performed  the 
operation  on  the  opposite  side  and  the  patient  died  three  days  later  from  grave 
cardiac  disease. 


REMARKS  533 

Routte's  second  patient  was  a  man  of  seventy.  The  operation  was  per- 
formed on  both  sides  at  the  same  sitting.  The  patient  remained  apparently 
well  for  over  eighteen  months  after  which  time  he  was  lost  to  sight. 

Out  of  five  patients  operated  on  by  Routte,  in  two  the  result  was  negative; 
out  of  three  operated  on  by  Ito  and  Soyesima  there  was  but  one  success,  but 
that  was  secured  in  a  man  of  thirty-eight  who  had  been  tapped  seven  times, 
been  subjected  successively  to  omentopexy,  renal  decortication  and  to  an 
attempt  at  drainage  into  the  subcutaneous  tissues  by  means  of  a  buried  cannula. 

Remarks. — Operations  which  promise  even  a  very  moderate  amount  of 
success  are  thoroughly  justifiable  in  such  a  fatal  condition  as  ascites  due  to 
hepatic  cirrhosis. 

The  patients  are  usually  in  such  poor  condition  that  they  are  incapable 
of  withstanding  any  severe  intervention. 

Narath's  modification  of  omentopexy  seems  superior  to  the  Talma-Morison 
operation  in  that  it  probably  establishes  a  permanent  and  efficient  drainage  of 
the  ascitic  fluid  into  the  subcutaneous  tissues  by  means  of  the  herniated 
omentum. 

Wynter's  remarks  quoted  by  Handley  are  very  weighty: 

"The  treatment  of  ascites  by  repeated  paracentesis,  commonly  employed 
in  hepatic  cirrhosis,  has  proved  unsatisfactory,  inasmuch  as  in  the  majority 
of  cases  the  fluid  returns  within  a  few  days,  and  the  patient  is  confined  to  bed 
or  hospital  for  the  remaining  brief  period  of  life,  which  seldom  extends  beyond 
two  or  three  months. 

"The  steady  downhill  course  and  rapid  loss  of  strength  after  paracentesis 
has  been  inaugurated  indicate  that  the  patient  pays  dearly  for  the  relief  of 
distention  by  the  sacrifice  of  so  much  nutrient  fluid,  whose  speedy  replace- 
ment drains  the  blood  and  tissue  and  starves  the  kidneys.  The  objects  aimed 
at  by  the  method  of  subcutaneous  drainage  are: 

"i.  The  saving  of  nutrient  material  to  the  patient. 

"2.  To  ensure  an  adequate  outflow  of  urine  from  the  kidneys  and  a  suffi- 
cient supply  of  fluid  to  the  tissues  by  draining  the  stagnant  pond  of  the  peri- 
toneal cavity. 

"3.  To  enable  the  patient  to  leave  his  bed  and  to  maintain  the  circulation 
of  the  body  fluids,  especially  in  the  portal  and  lymphatic  systems,  by  means  of 
exercise. 

"4.  To  relieve  intraabdominal  tension,  and  thus  promote  lymphatic  absorp- 
tion and  the  establishment  of  a  good  collateral  circulation." 

To  the  author  it  appears  that  much  of  the  good  obtained  from  omentopexy 
may  be  attributed  to  permanent  drainage  accidentally  established;  that  some 
form  of  subcutaneous  drainage  will  prove  the  treatment  of  choice;  that  all 
endeavors  after  direct  anastomosis  between  the  hepatic  and  systemic  circulations 
are  unjustifiable. 


534  RETRO-PERITONEAL    NEOPLASMS 

CHAPTER  XXXIX 
RETRO -PERITONEAL  NEOPLASMS 

Solid  retro-peritoneal  tumors  may  be  lipomata  or  sarcomata.  The  method 
of  operating  is  the  same  for  both  classes  of  tumor  though  when  sarcoma  can  be 
definitely  recognized  after  opening  the  abdomen  it  is  hardly  worth  while  to 
endeavor  to  remove  it,  unless  in  an  attempt  to  relieve  distressing  symptoms. 
The  mortality  after  removal  of  lipomata  has  been  high  because  of  the  late  stage 
in  which  operation  has  been  undertaken. 

In  operating  it  is  well  to  remember  that  retro-peritoneal  lipomata  arise 
principally  from  the  peritoneal  and  the  mesenteric  fat.  They  may  be  of 
enormous  size. 

B.  J.  Johnston  (of  Belfast)  in  1905  removed  easily  and  apparently  com- 
pletely, a  lipoma  weighing  21  pounds  from  beside  the  right  kidney.  After  two 
years  he  removed  one  of  12}'^  pounds  from  the  same  site  in  the  same  patient. 
There  was  no  evidence  of  malignancy.  George  Ben  Johnston  (Journ.  A.  M.  A., 
Oct.  22,  1914)  reports  two  cases  of  retro-peritoneal  lipoma  operated  on  by 
himself  and  gives  a  good  review  of  the  literature. 

Retro-peritoneal  tumors  in  their  growth  necessarily  push  the  intestines  in 
front  of  them  or  to  one  side;  if  they  arise  near  the  base  of  a  mesentery  they  grow 
into  the  mesentery,  the  vessels  of  which  become  spread  over  them;  they  can 
surround  important  structures  such  as  the  kidneys,  the  inferior  vena  cava,  etc. ; 
they  may  contract  adhesions  with  their  surroundings  so  that  removal  becomes 
difficult  or  impossible  or  they  may  be  easily  shelled  out  of  their  bed.  Diagnosis 
is  rarely  made  before  operation,  the  condition  presents  itself  to  the  surgeon  as  a 
surprise  when  he  has  opened  the  abdomen  for  exploration  or  on  an  erroneous 
diagnosis. 

The  rules  to  be  observed  in  operating  are:  (i)  Secure  free  exposure  so  as  to 
judge  if  it  is  justifiable  to  attempt  removal  and,  if  removal  is  attempted,  to  do 
the  operation  as  far  as  possible  under  guidance  of  the  eye.  (2)  Divide  the 
peritoneum  covering  the  growth  sufficiently  to  secure  free  exposure  but  in  such 
a  manner  as  to  avoid  injury  to  the  intestines  or  their  blood  supply.  If  the 
nutrition  of  a  segment  of  intestine  is  cut  off,  that  portion  of  gut  must  of  course  be 
removed.  (3)  In  separating  the  tumor  from  such  structures  as  the  inferior 
vena  cava  or  the  iliac  veins,  rather  leave  a  portion  of  the  tumor  in  situ  than 
hazard  their  integrity.  If  it  is  impossible  or  improper  to  avoid  injury  to  very 
large  and  important  veins  their  wounds  m.ust  be  sutured  at  once  secundum 
artem.  (4)  If  a  kidney  is  included  in  the  growth  and  is  not  readily  separated  it 
may  be  well  to  remove  it  always  provided  that  the  opposite  kidney  is  intact. 

The  following  description  of  an  operation  by  Fritz  Konig  (Berliner  Med. 
Woch.,  1900,  No.  28)  is  instructive  as  a  type  "the  peritoneal  cavity  was  opened 
above  the  navel  through  a  median  incision  which  extended  from  the  ensiform 
to  the  pubis,  but  neither  omentum  nor  intestine  could  be  seen  as  they  were 
displaced  upwards  into  a  small  cavity.  The  posterior  parietal  peritoneum  lay 
before  us,  pushed  far  forwards  by  a  yellowish  tumor.     The  reflection  of  the 


RETKO-PERITONEAL    CYSTS  535 

posterior  peritoneum  on  to  the  anterior  j^arietes  formed  a  fold  about  a  hands- 
breadth  below  the  umbilicus.  The  posterior  peritoneum  was  incised  in  the 
direction  of  the  external  wound  and  as  the  lobulated  tumor  seemed  to  be  a 
lipoma  its  extirpation  was  begun.  Vessels,  es{)ecially  mesenteric  vessels  did  not 
seem  to  run  deeply  in  the  interlobular  clefts.  The  tumor  was  firmly  attached 
posteriorly  and  seemed  to  arise  from  the  pelvis.  The  peritoneum  which  covered 
only  the  upper  third  of  the  tumor,  was  separated  with  diflficulty;  sharp  and  blunt 
lateral  reflection  of  the  soft  parts  covering  the  lower  portions  of  the  tumor  was 
likewise  difficult.  During  the  enucleation  much  effort  was  required  to  lift  the 
enormous  tumor  away  from  the  posterior  abdominal  wall.  The  urinary 
bladder  was  not  seen  nor  could  one  feel  a  catheter  which  had  been  introduced 
into  it.  During  the  dissection  of  the  right  posterior  part  of  the  growth  a  band 
was  found  passing  backwards  between  two  of  its  lobes.  On  division  this  was 
found  to  be  the  median  ligament  of  the  bladder  dragged  there  by  the  bladder 
which  lay  behind  the  tumor. 

On  the  left  side  the  iliac  veins  were  so  united  to  the  tumor  and  its  capsule 
that  they  required  to  be  freed  by  sharp  dissection.  The  left  vas  deferens 
(leading  to  an  atrophied  inguinal  testis)  was  so  surrounded  by  neoplasms  that  it 
had  to  be  divided.  On  the  right  side  the  vas  and  blood-vessels  were  not  in- 
volved. .  .  .  The  tumor  was  removed  in  one  piece  except  for  a  few  fragments 
left  attached  to  the  left  iliac  veins.  During  the  excision  a  vein  deep  in  the  pelvis 
was  lacerated  but  lateral  ligation  of  its  wall  was  efTective.  In  the  enormous 
wound  the  bladder  lay  to  the  right  of  the  pelvis  in  the  sacral  cavity,  to  the  left 
was  the  rectum  and  above  were  the  retro-peritoneal  tissues.  The  rapid  filling 
of  the  dilated  veins  especially  about  the  caecum  was  very  striking  in  a  peritoneal 
cavity  which  had  been  compressed  into  a  very  small  space."  The  peritoneum 
was  sutured  but  the  pelvic  cavity  was  packed  with  iodoform  gauze. 

Retro-peritoneal  Cysts. — Dermoid  cysts  from  an  operative  standpoint  may 
be  considered  in  the  same  class  as  lipomata  while  hydatids  ought  to  be  treated  in 
much  the  same  fashion  as  those  of  the  liver.  The  other  forms  of  retro-peritoneal 
cysts  appear  in  literature  under  various  names  such  as  pancreatic,  pseudo-pan- 
creatic, renal,  mesenteric,  etc.,  etc.  Dowd  (Annals  Surg.,  xxxii,  515)  be- 
lieves that  many  of  the  cysts  published  as  "chylous,"  "sanguineous"  etc.,  arise 
from  sequestrations  from  the  primitive  organs  of  generation.  Donoghue 
(Journ.  A.  M.  A.,  Dec.  22,  1906)  has  similar  views.  In  International  Clinics 
iv,  1906,  the  author  wrote,  'Tn  the  literature  on  cysts  of  the  lesser  peritoneum 
one  finds  few  reported,  apart  from  those  credited  to  the  pancreas;  it  is  often  so 
difficult,  or  even  impossible,  to  recognize  during  operation  the  precise  origin  of 
any  individual  cyst;  there  are  so  many  possible  sources  from  which  cysts  may 
develop  that  one  is  forced  to  believe  that  operators  and  writers  have  too  often 
assumed  their  pancreatic  origin  without  sufficient  diagnostic  data."  The 
operative  treatment  of  retro-peritoneal  cysts  varies  according  to  circumstances. 
If  the  cyst  lies  behind  the  ascending  or  descending  colon  it  ought  to  be  ap- 
proached through  an  incision  in  the  parietal  peritoneum  just  external  to  the 
colon,  in  fact  through  such  an  incision  as  is  used  in  mobilizing  the  colon  in 
colectomy.  If  the  cyst  occupies  the  lesser  peritoneal  cavity  (pseudo-pancreatic 
cyst)  it  may  be  approached  through  the  gastro-colic  omentum;  if  it  lies  in  a 


536  THE    PANCREAS 

mesentery  it  must  be  approached  through  the  peritoneum  of  the  mesentery,  very 
great  care  being  taken  to  incise  as  far  from  the  gut  as  is  possible  and  to  avoid 
injury  to  the  mesenteric  vessels  for  fear  of  jeopardizing  the  nutrition  of  the 
gut.  Once  the  cyst  wall  is  exposed  two  methods  of  treatment  may  be  available. 
(a)  If  it  is  easy  to  separate  the  cyst  wall  from  its  surroundings,  with  or  without 
evacuation  of  its  contents,  do  so.  Usually  the  cavity  left  is  at  once  obliterated 
by  the  collapse  of  its  sides,  otherwise  it  may  be  necessary  to  insert  a  drain. 
With  sutures,  close  any  peritoneal  wound,  (b)  If  enucleation  of  the  cyst 
seems  difficult  or  threatens  the  integrity  of  some  important  structure,  make  an 
opening  into  the  cyst  and  evacuate  its  contents.  Remove  as  much  of  the  cyst 
wall  as  possible  but  leave  enough  to  permit  of  its  suture  to  the  abdominal  wall 
without  tension.  Suture  the  edges  of  the  wound  in  the  cyst  to  the  parietal 
peritoneum  and  deep  aponeurosis.  (When  the  cyst  is  situated  in  the  flanks 
it  may  be  better  to  secure  the  marsupialization  through  a  postero-lateral  incision 
and  to  close  the  original  abdominal  wound.)  Sometimes  after  its  contents  have 
been  evacuated,  a  cyst  which  appeared  impossible  of  enucleation  may  become 
removable. 

If  it  is  impossible  or  improper  to  bring  the  cyst  into  contact  with  the  ab- 
dominal wound  place  a  purse-string  suture  of  catgut  around  the  opening  in  the 
cyst,  introduce  a  drain,  tighten  the  purse-string  round  the  drain  and  with  a 
needle  fasten  the  end  of  the  suture  to  the  tube  so  that  the  latter  cannot  escape 
before  the  catgut  is  absorbed.  Bring  the  end  of  the  tube  through  the  abdominal 
wound.  The  technique  of  drainage  in  these  cysts  is  very  similar  to  that  in 
cholecystostomy  and  the  results  are  very  good. 

If  a  loop  of  intestine  is  inseparably  attached  to  the  cyst  the  two  must  be 
removed  together. 

Pakowski  (Internat.  Abst.,  Feb.,  1913)  extirpated  dermoid  cysts  in  13  cases 
with  II  rapid  recoveries.  In  43  cases  of  dermoids  collected  by  him  the  site  of 
the  tumors  was  as  follows:  great  omentum  7;  lesser  omentum  i;  lesser  peri- 
toneal cavity  3 ;  mesocaecum  i ;  ascending  mesocolon  2 ;  transverse  mesocolon  5 ; 
descending  mesocolon  i;  meso-sigmoid  3;  in  neighborhood  of  rectum  8;  retro- 
peritoneum  12. 


CHAPTER  XL 
THE  PANCREAS 


The  pancreas  is  so  deeply  hidden  behind  the  abdominal  cavity  that  it  has 
been  much  neglected  by  the  pathological  anatomists.  The  fact  that,  when  it 
is  injured,  other  organs  are  always  notably  injured  at  the  same  time,  and  the 
patient  is  evidently  in  a  critical  condition,  has  led  operators  to  neglect  direct 
investigation  or  inspection  of  the  gland.  Until  very  recently  the  only  pan- 
creatic lesions  attacked  by  surgery  were  cysts.  To-day,  thanks  to  the  labors  of 
many  pathologists,  internists,  and  surgeons,  more  knowledge  has  been  attained 
and  this  "hermit  kingdom"  is  being  opened  up  to  surgical  therapy. 

The  pancreas  reaches  from  the  duodenum  to  the  spleen  and  discharges  its 
secretions  through  the  canal  of  Wirsung  into  the  duodenum.     Before  entering 


PANCREATIC   CYST 


537 


the  gut  the  canal  of  Wirsung  unites  with  the  common  bile-duct  to  form  the 
diverticulum  or  ampulla  of  Vater  (Fig.  672).  Besides  the  main  duct  or  canal 
of  Wirsung,  there  is  a  secondary  duct  (duct  of  Santorini),  which  arises  from  the 
main  duct  near  the  head  of  the  gland  and  discharges  into  the  duodenum  at  a 
slightly  higher  level.  The  tail  or  left  extremity  of  the  pancreas  lies  in  front  of 
the  left  kidney  and  the  suprarenal  capsule.  The  most  important  vascular 
relations  of  the  pancreas  are  the  splenic  artery  on  its  upper  surface,  while  at  its 
head  is  the  pancreatico-duodenal  artery,  which  forms  an  arch  with  the  superior 
mesenteric.     The  pancreas  lies  behind  the  posterior  parietal  peritoneum  and  in 


WJM.,0, 


TfMutMrae  CoIm 


Fig.  672. — Anatomical  relations  of  the  pancreas.     {Mayo.) 


front  of  the  lower  portion  of  its  head  is  the  transverse  mesocolon ;  in  front  of  its 
body  is  the  stomach. 

There  are  several  routes  by  which  the  pancreas  may  be  reached:  (i)  Through 
the  gastro-hepatic  omentum  above  the  stomach;  (2)  through  the  gastro-colic 
omentum  below  the  stomach;  (3)  through  the  transverse  mesocolon  back  of 
colon  and  the  stomach;  (4)  by  retracting  inwards  the  second  part  of  the  duo- 
denum; (5)  through  the  stomach;  (6)  from  the  loin  behind  the  peritoneum. 

Operation  upon  a  pancreatic  cyst  forms  a  good  type  on  which  to  base  a 
description  of  surgical  interference. 

Step  I. — Open  the  abdomen  in  or  near  the  middle  line  above  the  umbilicus. 
If  the  cyst  makes  a  prominent  swelling,  it  may  be  well  to  make  the  incision, 
vertically,  over  its  most  prominent  part.  Explore  the  abdomen,  note  the  pres- 
ence and  extent  of  adhesions,  and  where  the  cyst  presents.  This  may  be 
above,  behind  or  below  the  stomach,  behind  or  below  the  transverse  colon 
(Figs.  673,674,  675,676,  677). 

Step  2. — (A)  The  cyst  presents  or  is  most  prominent  above  or  behind  the 
stomach.  Make  a  vertical  tear  through  the  gastro-hepatic  omentum;  this  at 
once  exposes  the  cyst.     Endeavor  to  explore  the  relations  of  the  cyst,  but  do 


THE    PANCREAS 


Fig.  673.  Fig.  674.  Fig.  675. 

Fig.  673. — Tumor  of  pancreas.  Stomach  and  colon  both  below  it.  {Robson  and 
Moynihan.) 

Fig.  674. — Tumor  of  pancreas.  Stomach  and  colon  both  in  front  of  it.  (Robson  and 
Moynihan.) 

Fig.  675. — Tumor  of  pancreas  pushing  forwards  between  the  posterior  layer  of  the  great 
omentum  and  the  transverse  mesocolon.  Stomach  above,  colon  beneath  it.  (Robson  and 
Moynihan.) 


Fig.  676.  Fig.  677. 

Fig.  676. — Tumor  of  pancreas.  Stomach  in  front,  colon  below  it.  —  (Robson  and 
Moynihan.) 

Fig.  677. — Tumor  of  pancreas.  Stomach  and  colon  both  above  it. — (Robson  and 
Moynihan.) 


EXPOSURE    PANCREAS  539 

not  persist  in  the  exploration  if  great  difficulties  arise,  lest  harm  result.  In  a 
few  instances  it  may  be  found  possible  to  excise  the  disease;  most  commonly 
marsupialization  is  the  operation  of  choice. 

(B)  The  cyst  presents  between  the  stomach  and  transverse  colon,  behind 
the  colon,  or  behind  the  stomach.  Make  a  vertical  tear  through  the  gastro- 
colic omentum  and  expose,  explore,  and  treat  the  cyst.  J.  D.  Malcolm  ("Lan- 
cet," June  i6,  1906)  completely  and  successfully  removed  a  multilocular  cystic 
tumor  through  this  route.  Both  layers  of  the  transverse  mesocolon  were 
divided;  the  wound  in  the  inferior  layer  was  sutured.  Although  the  pancreas 
itself  was  incised  this  gave  no  subsequent  trouble,  probably  because  drainage 
was  established  posteriorly  below  the  twelfth  rib.  Acute  flexion  at  the  splenic 
angle  of  the  colon  necessitated  colo-colic  anastomosis  on  the  sixteenth  day  after 
the  primary  operation.     Recovery. 

(C)  The  cyst  presents  behind  or  below  the  transverse  colon.  Pull  the 
transverse  colon  and  great  omentum  out  through  the  belly  wound  and  turn 
them  upwards  exactly  as  is  done  in  posterior  gastro-enterostomy.  In  an  avas- 
cular area  of  the  transverse  mesocolon  make  an  appropriate  tear  and  expose,  ex- 
plore, and  treat  the  cyst.  Do  not  injure  the  mid-colic  artery  or  any  of  its  main 
branches. 

(D)  Korte  has  reached  the  head  of  the  pancreas  by  forcing  his  way  along 
the  side  of  the  duodenum  after  incising  lis  peritoneal  covering.  This  is  very 
similar  to  Vautrin's  method  of  reaching  the  lowest  segments  of  the  common 
bile-duct. 

Pauchet  (Sherwood-Dunn,  Am.  Jour,  of  Surg.,  Oct.,  1916)  has  exposed  the 
pancreas  satisfactorily  through  the  intercolo  epiploic  route  (p.  404). 

(E)  Transgastric  route:  Hagen  ("Archiv  f.  klin.  Chir.,"  Ixii,  157)  reports 
a  case  in  which  complications  compelled  him  to  attack  the  cyst  after  incision 
of  both  the  anterior  and  posterior  gastric  walls.  The  stomach  was  inseparably 
and  indistinguishably  adherent  to  the  cyst.  It  was  impossible  to  reach  the 
cyst  and  bring  a  portion  of  its  wall  to  the  parietes  by  any  ordinary  means. 
Hagen  made  a  two-inch  incision  through  the  anterior  wall  of  the  stomach  and 
a  small  one  through  the  posterior  wall.  There  was  no  line  of  demarcation  be- 
tween the  stomach  and  cyst-walls.  After  evacuation  of  the  contents  the  cyst 
was  explored  with  the  finger.  It  was  possible  with  care  to  bring  a  small  area 
of  cyst-wall  to  the  parietes,  to  the  left  of  the  great  curvature,  below  the  ribs, 
behind  the  left  gastro-epiploic  artery  and  vein.  Before  the  selected  portion  of 
cyst-wall  could  be  united  to  the  parietes  it  was  necessary  to  resect  the  cartilages 
of  the  ninth  and  tenth  ribs  on  the  left  side;  this  permitted  the  soft  belly- wall 
to  sink  inwards  and  meet  the  cyst-waU  as  it  was  elevated.  Closure  of  the  gas- 
tric wound  by  suture  and  marsupialization  of  the  cyst  completed  the  operation. 
Recovery.  Hagen  considered  the  possibility  of  lumbar  drainage,  but  in  his 
case  it  was  out  of  the  question. 

(F)  Lumbar  route:  Remember  that  the  tail  of  the  pancreas  lies  in  front  of 
the  left  renal  vessels,  hence  any  operation  by  which  the  hilus  of  the  kidney  is 
exposed  will  also  give  access  to  the  left  extremity  of  the  pancreas.  Exposure 
of  the  kidney  through  the  loin  is  so  fully  discussed  elsewhere,  and  exposure  of 
the  tan  of  the  pancreas  is  so  similar,  that  further  description  is  unnecessary  here. 


54° 


THE   PANCREAS 


In  the  course  of  transperitoneal  operations  it  is  often  advisable  or  necessary 
to  provide  lumbar  drainage.  To  efifect  this,  explore  the  cyst  with  the  finger; 
guided  by  the  finger  and  carefully  avoiding  all  important  structures  such  as  the 
renal  vessels,  etc.,  push  a  closed  forceps  through  the  posterior  parietes  below 
the  twelfth  rib  and  immediately  external  to  the  erector  spinae  muscle.  Incise 
the  skin  and  deep  fascia  at  the  point  made  prominent  by  the  forceps.  Make 
the  opening  large  enough  to  avoid  compression  of  the  tube  or  gauze  used  for 
drainage.  With  the  forceps  pull  a  drain  (gauze  or  tube)  into  position.  It  is 
well,  when  preparing  a  patient  for  any  operation  on  the  upper  half  of  the  belly, 
in  which  posterior  drainage  may  be  required,  to  follow  Park's  advice,  and  clean 
the  lumbar  region  as  well  as  the  abdomen;  thus  valuable  time  may  be  saved 
in  the  course  of  the  operation.  Deaver's  plate  (Fig.  678),  although  drawn  to 
illustrate  the  relations  of  the  kidney,  illustrates  the  important  anatomical  rela- 


FiG.  678. — Relation  of  pancreas.     (Denver.) 


tions  of  the  pancreas,  especially  with  regard  to  exposure  through  the  lumbar 
route.  Only  the  head  and  tail  of  the  pancreas  are  accessible  by  this  posterior 
route,  the  tail  being  more  easily  reached  than  the  head.  Peters  was  successful 
in  exposing  and  draining  a  hydatid  cyst  of  the  tail  of  the  pancreas  through  the 
left  lumbar  route. 

Step  3. — Treatment  of  the  cyst.  Dangers:  The  dangers  inseparable  from 
operations  on  the  pancreas  are  less  pronounced  in  cystic  than  in  other  diseases 
or  lesions.  It  will  be  convenient,  however,  at  this  time,  to  discuss  the  dangers 
of  pancreatic  operations  in  general;  v.  Mikulicz  gives  a  good  resume  of  these 
in  his  paper  on  "The  Surgery  of  Trauma  and  Inflammatory  Processes  in  the 
Pancreas"  ("Transactions  of  the  Congress  of  American  Physicians  and  Sur- 
geons," 1903). 

1.  Hemorrhage.  The  pancreas  is  exceedingly  vascular;  its  tissues  are  frag- 
ile, and  hence  simple  ligature  is  often  entirely  ineffective.  Sutures  involving  a 
mass  of  healthy  or  uninjured  tissue,  as  well  as  the  bleeding  area,  are  necessary 
in  spite  of  the  dangers  from  necrosis  incident  to  the  use  of  mass  ligatures.  Sec- 
ondary hemorrhage  is  common.  It  is  wise,  when  possible,  to  prepare  the  pa- 
tient, prior  to  operation,  by  the  exhibition  of  large  doses  of  chloride  of  calcium, 
as  recommended  by  Mayo  Robson  in  cases  of  jaundice. 

2.  Leakage  of  pancreatic  juice  into  the  parenchyma  of  the  gland  and,  the 


ROBSON    ON   PANCREATIC   DISEASE  54I 

surrounding  peritoneal  structures  constitutes  a  greater  danger  even  than  bleed- 
ing. The  juice,  even  when  sterile,  does  much  positive  damage;  it  also  dimin- 
ishes the  resisting  power  of  the  tissues  so  that  the  mildest  form  of  infection, 
ordinarily  harmless,  becomes  of  the  gravest  significance.  Infection  is  liable 
to  reach  the  injured  area  through  the  pancreatic  duct  from  the  duodenum  in  the 
same  manner  as  it  passes  up  the  common  bile-duct.  Fat  necrosis  and  pancrea- 
titis, both  chronic  and  hemorrhagic,  may  be  occasioned  by  trauma,  and  hence 
may  result  from  operation.  Peritonitis  is  very  liable  to  result  from  pancreatic 
leakage.  This  peritonitis  may  be  aseptic  and  is  frequently  followed  by  intesti- 
nal paralysis,  leading  to  rapidly  developing  obstruction,  which  often  so  modifies 
the  symptoms  as  to  lead  to  a  serious  mistake  in  diagnosis  (v.  Mikulicz).  During 
e.xcisionof  gastric  cancer  portions  of  the  adherent  pancreas  maybe  shaved  away, 
hemostasis  being  attained  by  sutures  and  by  covering  the  wound  with  perito- 
neum. The  fact  does  not  negative  the  value  of  the  preceding  remarks  as  in 
gastric  cancer  where  portions  of  the  pancreas  must  be  sacrificed,  these  portions 
have  been  subjected  to  simple  or  adhesive  inflammation  and  thus  are  prepared 
for  operation. 

3.  It  has  been  shown  that  by  the  time  such  definite  symptoms  of  pancreatic 
disease  arise  as  diabetes  or  severe  disturbance  of  its  fat-digesting  function, 
there  is,  as  a  rule,  already  such  great  destruction  of  its  substance  that  surgical 
interference  is  not  admissible.  The  author  operated  on  one  case  of  very 
recent  pancreatic  diabetes  in  the  hope  that  drainage  might  relieve  the  inflam- 
mation to  which  it  was  believed  the  disease  was  due;  the  patient  did  not  sur- 
vive more  than  twenty-four  hours.  Nash  ("Lancet,"  Nov.  i,  1902)  reports  a 
case  of  pancreatic  glycosuria  associated  with  cholelithiasis  in  a  man  of  sixty  years. 
After  removal  of  a  large  calculus  from  the  gall-bladder,  recovery  ensued.  The 
urine  four  months  after  operation  was  free  from  sugar.  In  Woolsey's  three 
successful  operations  for  acute  pancreatitis  only  one  had  glycosuria. 

Mayo  Robson  (''Brit.  Med.  Journ.,"  April  23,  1910)  after  discussing  the 
value  of  Cammidge's  reaction  as  a  means  of  diagnosing  pancreatic  disease  before 
and  after  the  appearance  of  glycosuria,  comes  to  the  following  conclusions: 

1.  That  the  early  recognition  and  treatment  of  interstitial  pancreatitis,  or 
of  pancreatic  catarrh,  by  drainage  of  the  bile-ducts,  and  thus  indirectly  of  the 
pancreatic  ducts,  and  the  removal  of  the  cause,  whether  that  be  gall-stones, 
duodenal  ulcer,  or  other  conditions,  may  be  the  means  of  averting  diabetes. 

2.  That  in  certain  diseases  of  the  pancreas,  even  after  the  appearance  of 
glycosuria,  surgical  treatment  is  well  worth  considering,  as  in  a  number  of  cases 
it  has  lead  to  a  complete  disappearance  of  sugar  from  the  urine,  and  in  others  to 
an  arrest  of  the  disease  causing  glycosuria. 

3.  That  every  case  of  diabetes  should  be  considered  from  its  etiological 
point  of  view,  seeing  that  certain  cases  of  glycosuria  of  pancreatic  origin  are  cur- 
able, and  in  others  the  progress  of  the  disease  may  be  arrested  by  suitable  surgi- 
cal methods  that  can  be  carried  out  with  small  risk. 

Robson  reports  a  number  of  cases  which  support  these  conclusions. 

(A)  Excision  of  the  Cyst. — This  operation  is  suitable  only  in  cases  where  ad- 
hesions are  few  or  where  the  cyst  has  become  pedunculated.  Ransohoff  has 
collected  23  cases  of  enucleation  with  2  deaths.     The  operation   requires  no 


542  THE    PANCREAS 

special  description,  as  the  surgeon  must  follow  the  common  principles  of  surgery 
after  the  tumor  has  been  exposed  by  one  of  the  methods  described  above,  v. 
Mikulicz  lays  down  the  absolute  rule  that  whenever  the  pancreatic  tissue  has 
been  exposed,  drainage  is  requisite. 

(B)  Marsupialization  or  Drainage. — Expose  the  cyst  by  any  of  the  methods 
described.  Protect  the  peritoneal  cavity  thoroughly  with  pads.  Note  the 
part  of  the  cyst  which  can  be  most  readily  brought  into  apposition  with  the 
abdominal  wall.  If  the  site  of  the  primary  abdominal  incision  proves  unsuitable, 
a  secondary  incision  may  be  made.  If  the  cyst  is  very  tense,  empty  it,  at  least 
in  part,  by  means  of  the  aspirator.  Suture  the  cyst-wall  to  the  parietal  peri- 
toneum. Explore  the  cyst  cavity.  Especially  note  if  the  tumor  is  a  true  pan- 
creatic cyst,  i.e.,  one  ^.rising  in  the  gland  itself;  or  a  false  one,  i.e.,  a  collection  of 
fluid  in  the  lesser  peritoneal  cavity  due,  as  a  rule,  to  injury  or  disease  of  the  pan- 
creas. If  necessary,  provide  drainage  by  means  of  lumbar  puncture.  Provide 
tubular  or  gauze  drainage  of  the  cyst  or  a  combination  of  tubular  and  gauze 
drainage.  If  the  cyst- wall  is  of  suitable  consistency,  it  is  well  to  fix  a  ''dressed 
drainage-tube''  into  it,  exactly  as  is  done  in  the  case  of  the  gall-bladder.  If 
the  cyst-wall  is  too  thin  to  be  sutured  with  safety  to  the  parietes  or  if  it  cannot 
be  brought  to  the  abdominal  wound,  protect  the  peritoneum  v;ith  gauze  packing 
around  a  tube  which  leads  into  the  cyst.  As  a  whole,  the  methods  of  draining 
pancreatic  cysts  are  identical  with  those  for  draining  the  gall-bladder,  but  in  the 
case  of  the  former  greater  danger  is  to  be  feared  from  the  effects  of  the  leakage  of 
fluid  into  the  peritoneum.  Having  provided  for  drainage,  close  the  excess  of 
wound  in  the  abdominal  wall. 

Usually,  under  the  above  treatment,  the  cyst  shrinks  and  becomes  ob- 
litered.     Occasionally  a  fistula  persists. 

Wohlgemuth  and  Karewsky  have  found  that  persistent  pancreatic  fistulae 
close  promptly  when  the  patients  are  put  on  rigid  antidiabetic  diet.  Walter 
Schmidt  ("Muench.  med.  Woch.,"  Dec.  lo,  1907)  reports  having  excised  a 
pancreatic  cyst:  the  gland  was  injured,  drainage  provided,  antidiabetic  diet 
was  ordered;  everything  went  well  until,  on  the  thirteenth  day  after  operation, 
a  more  liberal  diet  was  permitted  when  the  discharges  became  more  profuse 
and  continued  so  until  the  rigorous  diet  was  reestablished. 

Solid  tumors  of  the  pancreas  are  rarely  suitable  for  operation.  Ruggi, 
in  1890,  and  Gade,  in  1895,  successfully  removed  tumors  from  the  tail  of  the 
pancreas;  most  of  the  other  cases  reported  promptly  died. 

Excision  of  the  Head  of  the  Pancreas. — The  author  is  unaware  of  any 
operation  actually  performed  for  the  excision  of  the  head  of  the  pancreas  and 
the  duodenum,  but  the  steps  of  the  operation  as  elaborated,  on  the  cadaver, 
by  Desjardins  ("Rev.  de.  Chir.,"  June,  1907)  teach  so  many  valuable  lessons 
that  the  method  demands  attention.  Various  items  of  the  operation  are  well 
calculated  to  assist  a  surgeon  when  attacking  such  conditions  as  malignant 
disease  of  the  duodenum  near  the  ampulla  of  Vater,  etc.  Desjardins  remarks 
that  if  the  length  and  complexity  of  the  operation  demands  it,  the  procedure 
may  be  carried  out  in  two  sittings.  At  the  first  sitting  a  gastro-enterostomy 
(en  Y)  is  done,  the  jejunum  being  divided  lower  than  usual,  about  8  inches  from 
its  origin.     At  the  second  sitting  the  head  of  the  pancreas  is  removed  along  with 


EXCISION    PANCREAS  543 

the  duodenum  and  the  double  anastomosis  of  the  bile-duct  and  the  pancreas 
carried  out.  This  second  operation  consumes  about  the  same  time  as  does  an 
ordinary  pylorectomy. 

Desjardins'  Operation. — There  are  three  special  anatomical  dangers  to  be 
overcome  in  the  operation: 

a.  In  certain  cases  the  upper  end  of  the  ascending  colon  lies  directly  on  the 
right  surface  of  the  descending  duodenum  and  is  hence  in  danger  of  injury  when 
the  duodenum  is  being  mobilized. 

b.  At  the  third  portion  of  the  duodenum  the  superior  mesenteric  artery 
and  vein  emerge  from  under  the  lower  edge  of  the  pancreas  and  pass  over  the 
front  of  the  duodenum.  The  middle  colic  artery  arises  from  the  superior  mesen- 
teric and  courses  through  the  transverse  mesocolon;  it  is  easily  injured  and  in- 
jury leads  to  gangrene  of  the  gut  it  supplies.  The  mesenteric  artery,  lying  to  the 
left  of  its  companion  vein,  is  situated  in  the  groove  which  separates  the  body 
from  the  neck  of  the  pancreas ;  it  runs  downwards  and  to  the  right  in  a  curve 
which  is  convex  towards  the  left;  from  its  concave  or  right  side  as  soon  as  it 
emerges  from  the  pancreas  it  gives  off  the  colic  arteries.  To  the  left  of  the 
superior  mesenteric  vessels  there  is  an  avascular  region  in  which  there  is  no 
vessel  except  the  pancreatico-duodenal,  and  it  can  be  safely  tied. 

c.  Behind  the  pancreas  and  close  to  it,  lie  the  portal  vein  and  the  inferior 
vena  cava. 

Place  the  patient  in  Robson's  position. 

Step  I. — Make  a  median  incision  from  a  point  on  the  level  of  the  tip  of  the 
ninth  rib,  downwards  to  near  the  umbilicus.  From  the  upper  end  of  the  vertical 
incision  cut  upwards  and  to  the  right,  through  the  right  rectus,  until  the  costal 
margin  is  reached  above  and  to  the  inner  side  of  the  gall-bladder.  If  more 
room  is  required  make  an  oblique  cut  downwards  and  to  the  left  from  the 
lower  end  of  the  median  incision.  Before  making  the  two  supplementary 
cuts,  introduce  the  hand  and  explore  the  belly. 

Step  2. — Push  the  omentum  to  the  left.  Expose  the  duodenum.  Incise  the 
peritoneum  parallel  to  and  about  ^  inch  from  the  descending  duodenum 
after  noting  that  it  is  not  adherent  to  the  ascending  colon.  Through  the  peri- 
toneal wound  separate  the  duodenum  from  the  posterior  belly-wall  until 
the  portal  vein  and  vena  cava  are  passed.  The  head  of  the  pancreas  can  now 
be  completely  explored  and  even  brought  almost  out  of  the  wound. 

Step  3. — ^Ligate  the  pyloric  and  gastroduodenal  vessels  as  in  pylorectomy. 
Divide,  between  ligatures,  the  right  portion  of  the  great  omentum. 

Step  4. — Doubly  clamp  and  divide  the  pylorus  (Fig.  679).  Pull  the  mo- 
bilized duodenum  downwards  to  expose  the  common  bile-duct.  If  the  duct  is 
dilated  divide  it,  between  forceps,  as  low  as  possible;  if  not  dilated,  divide  it 
just  below  the  entrance  of  the  cystic  duct.  At  this  stage  it  may  be  necessary 
to  cautiously  dissect  the  mesocolon  in  order  to  disengage  the  portion  of  the  duo- 
denum lying  under  it.  Continue  the  separation  of  the  duodenum  until  the 
superior  mesenteric  vessels  are  passed  and  the  duodeno-jejunal  junction  is 
reached ;  doubly  clamp  and  divide  the  gut  here. 

Step  5. — The  pancreas  and  duodenum  are  still  attached  to  each  other. 
Place  a  clamp  on  the  body  of  the  pancreas  (Fig.  679).     The  clamp  must  be 


544 


THE   PANCREAS 


directed  obliquely  upwards  and  to  the  right  so  as  to  avoid  injuring  the  colic 
arteries.  When  so  placed,  the  lower  ends  of  the  clamps  are  remote  from  the 
mesentery  where  the  colic  vessels  arise.  Divide  the  pancreas  to  the  right  of  the 
clamp  or  between  the  clamps  if  two  have  been  used  (Fig.  680). 

Step  6. — Remove  the  head  of  the  pancreas  and  the  duodenum  being  careful 
not  to  injure  the  mesenteric  vessels  which  emerge  from  between  these  structures. 

Step  7. — Close  the  opening  in  the  stomach  where  the  pylorus  was  divided. 
With  a  Murphy  button  anastomose  the  open  end  of  the  jejunum  to  the  posterior 
surface  of  the  stomach. 


Fig.  679. — Excision  of  head  of  pancreas.     (Desjardin.) 


Step  8. — Anastomose  the  common  bile-duct  to  the  jejunum.  If  this  is 
impossible  because  of  the  small  size  of  the  duct,  close  the  duct  and  anastomose 
the  gall-bladder  to  the  jejunum. 

Step  9. — Apply  chain  sutures  to  the  cut  surface  of  the  pancreas  but  leave 
the  canal  of  Wirsung  free.  Isolate  about  i  inch  of  the  canal,  and  anastomose 
it  to  the  jejunum.  This  anastomosis  is  very  similar  to  that  between  the 
ureter  and  the  bladder.  If  Wirsung 's  duct  is  too  narrow  to  permit  of 
anastomosis  another  method  must  be  adopted;  often  a  number  of  small  ducts 
will  be  found  instead  of  one;  this  also  demands  a  change  in  method. 


ACUTE    PANCREATITIS 


545 


Alternative  Method. — Doubly  clamp  and  divide  the  jejunum  about  12  inches 
from  its  origin.  Opposite  the  point  of  section  free  and  divide  the  mesentery 
as  much  as  possible  without  damaging  the  blood  supply.  Anastomose  the 
distal  segment  of  gut  to  the  stomach  as  in  Step  7.  A  loop  of  jejunum  now 
lies  free  except  for  a  loose  mesenteric  attachment,  and  open  at  both  ends. 
Anastomose  one  end  of  this  loop  to  the  gall-bladder  after  closing  the  common 
duct;  into  the  other  open  end  of  the  segregated  loop,  push  the  divided  end 
of  the  pancreas  and  fix  it  there  by  sutures  introduced  as  nearly  as  possible 
in  the  Lembert  fashion.     Make  an  anastomosis  between  the  middle  of  the 


Fig.  680. — Excision  head  of  pancreas.     {Desjardin.) 


segregated  loop  of  jejunum  and  that  portion  which  is  anastomosed  to  the 
stomach.     Provide  free  drainage  especially  in  the  pancreatic  region. 

Acute  Pancreatitis. — The  tendency  at  the  present  time  is  to  operate  very 
early  in  this  most  fatal  disease.  Deaver  notes  that  few  patients  come  under 
the  surgeons  care  until  the  second  or  third  day  of  the  disease  and  that  under  these 
circumstances,  as  in  other  cases  of  diffuse  peritonitis  it  is  sometimes  safer  to 
encourage  localization  of  the  process  before  instituting  drainage.  This  does 
not  mean  encouraging  delay  until  the^patient  is  moribund  from  sepsis.  If  a 
case  is  seen  before  symptoms  of  diffuse  peritonitis  arise  no  time  should  be  lost 
35 


546  THE    PANCREAS 

before  operation  is  undertaken.  The  operation  consists  in  an  exploratory  in- 
cision above  the  umbilicus.  In  doing  this,  be  on  the  lookout  for  patches  of 
fat  necrosis;  these  are  yellowish-white  patches  of  various  sizes  situated  in  the 
subperitoneal,  mesenteric  and  omental  fatty  tissues.  Fat  necrosis  is  always 
indicative  of  pancreatic  disease. 

According  to  indications  found  after  the  abdomen  has  been  opened,  the 
pancreas  should  be  exposed  either  through  the  great  omentum  above  the  colon, 
or  through  the  transverse  mesocolon.  The  belly  cavity  must  be  thoroughly 
protected  by  gauze  packing.  If  abscess  is  present,  the  pus  is  now  evacuated, 
if  requisite,  incision  being  made  into  the  pancreas  for  this  purpose  (case  of 
Dr.  C.  B.  Porter  of  Boston,  reported  by  v.  Mikulicz,  "Trans.  Am.  Cong.  Phys. 
and  Surg.,"  1903).  Sloughs  and  gangrenous  tissue  should  be  removed  and 
drainage  provided.  In  spite  of  all  care  and  thoroughness  in  operating,  the 
disease  continues  to  prove  most  fatal. 

Subacute  Pancreatitis. — The  operative  treatment  of  subacute  pancreatitis 
is  practically  the  same  as  that  of  pancreatic  cysts  and  requires  no  special 
discussion.  Mayo  drained,  with  success,  one  case  of  this  nature  through  the 
gall-bladder,  as  is  done  in  chronic  pancreatitis. 

Chronic  pancreatitis  is  treated  by  cholecystostomy  or  cholecystenterostomy. 

Robson  ("Surg.,  Gyn.,  Obst.,"  Jan.,  1908)  finds  that  of  one  hundred  and 
two  operations  in  patients  in  whom  chronic  pancreatic  trouble  was  the  chief 
disease,  or  where  it  formed  a  serious  complication  of  other  diseases,  96.1  per 
cent,  of  cases  were  followed  by  complete  recovery,  giving  a  mortaUty  of  3.9 
per  cent.;  but  since  these  statistics  were  compiled  in  1904  experience  has  very 
largely  increased  and  the  mortality  has  diminished  to  a  Httle  over  2  per  cent. 
Of  course  where  biliary  or  pancreatic  stones  are  present  such  must  be  removed. 

Ruth  ("Colorado  Medicine,"  Oct.,  1907)  removed  a  mass  of  calculi  which 
weighed  280  grains  and  lay  throughout  the  whole  length  of  the  gland.  He  found 
the  duct  walls  }-i  inch  thick  and  very  strong. 

Pancreatic  Lithiasis. — Stones  are  formed  in  the  pancreatic  as  in  the  biliary 
duct.  Calculi  existing  near  the  ampulla  of  Vater  may  be  extracted  through 
a  duodenal  incision,  as  in  the  case  of  gall-stones.  As  a  rule,  the  removal  of 
pancreatic  calculi  has  been  accomplished  incidentally  during  the  evacuation  of 
abscesses  in  subacute  pancreatitis.  ^Moynihan  was  the  first  to  remove  a  calculus 
where  the  diagnosis  had  been  made  prior  to  operation.  When  a  calculus  can 
be  felt  in  the  exposed  pancreas  it  is  proper  to  incise  the  gland,  remove  the 
stone,  close  the  pancreatic  wound  with  sutures,  and  provide  for  drainage. 

Traumata. — Whenever  structures  around  the  pancreas  are  injured  one 
ought  to  suspect  and  look  for  injury  to  that  organ.  When  in  a  case  of  bullet 
wound  the  posterior  wall  of  the  stomach  is  penetrated,  it  is  extremely  probable 
that  the  pancreas  is  also  involved.  Remember,  experience  teaches  that  a 
comparatively  slight  injury  to  the  gland  may  lead  to  disastrous  results  from 
leakage  of  the  digestive  juice.  Lacerated  fragments  of  the  pancreas  must 
be  removed.  Wounds  in  its  substance  must  be  sutured  with  catgut,  care 
being  taken  not  to  occlude  the  duct  by  the  suture.  Whether  sutures  are 
used  or  not  drainage  must  be  established,  preferably  by  means  of  cigarette 
drains,  which  may  be  introduced  through  the  abdominal  wound  or  through  a 


SPLEXOPEXY  547 

special  lumbar  wound  or  by  both  routes.  After  the  pancreatic  lesion  has  been 
attended  to,  it  is  good  practice  thoroughly  to  douche  the  general  peritoneal 
cavity  with  hot  salt  solution  in  order  to  get  rid  of,  or  at  least  dilute,  any  effused 
jmncreatic  juice. 

As  anti-diabetic  diet  diminishes  pancreatic  secretion  (Wohlgemuth),  such 
a  diet  may  be  of  very  great  value  as  an  adjuvant  to  the  local  treatment  of 
injuries  to  the  pancreas. 


CHAPTER  XLI 
THE   SPLEEN 


Surgical  Anatomy. — "The  spleen  is  a  soft,  highly  vascular,  and  easily  dis- 
tensible organ,  of  a  dark,  purplish-gray  color.  It  is  placed  obliquely  in  the 
back  of  the  left  hypochondrium,  between  the  cardiac  end  of  the  stomach  and  the 
diaphragm,  and  in  the  line  of  the  axilla  extends  from  the  eighth  to  the  eleventh 
rib."  Its  shape  is  that  of  a  compressed  oval  having  three  surfaces.  "Of  these, 
one,  the  external  and  posterior,  is  large  and  convex,  fitting  against  the  com- 
mencement of  the  arch  of  the  diaphragm  and  looking  upwards,  backwards, 
and  to  the  left.  A  second,  the  narrowest,  is  placed  vertically,  and  looks  directly 
inwards,  being  applied  to  the  outer  border  of  the  left  kidney;  whilst  the  third 
surface,  which  is  separated  from  the  last  described  by  a  distinct  vertical  ridge,  is 
larger  than  it  and  concave.  This  surface  is  applied  to  the  great  cul-de-sac 
of  the  stomach  and  is  in  contact  also  with  the  tail  of  the  pancreas  and  with  the 
extremity  of  the  arch  of  the  colon  (splenic  flexure).  Near  the  ridge  above 
mentioned  there  is  a  vertical  fissure  in  the  anterior  surface,  at  the  part  where 
the  vessels  and  nerves  enter  the  organ;  this  part  is  termed  the  hilus"  (Quain). 
The  spleen  is  held  in  place  by  means  of  reduplications  of  peritoneum.  Such 
are  the  gastro-splenic,  pancrealico-splenic,  and  phreno-splenic  ligaments.  Occa- 
sionally there  is  a  colo-reno-splenic  ligament  at  the  lower  extremity  of  the 
spleen  (Villar).  The  splenic  blood  vessels  are  contained  in  the  gastro-splenic 
omentum.  The  splenic  artery,  after  giving  off  the  gastro-epiploica  sinistra, 
breaks  up  into  a  number  of  branches,  a  few  of  which — the  vasa  brevia — turn 
back  to  the  stomach.  The  remaining  branches  enter  the  spleen  at  the  hilus. 
The  splenic  vein,  in  its  origin,  corresponds  to  the  artery.  It  is  a  large  vessel  and 
lies  below  the  artery.    In  its  subsequent  course  it  is  situated  behind  the  pancreas. 

Splenopexy.— Splenopexy  is  performed  for  the  cure  of  "floating  spleen." 
Several  methods  have  been  devised  to  anchor  the  spleen  in  the  left  hypochon- 
drium. 

(A)  Rydygier's  Method. — Freely  open  the  belly  in  the  middle  line.  Locate 
the  spleen.  Betw^een  the  ninth  and  tenth  ribs  make  a  transverse  incision 
through  the  parietal  peritoneum  (Fig.  68i).  Introduce  the  fingers  through 
this  incision  and  separate  the  peritoneum,  below  the  incision,  from  the  parietes, 
and  thus  form  a  pocket  whose  mouth  is  directed  upwards  (A,  A,  Fig.  682).  The 
pouch  is  made  sufficiently  large  to  receive  the  lower  end  of  the  spleen.  If  the 
spleen  (B)  is  placed  in  this  pouch,  its  weight  may  enlarge  it  so  that  the  opera- 
tion is  rendered  useless.     To  prevent  this,  insert  a  few  catgut  sutures  through 


548 


THE    SPLEEN 


the  peritoneum  and  part  of  the  parietes  immediately  below  the  lower  limit  of  the 
pouch.  These  will  prevent  further  separation  of  the  peritoneal  flap  from  the 
parietes.  Place  the  lower  end  of  the  spleen  in  the  pouch.  Unite  the  free  edge 
of  the  peritoneal  flap,  forming  the  pouch,  to  the  gastro-splenic  ligament  by  one 
or  more  sutures.  If  it  seems  desirable,  suture  the  spleen  itself  to  the  peritoneal 
incision,  or  form,  from  the  peritoneum  above,  a  flap  with  its  base  next  the  spleen; 
reflect  this  flap  over  the  spleen  and  suture  it  to  the  gastro-splenic  ligament. 

(B)  Bardenheuer's  Method. — Place  the  patient  on  his  right  side.  Make  an 
incision  in  the  axillary  line,  from  the  tenth  rib  to  the  iliac  crest.  At  the  level  of 
the  tenth  rib  make  an  incision  at  right  angles  to  the  first.  Divide  the  soft  parts 
down  to  the  peritoneum.  Make  an  opening  through  the  peritoneum  of  size 
sufficient  to  permit  of  exploration  and  of  the  passage  of  the  spleen  through  it. 


FiG.  68r.  Fig.  682. 

Figs.  681  and  682. — Rydygier's  splenopexy.     {Monod  and  Vanverts.) 

Have  an  assistant,  with  his  hand  on  the  belly-wall,  push  the  spleen  towards 
the  wound.  Bring  the  spleen  out  through  the  peritoneal  wound.  With  sutures 
diminish  the  size  of  the  peritoneal  wound  and  unite  it  to  the  splenic  pedicle. 
Pass  one  stout  suture  through  the  lower  end  of  the  spleen  and  tie  it  around 
the  tenth  rib.  Close  the  wound  in  the  soft  parts.  The  spleen  now  lies  with 
its  inferior  pole  in  a  retro-peritoneal  pouch;  its  pedicle  is  fixed  to  the  peritoneal 
wound,  and  its  body  is  suspended  from  the  tenth  rib. 

The  foregoing  operations  are  so  recent  that  their  merits  have  not  been  fully 
tested;  probably  Bardenheuer's  is  the  safer  and  easier. 

Splenectomy. — The  spleen  may  be  removed  for  the  following  conditions 
(Greig  Smith) : 

Injury  or  prolapse. 

Certain  cases  of  movable  spleen. 

Simple  hypertrophy,  with  or  without  cirrhosis. 

Sarcoma  or  lympho-sarcoma  in  the  early  stages. 

Cysts. 

Hydatid  disease. 


SPLENECTOMY 


549 


To  these  indications  it  is  safe  to  add  that  of  splenic  anemia  or  Banti's  dis- 
ease or  hemolytic  jaundice  with  splenomegaly.  The  results  of  splenectomy  in 
this  condition  has  been  most  gratifying  and  surprising.  Tansini  in  1901  com- 
bined splenectomy  with  omentopexy  in  a  case  of  Banti's  disease  with  ascites. 
The  result  was  excellent.  The  combined  operations  have  been  performed  a 
number  of  times  and  while  the  mortality  is  high  the  prospects  of  complete 
relief  entirely  justify  the  risk  (Tansini  and  Morone,  Rev.  de  Chir.,  Aug.,  1913, 
Losio,  La  Pr.  Med.,  July  31,  1919).  Encouraged  by  the  results  obtained  in 
Banti's  disease  Eppinger  and  Exner  performed  splenectomy  for  pernicious 
anaemia  on  March  15,  1913;  Decastello  and  Finsberger  did  the  same,  independ- 
ently, on  March  20,  1913.  Lenormant  (La  Pr.  Med.,  23,  May,  1914)  analyzes 
24  collected  cases  with  5  deaths.  (Two  deaths  were  perhaps  not  due  to  the 
operation.)  In  the  patients  who  survived  there  was  rapid  and  constant  im- 
provement in  the  general  condition,  the  appetite  improved  and  weight  increased 
even  before  there  was  any  improvement  in  the  blood  picture.  Icterus  disap- 
peared and  there  was  diminution  in  the  excretion  of  urobilin.  The  blood 
picture  following  operation  was  rather  ir- 
regular— in  some  cases  it  became  excellent, 
in  others  improvement  was  not  so  marked. 
Ranzi  speaks  of  the  dangers  which  may 
be  present  in  operation  due  to  adhesions 
to  the  diaphragm  and  to  a  development 
and  dilatation  of  vessels  almost  equivalent 
to  aneurysm. 

In  one  case  reported  by  Huber  the  pa- 
tient showed  hemoglobin  10  to  20  per 
cent.;  red  cells,  1,000,000;  oedema;  retinal 
hemorrhages;  slight  icterus;  urobilinuria; 
dyspnoea,  etc.  The  patient  being  too 
weak  for  operation  was  given  intra-mus- 
cular  injections  of  defibrinated  blood  and 
later  splenectomy  was  performed.  In  five 
weeks  after  operation  the  hemoglobin  was 
50  per  cent,  and  red  cells  2^^  millions.     In  three  months  the  patient  could  walk. 

Eppinger  and  Ranzi  operated  on  a  moribund  patient  with  only  500,000 
red  cells  who  recovered  to  such  an  extent  as  to  be  able  to  do  moderate  work. 

Balfour  advocates  transfusion  of  blood  not  only  as  a  therapeutic  measure 
but  for  prognosis.  If  improvement  results  splenectomy  will  probably  be  of 
value;  if  transfusion  proves  without  value  splenectomy  will  fail. 

C.  H.  Peck  and  others  (Trans.  Surg.  Sect.,  A.  M.  A.,  1916)  advocate  splen- 
ectomy in  hemolytic  jaundice. 

In  cases  of  leucocythaemia  the  spleen  ought  never  to  be  removed. 

Splenectomy. — Place  the  patient  in  an  exaggerated  Mayo-Robson  position, 
i.e.,  in  marked  lordosis. 

Step  I .  Method  A . — Make  a  left  rectus  incision  almost  identical  with  Rob- 
son's  incision  for  exposure  of  the  gall-bladder  but  on  the  opposite  side. 

Method  B. — Make  an  incision  parallel  to  and  a  little  below  the  costal  border 


Fig.  683. 


^.■)^ 


THE    SPLEEN 


from  the  epigastrium  to  a  point  opposite  the  end  of  the  eleventh  rib  from  which 
point  the  incision  may  be  continued  vertically  downwards  for  a  short  distance 
if  necessary. 

Step  2. — Explore  the  region  of  the  spleen.  If  adhesions  are  present  never 
rupture  them  bhndly;  usually  it  is  easy  to  expose,  doubly  ligate  and  divide  those 
to  the  omentum,  the  colon  and  the  abdominal  wall.  Adhesions  to  the  dia- 
phragm are  more  difficult  to  master — if  it  is  impossible  to  doubly  ligate  them 
before  division.  Hartmann  advises  that  the  operation  be  given  up  otherwise 
disaster  is  invited. 


Fig.  684. — Ligation  of  splenic  artery.     {Hartmann,  La  Prcssc  Mcdicale.) 

Step  3. — The  spleen  is  now  free  except  for  its  true  pedicle.  Deliver  from  the 
abdomen  first  its  inferior  pole,  then  its  superior.  If  the  spleen  is  mobile  ligate 
its  pedicle  by  transfixion  (A  A',  Fig.  683)  being  careful  to  cross  the  threads. 
Apply  a  clamp  to  the  pedicle  near  the  spleen.  Divide  the  pedicle  between  the 
ligatures  and  the  clamps.  Remove  the  spleen.  Inspect  the  ligated  stump  and 
apply  ligatures  to  the  individual  vessels  as  an  additional  safeguard.  If  the 
spleen  is  not  mobile,  ligation  of  the  pedicle  en  masse  is  impossible  without  ligat- 


SPLENECTOMY 


551 


ing  the  tail  of  the  pancreas  at  the  same  time.  If  time  is  of  great  importance  this 
may  be  done  though  it  is  generally  better  to  proceed  as  follows:  Pull  and  rotate 
the  spleen  towards  the  left  so  as  to  expose  the  gastro-splenic  omentum  with  the 
vasa  brevia  and  the  left  gastro-epiploic  vessels  running  in  it  from  the  splenic 
artery  to  the  stomach.  Doubly  ligate  the  vasa  brevia  and  the  left  gastro- 
epiploics  (Y  Y',  Fig.  683)  and  divide  the  gastro-splenic  omentum  between  the 
ligatures  thus  gaining  access  to  the  lesser  peritoneal  cavity.  Note  the  pancreas 
with  the  splenic  artery  and  vein  on  it  lying  behind  the  posterior  peritoneal  wall 
of  the  lesser  cavity.  Pick  up  and  incise  the  peritoneum  over  the  splenic  vessels 
and  tie  them  (X  X',  Fig.  683).     Remove  the  spleen.     The  splenic  vessels  may 


jM 


Fig.  685. — Control  of  splenic  vessels.     (Mayo.) 


be  reached  not  only  through  the  gastro-splenic  omentum  but  through  the  gastro- 
hepatic,  or  the  gastro-colic  omenta  or  even  from  below  upwards  through  the 
transverse  meso-colon.  When  separation  of  the  spleen  is  rendered  difficult  and 
dangerous  because  of  adhesions  John  Gerster  advises  ligation  of  the  splenic 
artery  near  its  origin.  This  may  be  easily  accomplished  through  a  hole  torn  in 
the  lesser  omentum  (Fig.  684) .  To  this  must  be  added  ligation  of  the  left  gastro- 
epiploic artery  (branch  of  the  splenic)  just  as  it  reaches  the  stomach,  because 
of  its  being  in  continuation  with  the  right  gastro-epiploic.  The  left  gastro- 
epiploic artery  may  be  exposed  by  pulling  the  stomach  and  left  margin  of  the 
great  omentum  towards  the  right.  "  While  cessation  of  the  arterial  stream  does 
not  afford  absolute  hemostasis,  the  hemorrhage  from  the  torn  veins  alone  is. 


552  THE    SUPRARENAL    BODIBS 

easier  of  control  and  is  certainly  less  than  if  it  came  from  both  arteries  and 
veins."     (John  Gerster,  Journ.  A.  M.  A.,  Aug.  7,  1915.) 

Step  4. — With  sutures  close  all  the  wounds  made  in  the  posterior  peritoneum 
and  if  the  gastro-splenic  omentum  was  divided  separately  suture  its  stump  to  the 
posterior  abdominal  wall. 

Step  5. — Close  the  abdomen. 

In  Banti's  disease  (splenic  anaemia)  Mayo  has  found  not  only  complete  but 
even  partial  splenectomy  useful.  After  exposing  and  pulling  the  spleen  for- 
wards out  of  its  bed,  using  blunt  dissection  to  form  a  passage-way  around  the 
pedicle,  grasp  the  pedicle  with  the  blades  of  a  suitable  clamp  (gastro-enteros- 
tomy  clamp  with  blades  protected  by  rubber  tubing).  Complete  the  separation 
of  the  spleen  from  its  connections  and  deliver  it  through  the  abdominal  wound. 
The  forceps  on  the  pedicle  should  be  placed  as  far  away  from  the  spleen  as  possi- 
ble for  obvious  reasons  (Fig.  685).  If  partial  splenectomy  is  chosen,  cut  away 
as  much  of  the  organ  as  necessary  and  close  the  wound  with  a  continuous 
button-hole  suture  of  catgut  introduced  with  a  round  needle;  loosen  the  clamp. 
If  hemorrhage  occurs  temporarily  reapply  the  clamp  and  introduce  more  sutures 
where  they  will  do  most  good.  If  complete  splenectomy  is  chosen  the  tempo- 
rary control  of  the  pedicle  makes  its  permanent  ligation  easy. 

Mayo  ("Journ.  A.  M.  A.,"  Jan.  i,  1910)  notes  that  "it  has  been  shown  ex- 
perimentally that  reduction  of  the  arterial  supply  by  ligation  results  in  atrophy 
of  the  spleen  and  that  as  long  as  the  veins  are  left  intact  necrosis  does  not  occur. 
If  the  splenic  artery  divides  in  the  hilum,  ligation  of  branches  would  appear 
to  be  an  active  competitor  of  partial  splenectomy.  Lanz  (quoted  by  John 
Gerster)  ligated  the  splenic  artery  in  the  case  of  a  man  with  a  spleen  which  was 
adherent  in  the  bony  pelvis  and  which  was  causing  severe  pain  on  urination 
and  defecation.  Six  months  later  the  splenic  tumor  could  not  be  palpated. 
Hartmann  (La  Pr.  Med.,  30,  Sept.,  191 1)  states  that  "in  the  four  cases  where 
this  ligation  has  been  practised  (Battle;  Wyman;  Tricomi;  Kiister)  the  opera- 
tion was  fatal.  These  failures  are  explained  by  the  fact  that  the  splenic  is  a 
terminal  artery  without  anastomosis.  The  operation  might  be  done  by  apply- 
ing the  ligature  proximal  to  the  short  vessels  so  that  a  partial  circulation  might 
be  established  in  the  spleen  by  means  of  the  union  of  the  vasa  brevia  with  the 
other  gastric  vessels." 


CHAPTER   XLII 
THE  SUPRARENAL  BODIES 

The  suprarenal  bodies  rest  upon  the  diaphragm  opposite  the  eleventh  and 
twelfth  ribs.  They  are  separated  from  one  another  by  an  interval  of  2  to  2^-^ 
inches.  They  are  situated  at  the  upper  and  inner  border  of  each  kidney,  and 
obtain  a  rich  supply  of  blood  through  special  arteries  from  the  aorta  and  through 
branches  of  the  renal  and  phrenic  arteries.  In  front  of  the  left  suprarenal  lies 
the  stomach;  to  its  outer  side  is  the  spleen.  The  right  suprarenal  "is  related 
in  front  to  both  the  inferior  and  posterior  surfaces  of  the  right  lobe  of  the  liver 
(impressio  suprarenalis) ;  internally  to  the  vena  cava,  which  slightly  overlaps  it, 


ADRENALECTOMY  553 

and  its  inferior  angle  is  crossed  by  the  first  bend  of  the  duodenum.  It  lies 
behind  the  foramen  of  Winslow."     (Woolsey.) 

Adrenalectomy. — The  surgery  of  the  suprarenal  bodies  belongs  more  to  the 
future  than  the  present  but  even  now  enough  has  been  done  to  demand  a  short 
notice  here. 

The  most  common  cause  of  Addison's  disease  is  tuberculosis  of  the  supra- 
renal body,  and  most  of  the  successful  operations  have  been  performed  in  such 
cases.  Usually  operation  has  been  undertaken  on  a  diagnosis  of  "retro-perito- 
neal tumor"  or  of  a  tumor  affecting  the  upper  pole  of  the  kidney,  and  these 
errors  in  diagnosis  are  liable  to  be  repeated  in  the  future.  An  early  recogni- 
tion of  suprarenal  disease  is  impossible  in  our  present  state  of  knowledge  or 
ignorance. 

The  suprarenal  bodies  may  be  reached  through  the  lumbar  region  or  through 
the  peritoneum.  When  the  former  route  is  chosen,  the  incision  must  be  ex- 
tensive, and  exactly  like  that  for  nephrectomy.  In  most  cases  of  adrenalec- 
tomy, nephrectomy  will  be  part  of  the  operation,  for  two  reasons:  (a)  because 
the  removal  of  the  kidney  renders  less  diflScult  an  atrociously  difficult  operation ; 
(6)  because  the  kidney  is  often  involved  in  the  disease,  especially  if  that  disease 
is  malignant. 

Helferich  operated  through  the  lumbar  route  and  partially  removed  a 
tuberculous  suprarenal  with  complete  success  (Schede,  "Handbuch  der  prak- 
tischen  Chir.,"  iii,  1106).  Most  operations  have  been  performed  by  the  trans- 
peritoneal route.  Oestreich  diagnosed  and  Hadra  operated  upon  a  pulsating 
tumor  of  the  suprarenal.  When  the  abdomen  was  opened  in  the  middle  line 
above  the  umbilicus,  a  tumor  the  size  of  a  hen's  egg,  of  a  whitish  and  yellowish- 
brown  color,  was  seen  through  the  lesser  omentum.  This  tumor  was  on  and 
to  the  left  of  the  aorta,  and  after  excision  proved  to  be  a  much  caseated  supra- 
renal body.  The  wound  was  packed  and  the  patient  recovered.  In  a  case 
operated  on  by  Jonas  (Schede,  loc.  cit.)  the  bronze  hue  so  characteristic  of 
Addison's  disease  faded  in  ten  days  and  disappeared  in  three  weeks.  There 
is  little  prospect  of  much  benefit  from  operation  on  malignant  tumors  of  the 
suprarenals. 


CHAPTER  XLIII 
OPERATIONS  UPON  THE  LIVER 

OPERATIONS    FOR    HEPATOPTOSIS,    OR    MOBILE    OR    FLOATING 

LIVER 

Ptosis  of  the  liver  may  be  partial  or  complete. 

Partial  ptosis  means  that  a  portion  of  the  liver  in  more  or  less  pushed  away 
or  snared  off  from  the  rest  of  the  organ  as  a  result  of  error  in  dress  (tight  lacing) 
or  ot  some  disease.  Riedel's  tongue-shaped  lobe,  so  common  in  choleHthiasis, 
may  be  a  form  of  partial  ptosis.  Occasionally  the  junction  between  the  aberrant 
lobe  and  the  rest  of  the  liver  is  thin,  and  from  irritation,  etc.,  has  become 
sclerosed. 


554  OPERATIONS    UPON    THE    LIVER 

Complete  ptosis  means  that  the  liver  is  dislocated  en  masse  to  a  greater  or 
less  degree. 

(A)  Operations  for  Partial  Hepatoptosis.— i .  Indirect  Operations. — When  the 
ptosis  is  in  the  form  of  a  Riedel  lobe  and  dependent  on  gall-bladder  disease, 
the  latter  disease  must  be  treated  according  to  the  methods  advised  in  the 
chapter  on  Biliary  Surgery.     Excellent  results  are  thus  obtained. 

2.  Excision. — The  mobile  lobe  may  be  excised.     (See  "Hepatectomy.") 

3.  Ventro-fixation. — Open  the  abdomen  over  the  most  prominent  part  of 
the  tumor.  Suture  the  "floating  lobe"  to  the  parietes  by  several  thick  catgut 
sutures.     Before  tying  the  sutures  scarify  the  surfaces  about  to  be  opposed. 

4.  Kehr's  Operation. — Kehr,  adopting  Rydygier's  idea  in  splenopexy,  applies 
it  to  the  fixation  of  partial  hepatoptosis.  Make  a  horseshoe-shaped  incision 
(concavity  upwards)  around  the  lower  circumference  of  the  mobile  lobe  down 
to  but  not  through  the  transversalis  fascia.  At  the  lowest  point  in  the  wound 
open  the  belly  by  a  transverse  incision  through  the  transversalis  fascia  and  the 
peritoneum.  Separate  the  transversalis  fascia  and  the  peritoneum,  together, 
from  the  more  superficial  structures  of  the  parietes  over  an  area  corresponding 
to  the  horseshoe-shaped  incision.  At  the  upper  end  of  this  loosened  area  make 
an  incision  through  the  fascia  and  peritoneum  parallel  to  the  lower  transverse 
incision.  A  pocket  of  fascia  and  peritoneum  is  thus  formed  into  which  the 
"floating  lobe"  or  its  lower  margin  may  be  tucked  and  secured.  Close  the 
wound  with  sutures. 

(B)  Operations  for  Complete  Hepatoptosis. —  (I)  Step  1. ^Exposure  of  organ : 
This  may  be  accomplished  by  a  vertical  incision  either  in  the  middle  line  or 
along  the  external  border  of  the  right  rectus  muscle  or  by  a  cut  parallel  to  the 
costal  arch.  The  vertical  incisions  are  the  better,  and  may  be  supplemented 
by  a  transverse  cut  if  such  appears  necessary. 

Step  2. — Return  the  liver  to  its  normal  position:  If  the  organ  has  become 
adherent  in  its  faulty  location,  and  adhesions  must  be  separated,  unless,  of 
course,  they  are  so  extensive  that  the  danger  involved  in  their  separation  would 
be  out  of  proportion  to  the  good  to  be  attained  by  a  successful  hepatopexy. 
An  assistant  supports  the  liver  in  its  improved  position  while  the  surgeon 
carries  out  the  next  step. 

Step  3. — Fixation  of  the  liver  by  sutures:  Pass  coarse  catgut  or  silk  sutures 
through  the  parenchyma  of  the  anterior  edge  of  the  liver,  each  suture  taking 
a  deep  hold  of  the  organ,  and  then  make  the  sutures  penetrate  between  the 
cartilages  of  the  adjacent  ribs.  During  this  procedure  the  pleura  has  been 
injured,  but  no  harm  has  resulted.  The  sutures  must  be  thick  to  avoid  cutting 
the  friable  organ.  In  actual  practice  the  number  of  sutures  has  varied  from 
two  to  eight;  the  more  numerous  they  are,  the  more  is  the  strain  divided  and 
the  Uability  to  cut  lessened.  The  hepatic  and  parietal  surfaces  which  are  to 
be  opposed  should  be  scarified  before  the  sutures  are  tied.  Care  must  be 
taken,  when  the  sutures  are  being  tied,  to  avoid  cutting  the  liver  substances 
with  the  threads.  Some  surgeons  apply  a  few  sutures  between  the  liver  and 
the  upper  end  of  the  abdominal  wound.  Lucas  Championniere  modifies  the 
operation  by  passing  some  of  the  threads  through  the  suspensory  ligament. 


HEPATECTOMY  555 

If  it  is  impossible  to  reduce  the  liver,  it  may  be  fixed  by  suture  wherever 
possible  so  as  to  give  relief  from  distressing  symptoms. 

(II)  Depage's  Operation  {Uepatopexy  and  Lapareclomy) . — Depage  considers 
laxity  of  the  abdominal  walls  a  great  factor  in  the  production  of  hepatoptosis 
and  directs  his  attention  specially  towards  removal  of  this  condition. 

Step  I. — Make  the  horizontal  incision  A  B  (Fig.  686)  from  the  tip  of  the 
eleventh  rib  on  one  side  to  the  tip  of  the  eleventh  rib  on  the  other  side.  From 
the  point  A  make  an  incision  A  C,  downwards  and  inwards  to  meet  an  imaginary 
line  passing  horizontally  through  the  umbilicus.  The  length  of  the  cut  A  C 
is  equal  to  one-half  the  cut  A  B.  From  the  point  B  make  the  incision  B  D  in 
the  same  way  as  A  C  was  made.  From  the  point  C  and  D  make  curved  in- 
cisions downwards  to  near  the  pubis.     The  convexity  of  the  curves  is  outwards. 


Fig.  686.  Fig.  687. 

Figs.  686  and  687. — Depage's  laparectomy.     {Monod  and  Vanverts.) 

These  cuts  meet  at  the  point  E.  Remove  all  the  skin  enclosed  by  the  above 
incisions.  Dilatation  of  the  belly  has  caused  the  linea  alba  to  become  very 
wide.  "Remove  the  linea  alba,  including  the  peritoneum,  from  the  anterior 
or  internal  border  of  one  rectus  muscle  to  the  internal  borders  of  the  other 
rectus  muscle.  Make  traction  upon  the  umbilical  ligament  of  the  liver  and 
the  inferior  extremity  of  the  falciform  ligament,  and,  pulling  them  into  the 
upper  angle  of  the  wound,  shorten  and  anchor  them  there  by  sutures." 

Step  2. — Suture  the  abdominal  wound  with  extreme  care.  Depage  sutures 
in  planes  as  follows:  (a)  The  peritoneum  alone;  ih)  the  peritoneum  and  mus- 
cular planes  together;  (c)  the  muscular  plane  alone;  {d)  the  aponeurotic  and 
muscular  planes  together;  {e)  the  aponeurosis  alone;  (/)  the  skin  and  sub- 
cutaneous tissue  together;  (g)  the  skin  alone.  In  suturing,  the  edge  of  the 
wound  A  C  is  united  to  the  edge  A  F;  the  edge  B  D  to  B  F,  and  the  edge  C  E  to 
the  edge  D  E.     The  resultant  scar  is  T-shaped  (Fig.  687). 

HEPATECTOMY.     EXCISION  OF  HEPATIC  TUMORS,   ETC. 

As  it  is  self-evident  that  the  liver  can  never  be  removed  in  toto,  it  is  useless 
to  prefix  the  word  partial  to  the  title  of  this  section. 

The  experiments  of  Ponfick,  repeated  and  supported  by  other  observers, 
have  proved  that  much  liver  tissue  can  be  removed  without  specific  injury 
(three-fourths  was  removed  in  animals),  and  that  new  liver  tissue  is  formed  to 
take  the  place  of  that  removed.  The  great  impediment  to  hepatic  surgery 
has  been  the  fear  of  hemorrhage.  Many  methods  have  been  adopted  to  over- 
come this  real  danger.     A  few  of  the  methods  will  be  described. 


556  OPERATIONS    ll'OX    THK    LIVER 

I.  Exposure  of  the  Tumor. — ^The  abdomen  is  opened  over  the  tumor  by  a 
cut  made  in  any  direction  which  may  be  convenient  or  by  a  combination  of 
cuts.  The  incision  must  be  large  enough  to  give  very  free  access  to  the  field 
of  operation.  The  tumor  is  now  examined  as  to  kind  and  location.  It  is  as- 
sumed that  the  diagnosis  is  such  that  radical  operation  is  permissible.  If 
the  tumor  involves  most  of  the  right  lobe  of  the  liver,  the  operation  must  be 
at  once  abandoned,  so  also  if  the  hilus  is  much  involved.  Tumors  on  the  pos- 
terior and  superior  parts  of  the  liver  are  inaccessible.  Tumors  of  the  left 
lobe  and  of  the  anterior  margin  of  the  organ  may  be  brought  forwards  by 
division  of  parts  of  the  Iffcpatic  ligaments;  this  permits  of  partial  dislocation 
of  the  whole  organ.  Some  surgeons  have  excised  the  lower  ribs  (subperios- 
teally)  and  have  thus  been  enabled  to  retract  the  diaphragm  upwards.  When 
the  patient  is  lying  on  his  back  with  the  posterior  hepatic  region  supported  on  a 
sand-bag,  it  is  extraordinary  how  much  of  the  liver  may  be  brought  out  through 
the  Mayo-Robson  incision  (page  563)  without  any  resection  of  ribs.  It  is 
difficult  to  believe  that  enough  benefit  can  be  attained  by  rib  resection  to  warrant 
the  extra  trauma  and  risk. 

II.  Removal  of  the  Tvunor. — When  peritoneum  exists  over  the  tumor  and 
is  free  from  disease,  it  should  be  divided  and  reflected  from  the  surface  of  the 
tumor.  If  the  tumor  is  non-malignant  and  appears  to  be  fairly  well  encap- 
sulated, it  may  often  be  shelled  out  of  its  hepatic  bed  with  but  little  hemorrhage. 
When  the  tumor  is  very  small  and  situated  at  the  liver  margin,  it  may  be  re- 
moved by  a  V-shaped  incision  made  with  knife,  scissors,  or  thermocautery. 
While  the  cut  is  being  made  an  assistant  compressing  the  neighboring  liver 
controls  bleeding  temporarily.  When  the  tumor  is  attached  to  the  liver  by 
a  distinct  pedicle,  the  pedicle  may  be  surrounded  by  an  elastic  ligature  and 
the  tumor  removed,  or  the  removal  may  be  accomplished  without  the  aid  of 
the  elastic  constrictor.  In  all  the  above  instances  bleeding  is  temporarily 
controlled  while  the  tumor  is  being  removed.  When  the  tumor  is  non-en- 
capsulated, non-pedunculated,  or  involves  much  of  the  liver  substance,  one 
requires  to  proceed  step  by  step,  stopping  bleeding  as  one  goes. 

Methods  of  Hemostasis. — I.  During  the  operation: 

(a)  Temporary  elastic  ligature:  A  rubber  tube  thrown  around  a  pedicle 
permits  the  surgeon  to  remove  the  tumor  at  his  leisure  and  subsequently 
take  other  means  to  stop  the  bleeding  permanently.  When  there  is  no 
pedicle  it  has  been  advised  to  pierce  the  whole  thickness  of  the  liver 
behind  the  tumor  with  a  cannula,  place  a  double  elastic  ligature  through  the 
instrument,  and  tie  the  ends  of  the  ligature  on  each  side  of  the  tumor  so  as  to 
act  as  a  tourniquet. 

{h)  Pringle's  Method. — Pringle  ("Annals  Surg.,"  xlviii,  p.  541)  has  used 
digital  compression  of  the  portal  vein  at  the  foramen  of  Winslow  and  thus 
secured  good,  safe  temporary  hemostasis.  To  gain  access  to  wounds  of  the 
liver  after  temporary  hemostasis  is  secured,  Pringle  thinks  well  of  Langenbuchs' 
suggestion  to  divide  the  coronary  and  right  lateral  ligaments  so  as  to  allow  the 
liver  to  be  dislocated  and  delivered  up  to  the  abdominal  wall,  or  to  give  more 
room  by  dividing  some  of  the  lower  ribs  and  turning  up  a  flap  of  ribs  and 
diaphragm.     Willy  Meyer  has  carried  out  this  plan. 


HEMOSTASIS 


557 


(c)  McDill's Method. — McDill  ("Journ.  A.M. A.,"  Oct.  5.,  191 2) compresses 
the  vessels  by  means  of  an  enterostomy  forceps,  the  blades  of  which  are 
protected  with  rubber  tubing.  After  the  gall-bladder  region  is  fully  exposed 
in  the  usual  fashion  McDill  makes  a  i-inch  skin  incision  immediately  below 
the  costal  margin  in  the  right  axillary  line,  tunnels  from  here  through  the 
parietes  and  introduces  the  enterostomy  clamp  through  the  tunnel  (Fig.  688). 

{d)  Auvray  recommend^  applying  to  the  liver  around  the  portion  to  be 
removed  a  series  of  interlocked  ligatures  of  thick  silk  or  catgut.  To  apply 
the  ligatures  use  a  blunt  pedicle  needle  with  a  very  long  curve.  Each  indi- 
vidual ligature,  after  being  crossed  with  its  fellow  to  the  right  and  left,  is  slowly 


Fig. 


-(McDill,  Jonrn.  A.  M.  A.) 


and  steadily  tied  with  such  firmness  that  the  liver  parenchyma  is  cut,  but 
the  vessels  remain  undivided  in  the  loop.  When  the  whole  series  of  ligatures 
is  tied,  the  tumor  is  removed  with  cautery,  knife,  or  scissors.  It  is  of  impor- 
tance while  transfixing  the  Hver  with  the  needle  to  use  little  force,  and  when 
any  obstacle  to  tJie  passage  of  the  instrument  is  encountered,  to  manipulate 
the  needle  from  side  to  side  and  so  gently  guide  it  past  the  obstruction.  Such 
obstructions  are  usually  large  vessels,  and  any  force  used  might  injure  them. 
The  points  of  transfixion  should  be  about  one  centimeter  {%  inch)  apart. 
Auvray's  researches  have  been  very  thorough  and  successful.  The  method 
he  advises  certainly  appeals  to  one's  common  sense. 

Using  practically  the  same  method  as  Auvray,  Cullen  has  removed  a  large 
carcinoma  of  the  liver.     He  used  silver  needles  straight  and  curved,  exactly  the 


558 


OPERATIONS    UPON    THE    LIVER 


same  as  Hagedorn's  except  that  they  had  blunt  ends.  After  the  ligatures  were 
in  place  he  found  that  the  "raw  surface  could  be  rolled  in  upon  itself,  so  that 
the  two  halves  formed  flaps.  These  were  brought  together  until  little  or  no 
raw  surface  remained.  The  ends  of  the  sutures  that  had  already  been  tied 
were  utilized  to  bring  the  opposite  sides  together." 

Freeman  has  used  with  success,  for  the  same  purpose  and  in  similar  manner 
narrow  strips  of  gauze.  He  found  much  difficulty  in  removing  the  gauze 
because  the  knots  sank  into  the  liver  substance,  so  he  now  recommends  that 
the  ends  of  gauze  be  fastened  with  forceps  or  catgut  instead  of  being  knotted. 
("Trans.  Am.  Surg.  Assoc,"  1904.) 

Kornew  and  Schaack  (Zent.  fiir.  Chir.,  14,  June,  19 13,  page  949)  have  fre- 
quently successfully  removed  large  masses  of  liver  in  dogs  as  follows:  Take  two 

broad  strips  of  fascia  (obtained  from 
any  convenient  place  on  the  same 
patient,  e.g.,  the  thigh)  and  place 
them  on  the  upper  and  under  surface 
of  the  liver  just  internal  to  the  line 
of  proposed  section.  With  a  long 
rounded  needle   introduce  near  the 


Fig.  689.  Fig.  690. 

Figs.  689  and  690. — {Kornew  and  Schaack,  Zentralblait  fiir  Chirurgie.) 


inner  edge  of  the  strips  of  fascia  a  row  of  continuous  mattress  sutures. 
These  sutures  are  of  thick  catgut  or  silk  and  pass  through  both  the 
fascial  strips  and  the  liver  and  ought  to  be  applied  in  the  shoemaker  fashion. 
After  the  sutures  are  pulled  tight  they  are  tied  together  at  the  anterior  and 
posterior  edge  of  the  liver  (Fig.  689).  Cut  away  the  portion  of  liver  condemned 
Cover  the  liver  stump  with  the  cuff  formed  by  the  fascia  (Fig.  690). 

Auschiitz  ("Deutschen  Gessellsch.  fiir  Chir.,"  1907)  lays  down  the  following 
rules  for  resection  of  the  liver: 

1.  The  incision  through  the  liver  substance  should  be  made  with  a  sharp 
knife  and  the  vessels  picked  up  with  forceps  and  ligated.  If  the  hepatic  tissue 
is  divided  by  blunt  force  the  vessels  subsequently  retract  and  are  difficult  to 
find  and  secure. 

2.  When  possible  the  liver  wound  should  be  wedge-shaped  to  permit  closure 
with  suture. 


RESECTION   LIVER  559 

3.  No  special  instruments  are  required  for  the  insertion  of  deep  ligatures 
in  the  liver.     The  ligatures  should  be  tied  slowly  but  firmly. 

4.  In  suitable  cases  the  temporary  use  of  an  elastic  ligature  is  valuable. 

5.  Usually  no  abdominal  tampon  is  required  after  suture. 

6.  Division  of  the  hepatic  ligaments  is  often  an  aid  in  resection. 

7.  When  it  is  necessary  to  attack  the  dome  of  the  liver,  do  not  hesitate  to 
resect  the  right  costal  arch  and   to  divide  the  suspensory  ligament. 

Garre  uses  catgut  No.  2  for  deep  sutures  which  go  through  the  whole  thick- 
ness of  the  liver,  while  for  serous  sutures  and  for  the  ligation  of  individual 
vessels  on  the  cut  surface  of  the  liver  he  uses  extremely  fine  silk.  He  does  not 
treat  the  stump  extraperitoneally,  has  not  lost  a  single  case  and  has  penetrated 
the  liver  substance  to  the  extent  of  fully  5  inches  (10  to  14  cm.). 

(e)  Thermocautery:  Many  surgeons  use  the  thermocautery  instead  of  the 
knife  when  dividing  liver.  While  the  cautery  does  not  control  bleeding  from 
the  larger  vessels,  it  certainly  does  control  oozing.  The  cautery  ought  always 
to  be  ready  when  hepatic  incisions  are  made,  since  it  may  be  found  useful, 
at  least  as  an  aid  to  other  methods. 

(/)  Ligature:  The  ligation  of  hepatic  vessels  is  often  difficult,  their  walls 
being  thin  and  delicate.  Frequently  direct  ligation  of  the  vessels  is  impossible. 
When  this  is  the  case,  one  may,  with  a  curved  needle,  pass  a  suture  around 
the  vessel,  and  on  gently  tying  it  the  bleeding  ceases.  To  this  suture-ligature 
the  Germans  give  the  name  "Umstechung.' 

The  above  are  the  principal  means  of  hemostasis  used  during  the  operation. 

II.  The  methods  of  securing  hemostasis  after  the  operation  are  practically 
the  same  as  the  methods  of  treating  the  stump. 

(A)  Intraperitoneal. — The  liver  wound,  having  been  closed  by  suture  or 
ligature,  or  charred  by  the  thermocautery,  is  allowed  to  drop  back  in  the  belly. 
If  peritoneal  flaps  were  dissected  back  from  over  the  tumor,  they  are  replaced 
and  sutured  together.  Place  a  strip  of  gauze  under  the  liver  and  against 
the  liver  wound;  bring  the  end  of  this  strip  out  through  the  abdominal  wound. 
Close  the  excess  of  wound. 

(B)  Extraperitoneal. — The  tumor  is  delivered  through  the  abdominal  wall. 
The  pedicle  is  compressed  by  an  elastic  ligature.  The  tumor  is  cut  away. 
The  stump  is  fixed  to  the  abdominal  wall  by  sutures  or  by  pedicle  pins.  The 
elastic  ligature  is  left  in  situ.  The  dangers  of  this  method  are,  first,  that  the 
sutures  or  pins  fixing  the  liver  to  the  abdominal  wall  are  very  liable  to  cut 
through  the  friable  liver  substance;  and,  second,  that  the  risks  of  infection 
through  the  stump  are  very  real.  Some  surgeons  have  performed  the  opera- 
tion in  two  stages.  At  the  first  sitting  the  liver  is  attached  to  the  belly-wall. 
Only  after  adhesions  have  formed  is  the  tumor  removed.  When  applicable, 
this  may  be  a  good  method. 

(C)  The  pedicle  is  treated  as  in  A,  but  the  liver  wound  is  walled  ofif 
from  the  rest  of  the  peritoneal  cavity  by  means  of  gauze  packs  and  a  tampon 
of  gauze  is  pressed  against  the  wound  itself.  The  ends  of  the  pieces  of 
gauze  used  for  pack  and  tampon  are  brought  out  through  the  abdominal 
wound. 

Undoubtedly  the  best  way  to  treat  the  stump  where  possible  is  by  a  com- 


560  OPERATIONS    UPON    THE    LIVER 

bination  of  suture  and  packing.  The  surface  of  the  pack  facing  the  abdominal 
cavity  should  be  covered  by  rubber  tissue.  The  ends  of  the  catgut  sutures 
applied  to  the  liver  should  be  left  long  and  tied  over  the  pack  so  as  to  keep 
the  latter  in  place.     (See  "Cholecystectomy.") 

To  exert  hemostatic  pressure  upon  the  liver  and  to  prevent  the  cutting 
of  the  parenchyma  by  sutures  one  rubber  tube  may  be  laid  on  the  upper  surface 

of  the  liver,  another  on  the  lower  surface. 
Thick  catgut  sutures  (A,  B,  Fig.  691)  pene- 
trating the  liver  are  fastened  to  the  tubes. 
The  ends  of  the  tubes  are  brought  out  of 
^  the  wound   and  are   to   be   removed   when 

r  ^    .        TT        .    •  V  they   have  served   their    purpose.     Instead 

riG.  691. — Hemostasis  liver.  ■'  f     t- 

of  rubber  tubes,  plates  of  decalcified  bone 
and  of  various  materials  have  been  employed. 

Kocher  has  applied  his  large  stomach  clamp  to  the  liver  with  force,  crushing 
through  the  parenchyma  and  excising  the  portion  of  liver  distal  to  the  clamp. 
He  leaves  the  clamp  in  situ  for  forty-eight  hours. 

Van  Buren  Knott  has  successfully  removed  a  primary  sarcoma  from  the 
anterior  border  of  the  liver  (the  tumor  was  pedunculated  and  weighed  over 
one  pound)  using  rubber-covered  clamps  which  he  left  in  situ.  The  opera- 
tion was  dijficult  because  of  adhesions  and  the  patient  was  much  debilitated. 

Stuckey  ("Archiv.  fiir  klin.  Chir.,"  xcix,  384)  in  cases  of  hemorrhage  from 
the  liver  after  cystectomy  has  found  that  he  could  stop  the  bleeding  as  follows: 
Pick  up  a  terminal  segment  of  omentum  of  suitable  size,  ligate  and  excise  it. 
Cover  the  liver  wound  with  the  excised  (free)  flap  of  omentum  and  hold  it  in 
position  by  gauze  pressure  for  a  short  time.  Very  quickly  the  omentum  adheres 
to  the  liver  wound  and  stops  the  bleeding.  A  gauze  pack  may  be  used  to  hold 
the  graft  in  position  as  an  extra  precaution. 

ABSCESS   OF  THE  LIVER 

Aspiration. — Aspiration  as  a  method  of  treatment  for  liver  abscess  is  not 
to  be  recommended.  It  has  its  sphere  of  usefulness  as  a  means  of  diagnosis, 
but  its  use  is  not  without  danger. 

The  skin  is  cleaned  over  the  most  prominent  or  most  tender  part  of  the 
swelling,  usually  the  ninth  or  tenth  interspace  vertically  below  the  angle  of 
the  scapula,  and  the  sterilized  aspirating  needle  is  inserted  in  various  direc- 
tions until  pus  is  found.  Greig  Smith  remarks  that  "the  movements  of  the 
needle,  following  the  movements  of  the  liver  (if  it  moves  with  respiration), 
must  not  be  checked,  as  thereby  the  liver  tissue  may  be  torn  and  permit  escape 
of  pus  into  the  peritoneum." 

Hepatotomy. — (A)  Abdominal  Route.- — The  object  of  operation  is  to  expose 
the  enlarged  liver;  to  examine  it;  to  incise  and  evacuate  the  contained  pus 
without  soiling  the  general  peritoneal  cavity.  An  incision  four  to  five  inches 
in  length  is  made  over  the  most  prominent  part  of  the  swelling.  This  incision 
is  usually  longitudinal.  The  belly  is  opened  and  the  liver  examined.  If  the 
liver  is  found  adherent  to  the  parietes  opposite  the  wound  these  adhesions 


ABSCESS    LR'ER  56 1 

ought  to  be  preserved,  as  the  avoidance  of  peritoneal  contamination  is  ren- 
dered easier  by  their  presence.  When  a  sufficiency  of  adhesions  is  not  pres- 
ent, the  portion  of  liver  about  to  be  attacked  is  carefully  isolated  from  the 
peritoneum  by  pads  of  gauze.  Unless  the  exact  location  of  the  abscess  is 
very  evident,  an  aspirating  needle  is  passed  into  the  liver  until  pus  is  found. 
The  needle  being  held  in  place,  a  knife  or  the  blade  of  a  cautery  is  inserted 
into  the  abscess,  guided  by  being  kept  in  contact  with  the  needle.  The  needle 
is  withdrawn.  The  forefinger  is  pushed  into  the  abscess  along  the  side  of  the 
knife,  which  is  now  taken  out.  The  abscess  cavity  is  explored  digitally  and 
any  signs  of  a  second  abscess  noted.  If  such  exists,  it  may  be  opened  from 
the  first  cavity  by  the  finger  or  a  closed  hemostat  being  pushed  into  it.  The 
abscess  cavity  is  now  carefully  douched  with  hot  water,  a  rubber  drainage- 
tube  is  inserted  to  its  deepest  part,  and  the  rest  of  the  cavity  loosely  filled  with 
mildly  iodoformized  gauze.  The  pads  of  gauze  which  have  protected  the 
peritoneal  cavity  are  removed  and  the  neighboring  peritoneum  is  mopped 
clean  and  dry.  Smith  recommends  that  the  whole  length  of  the  incision  in 
the  liver  be  sutured  to  the  abdominal  wound.  This  may  be  done  with  very 
coarse  catgut  or  silk  sutures.  Coarse  sutures  are  necessary,  as  fine  ones  would 
cut  through  the  liver  substance.  Any  of  the  abdominal  wound  unoccupied 
by  attached  liver  is  closed  by  sutures.  Abundant  absorbent  dressings  are 
applied  and  the  patient  put  to  bed. 

According  to  the  amount  of  discharge  the  wound  will  require  dressing  at 
more  or  less  frequent  intervals.  The  outer  dressings,  i.e.,  those  down  to  the 
drainage-tube,  will  probably  require  to  be  changed  in  a  few  hours.  Unless 
demanded  by  the  condition  of  the  patient,  the  packing  of  iodoform  gauze  filling 
the  abscess  cavity  ought  not  to  be  changed  before  twenty-four  or  forty-eight 
hours  after  operation.  When  the  packing  is  withdrawn,  if  necessary,  the 
abscess  cavity  may  be  gently  douched  with  hot  water.  This  is  best  accom- 
plished by  attaching  a  soft-rubber  catheter  to  the  tube  of  an  irrigator  and  pass- 
ing it  into  the  deepest  part  of  the  cavity.  Thorough  and  gentle  lavage  is  thus 
insured.  The  irrigator  ought  not  to  be  elevated  much  more  than  two  feet. 
After  washing,  the  cavity  is  once  more  loosely  filled  with  mildly  iodoformized 
gauze  and  the  dressings  applied.  In  all  such  cases  iodoform  is  better  than 
plain  gauze,  but  the  iodoform  ought  to  be  in  small  quantity,  as  absorption  is 
liable  to  be  great  in  such  an  organ  as  the  liver. 

(B)  Transpleural  or  Thoracic  Route. — When  the  abscess  is  situated  far 
back  on  the  dorsum  of  the  liver,  evacuation  by  the  abdominal  route  is  inap- 
plicable. By  the  time  that  a  hepatic  abscess  has  become  large  enough  to  be 
diagnosed  and  its  position  ascertained,  there  is  almost  always  adhesive  pleuritis 
present;  the  liver  is  adherent  to  the  diaphragm,  and  the  diaphragmatic  pleura 
to  the  parietal,  so  that  a  safe  route  exists  to  the  pus  via  the  obliterated  portion 
of  the  pleural  cavity . 

The  Operation. — Place  the  patient  on  his  sound  side.  Demonstrate  the 
presence  and  location  of  the  pus  by  the  aspirating  needle  introduced  through 
the  ninth  or  tenth  intercostal  space  vertically  below  the  angle  of  the  scapula. 
Make  an  incision  about  three  or  four  inches  in  length  along  the  rib  immediately 
below  the  aspirating  needle.     Excise  about  two  inches  of  this  rib,  subperi- 

36 


562  OPERATIONS    ON    THE   BILIARY    PASSAGES 

osteally.  As  a  rule,  the  site  of  the  excised  rib  is  below  the  pleura  or  this  portion 
of  pleura  is  obliterated.  If  the  pleural  cavity  is  opened  by  accident  or  design, 
it  must  be  at  once  protected  (a)  by  the  insertion  of  a  few  catgut  stitches  to  close 
the  cavity,  (b)  by  applying  a  pack  of  gauze.  This  gauze  pack  may  well  be 
held  in  place  by  a  few  stitches  of  fme  plain  catgut.  By  the  time  it  is  safe  to 
remove  the  gauze  the  catgut  will  have  been  absorbed.  The  diaphragm  lies 
exposed;  seize  it  with  forceps  and  incise  it.  This  exposes  the  liver,  usually 
adherent  to  the  diaphragm.  The  aspirating  needle  still  in  situ  forms  a  guide 
to  the  abscess,  which  must  be  evacuated  as  described  in  the  preceding 
paragraphs. 

Choice  of  Operation.^ — Many  surgeons  consider  the  thoracic  route  the 
preferable.  When  sufl&cient  adhesions  are  present,  it  undoubtedly  is  ex- 
ceedingly safe,  but,  on  the  whole,  the  abdominal  route  is  the  better.  More 
cases  of  liver  abscess  can  be  reached  through  the  abdomen  than  through  the 
chest,  and,  while  a  satisfactory  examination  of  the  liver  for  secondary  and 
complicating  disease  is  possible,  the  dreaded  increased  danger  from  possible 
soiling  of  the  peritoneum  can  be  practically  completely  averted  by  suitable 
packing  with  gauze. 

SUBPHRENIC  ABSCESS 

Subphrenic  abscess  is  commonly  a  sequel  of  perforative  gastric  ulcer,  of 
appendicitis,  and  of  hepatic  abscess;  its  treatment  may  be  merely  an  extension 
of  the  treatment  of  the  primary  disease.  The  treatment,  of  course,  consists 
in  evacuating  the  pus  and  in  securing  efficient  drainage.  The  pus  is  reached 
in  practically  the  same  manner  as  is  that  in  a  hepatic  abscess,  and  the  methods 
require  no  special  description.    Counter-openings  for  drainage  may  be  necessary. 


CHAPTER  XLIV 
OPERATIONS   ON  THE  BILIARY  PASSAGES 

Operations  on  the  gall-bladder  and  bile-ducts  are  most  commonly  required 
because  of  the  presence  of  gall-stones  or  of  infective  processes. 

Preparation  of  the  Patient. — The  preparation  for  the  operation  is  iden- 
tical with  that  for  almost  any  other  abdominal  operation,  but  when  chronic 
jaundice  is  present,  calcium  chloride  should  be  administered  by  the  mouth  in 
thirty-grain  (gr.  xxx)  doses  for  two  or  three  days  prior  to  the  operation,  and  in 
sixty-grain  (gr.  Ix)  doses  per  rectum  for  a  few  days  thereafter  (Mayo-Robson). 
This  rather  heroic  exhibition  of  calcium  chloride  is  the  great  preventive  of  the 
hemorrhage  which  is  so  often  fatal  after  operations  on  the  jaundiced.  All  cases 
of  obstruction  due  to  stone  in  the  common  duct,  in  which  purpuric  spots  are 
present  in  the  skin,  die  from  hemorrhage  if  operated  upon.  Some  of  these 
cases  when  treated  with  calcium  chloride  improve  sufficiently  for  operation  to 
become  justifiable. 

Position  of  the  Patient. — Place  the  patient  on  his  back  and  support  the 
region  of  the  liver  on  a  firm  sand-bag  18  inches  long,  6  inches  wide,  and  3^^ 
inches  deep.     This  opens  the  costal  angle  and  makes  the  intestines  gravitate 


EXPOSURE    GALL-BLADDER 


;63 


from  the  field  of  operation;  it  also  pushes  "The  spine  forwards,  and  with  it  the 
liver  and  bile-ducts,  so  that  the  common  and  hepatic  ducts  are  brought  several 
inches  nearer  to  the  surface."  (Robson.)  this  position  (Robson's)  is  con- 
veniently obtained  without  the  use  of  a  sand-bag  on  the  table  shown  in  Fig.  692. 
Emmet  Rixford  uses  exactly  the  opposite  posture,  the  chest  and  thigh  being 
both  raised  so  as  to  relax  the  abdomen. 


Fig.  692. 


Method  of  Exposure  of  the  Gall-bladder  and  Ducts. — Very  many  in- 
cisions have  been  advocated  and  used. 

Method  A. — Mc Arthurs  incision:  ]Make  a  vertical  incision  through  the 
rectus  over  the  gall-bladder.  Retract  the  edges  of  the  muscle  wound.  Note 
the  aponeurosis  of  the  transversalis  muscle  with  some  of  its  muscle  fibres 
running  transversely  in  the  posterior  rectus  sheath.  Divide  the  posterior  rec- 
tus sheath  transversely  to  the  long  axis  of  the  body. 
This  wound  is  easily  and  securely  closed  and  gives 
sufficient  access  in  easy  cases  of  cholecystostomy.  If 
more  room  is  required  the  wound  may  be  converted 
into  a  Bevan  incision. 

Method  B. — Mayo-Rohson's  incision:  Make  a 
vertical  incision  over  the  middle  of  the  right  rectus 
muscle.  Separate  the  fibres  of  the  muscle  with  the 
fingers  or  the  handle  of  a  scalpel.  Divide  the  posterior 
sheath  of  the  rectus  and  the  peritoneum  together. 
This  incision  is  two  to  three  inches  in  length.  When  it 
is  necessary  to  explore  the  hepatic,  common,  or  deeper  ^^^-  ^^^'•^■^sj^n^  °  ^^"^  ^ 
portion    of    the  cystic   ducts,    continue    the    original 

incision  upwards  as  far  as  possible  in  the  space  between  the  ensiform  carti- 
lage and  the  right  costal  margin  following  the  costal  margin  (Fig.  693). 
The  incision  is  similar  to  the  upper  part  of  Bevan's  incision.  It  freely 
exposes  the  upper  surface  of  the  liver.  Lift  the  lower  border  of  the 
liver  in  bulk  (if  necessary,  drawing  the  organ  downwards  from  under 
cover    of    the  ribs),   thus  bringing  the  whole  of   the    gall-bladder  and  the 


5^4 


OPERATIONS    ON    THE   BILIARY    PASSAGES 


cystic  and  common  ducts  quite  close  to  the  surface.  As  the  gall-bladder 
is  usually  strong  enough,  let  the  assistant  take  hold  of  it  with  his  fingers  or 
forceps  and  by  gentle  traction  keep  the  parts  well  exposed,  while  at  the  same 
time  he  protects  and  retracts,  with  a  sponge  in  his  left  hand,  the  left  side  of 
the  wound  and  the  viscera,  which  would  otherwise  obstruct  the  view.  "It 
will  now  be  observed  that  instead  of  the  gall-bladder  and  cystic  duct  making 
a  considerable  angle  with  the  common  duct,  an  almost  straight  passage  is 
found  from  the  fundus  of  the  gall-bladder  to  the  entrance  of  the  bile-duct 
into  the  duodenum,  and  if  adhesions  have  been  thoroughly  separated,  the  sur- 


rectus  irlocAHv  .  s^rui.     | 


fxcoJ-lru:^  51 
vertical  p^a•akrcmrAl 
ina^'wn.  In  Anterior 


Fig.  694. — {Gray,  by  permission  from  the  British  Journal  of  Surgery.) 


geon  has  immediately  under  his  eye  the  whole  length  of  the  ducts  with  the 
head  of  the  pancreas  and  the  duodenum.  (Robson,  "Brit.  Med.  Jour.," 
January  24,  1903.) 

Method  C. — Bevan's  incision:  Bevan  criticizes  the  vertical  incision  in  the 
right  semilunar  line  as  being  insufficient,  and  when  long,  objectionable  because 
of  nerve  destruction;  a  T-shaped  incision  is  difficult  to  close  and  is  liable  to  lead 
to  hernia;  median  incision  does  not  give  free  access  to  the  gall-bladder.  He 
advocates  the  following  method  ("Annals  of  Surgery,"  xxx,  17):  Make  a 
vertical  incision  along  the  outer  border  of  the  right  rectus  muscle  or  between 
its  outer  fibres.     This  suffices  for  the  exploration  or  the  completion  of  a  simple 


EXPOSURE    GALL-BLADDER 


565 


cystostomy.  If  it  seems  necessary  to  expose  or  work  on  the  ducts,  enlarge 
the  incision  by  continuing  its  upper  end  obliquely  upwards  and  inwards,  its 
lower  end  obliquely  downwards  and  outwards. 

Method  D. — Kehr's  incision:  From  the  ensiform  process  make  a  cut  in  the 
middle  line  downwards  for  about  i}^  inches;  then  divide  the  right  rectus  ob- 
liquely and  continue  the  cut  downwards  in  the  semilunar  line. 

Method  E. — Kocher's  oblique  incision:  Make  an  incision  four  inches  in 
length  parallel  to  and  about  two  inches  below  the  right  rib  margin.  This 
incision  divides  the  outer  fibres  of  the  rectus  muscle  and  portions  of  both  the 


cio\i'c<x-  line  of  Iruri.^toT'i- 


Fig.  695. — {Gray,  by  permission  from  the  British  Journal  of  Surgery.) 


internal  and  external  oblique.  Branches  of  the  intercostal  nerves  run  across 
the  incision  towards  the  rectus,  and  these  must  be  retracted  downwards  or 
upwards  and  preserved  uninjured.  Kocher's  incision  gives  very  free  access 
to  the  biliary  region,  but  necessitates  an  undue  amount  of  muscle  injury. 

Kocher  also  uses  an  incision  which  passes  in  the  middle  line  from  near  the 
ensiform  cartilage  to  near  the  umbilicus  and  thence  outwards  through  the  rectus 
muscle.  Pannett  modifies  this  cut  as  follows:  "A  long  paramedian  rectus 
sheath  incision  is  made  from  about  i  inch  below  the  ensiform  cartilage  to  the 
umbilicus,  and  the  abdomen  opened  in  the  usual  way.  Exploration  is  then 
made  to  ascertain  whether  exposure  is  adequate.     If  it  is  not,  the  anterior 


566  OPERATIONS    OX    THE    BILIARY    PASSAGES 

rectus  sheath  is  separated  from  the  muscle  and  pulled  outwards.  The  rectus 
itself  is  divided  part  of  the  way  across,  at  a  point  midway  between  the  ensiform 

cartilage  and  the  umbilicus With  adequate  retraction  such  an  incision 

gives  ample  room " 

Method  F. — Frilz  Konig's  incision:  F.  Konig  thinks  that  high  epigastric 
incisions  affect  respiration  unfavorably.  Beginning  not  less  than  three  finger- 
breadths  below  the  ensiform  cartilage  make  a  median  incision  downwards  for 
^i  to  i3^  inches  then  curve  the  cut  transversely  across  the  right  rectus  muscle 
to  its  external  margin.  It  is  always  possible  to  avoid  injuring  the  nerves. 
The  location  of  the  transverse  part  of  the  incision  depends  on  how  low  the  liver 
and  gall-bladder  lie.  Perthes'  incision  is  very  similar  but  has  some  distinctive 
features.  H.  M.  W.  Gray  endorses  its  value.  (Brit.  J.  of  Surg.,  1,  page  200.) 
Make  a  vertical  incision  through  the  right  rectus  close  to  the  middle  line  from 
the  ensiform  to  the  umbiUcus.  From  the  lower  end  of  this  incision  cut  hori- 
zontally outwards,  through  the  skin  and  subcutaneous  tissues,  to  near  the  costal 
margin.  With  two  rows  of  sutures  unite  the  aponeurosis  to  the  rectus  muscle 
(Fig.  694).  Divide  the  rectus  transversely  and  reflect  it  upwards,  and  outwards 
as  a  flap  with  the  skin  (Fig.  695).  Divide  the  posterior  sheath  of  the  rectus 
and  the  peritoneum  obliquely  near  the  base  of  the  muscular  flap.  The  vascular 
and  nerve  supply  of  the  rectus  is  well  protected. 

Method  G. — SprengeVs  incision:  Oblique  section  of  the  right  rectus  parallel 
to  the  costal  arch.  If  more  room  is  required  make  a  short  incision  upwards 
and  outwards  at  the  outer  end  of  the  wound  and  split  the  fibres  of  the  external 
oblique.  Retract  the  edges  of  the  wound  in  the  external  oblique  and  separate 
the  fibres  of  the  internal  and  transversalis.  If  the  common  duct  requires  ex- 
posure extend  the  incision  so  as  to  partially  or  completely  divide  the  left  rectus. 

Method  H. — Rutherford  Morison's  incision:  Make  a  transverse  incision 
from  the  ileo-costal  space  behind  to  the  outer  edge  of  the  rectus  in  front.  Be- 
sides giving  free  access  to  the  gall-bladder  and  ducts  this  permits  of  easy 
posterior  drainage. 

EXAMINATION  OR   EXPLORATION   OF  THE    G.ALL-BLADDER 

AND   BILE-DUCTS 

When  the  abdomen  is  opened,  the  gall-bladder  is  usually  easily  recognized 
and  it  is  easy  to  palpate  this  viscus,  to  follow  the  cystic  duct  downwards,  and, 
by  passing  the  finger  through  the  foramen  of  Winslow,  to  palpate  at  least  the 
supra-duodenal  portion  of  the  common  duct.  Often  the  gall-bladder  is  hidden 
in  a  mass  of  adherent  omentum  or  other  viscera,  or  it  may  be  much  shrunken 
as  well.  Under  these  circumstances,  beginning  at  the  liver  margin,  separate 
the  adhesions.  Use  the  liver  as  a  guide  to  the  site  of  the  gall-bladder.  Many 
of  the  adhesions  may  be  separated  by  the  fingers,  but  many  must  be  cut  be- 
tween ligatures.  The  separation  of  adhesions  must  be  accomplished  with 
much  circumspection,  as  nature  occasionally  herself  performs  the  operation 
of  cholecystenterostomy,  and  when  this  is  the  case,  the  surgeon  is  liable  to  pene- 
trate the  junction  between  the  gall-bladder  and  the  gut.  When  this  accident 
occurs,  the  hole  in  the  gut  must  at  once  be  closed  by  a  double  line  of  sutures. 


C-nOT.KCYSTOSTOMY  567 

When  the  gall-bladder  is  much  shrunken,  the  search  for  it  makes  a  severe 
call  on  the  patience  of  the  surgeon.  When  the  gall-bladder  is  distended  or 
not  shrunken,  it  is  easy  to  pull  it  up  into  the  wound.  Before  breaking  down 
adhesions  around  the  biliary  passages  be  careful  to  protect  thoroughly  the 
peritoneal  cavity  by  means  of  suitable  pads  or  sponges.  When  freeing  the 
gall-bladder  and  the  ducts  from  surrounding  adhesions,  one  is  liable  at  any 
moment  to  open  into  some  collection  of  infective  material,  and  dangers  from 
this  source  must  be  guarded  against.  As  was  hinted  when  describing  Robson's 
incision,  it  is  of  first-rate  importance  to  free  the  bile-ducts  from  surrounding 
adhesions;  if  this  is  not  done,  the  exploration  becomes  a  sham.  The  guide 
to  the  common  duct  is  the  gall-bladder  and  cystic  duct. 

OPERATIONS   ON  THE   GALL-BLADDER  AND   DUCTS 

Ideal  Cholecystotomy. — This  operation  consists  in  opening  the  gall-bladder, 
removing  any  stones  which  it  may  contain,  and  closing  the  wound  by  two 
layers  of  sutures  exactly  as  one  would  close  a  wound  in  the  small  intestine. 
Bernays  has  advocated  this  procedure  and  called  it  ideal.  Vautrin  carried 
out  a  similar  operation,  but  sutured  the  closed  viscus  to  the  upper  part  of 
the  abdominal  incision  (cholecystopexy).  Union  of  the  gall-bladder  to  the 
upper  part  of  the  wound  has  the  advantage  that,  the  fundus  being  fixed  in 
an  elevated  position,  natural  drainage  of  the  viscus  is  aided. 

Cholecystostomy. — Cholecystostomy  is  an  operation  which  creates  a  fistula 
between  the  gall-bladder  and  the  parietes.  It  may  be  executed  in  either  one 
or  two  sittings,  usually  in  one. 

Cholecystostomy  in  Two  Sittings. — First  sitting:  Expose  and  explore  the 
gall-bladder  and  ducts.  Bring  the  fundus  of  the  gall-bladder  into  the  upper 
part  of  the  abdominal  wound  and  suture  it  to  the  peritoneum  and  deepest 
layer  of  fascia  (transversalis  fascia),  but  not  to  the  skin.  It  is  said  that  the 
sutures  ought  not  to  penetrate  into  the  cavity  of  the  viscus,  but  should  merely 
include  a  portion  of  the  thickness  of  its  wall  (serous  and  muscular,  not  mucous, 
coats).  Close  the  rest  of  the  abdominal  wound  with  sutures.  It  is  well  to 
attach  a  long  silk  suture  to  the  exposed  portion  of  the  fundus  of  the  gall-bladder, 
to  act  as  a  guide  when  the  viscus  is  opened  at  a  later  date. 

Second  sitting:  In  a  few  days,  when  adhesions  have  formed  between  the 
gall-bladder  and  the  abdominal  wall,  make  an  opening  with  a  knife  into  the 
gall-bladder  and  so  establish  the  fistula. 

This  operation  is  eminently  safe  and  was  a  great  aid  in  establishing  the 
surgery  of  this  region,  but  to-day  the  operation  in  one  sitting  has  become 
practically  as  safe  and  has  the  incomparable  advantage  that  it  permits  the 
finger  on  the  outside  of  the  gall-bladder  to  assist  in  the  extraction  of  calculi 
and  in  exploration.  When  the  finger  cannot  enter  the  abdominal  cavity  out- 
side the  gall-bladder,  the  extraction  of  all  the  calculi  present  becomes  a  matter 
of  extreme  uncertainty.     The  "two  stage"  operation  is  obsolete. 

Cholecystostomy  in  One  Sitting. — Expose  and  explore  the  gall-bladder 
and  ducts.  Separate  all  adhesions  which  impede  the  work.  Thoroughly 
protect  the  belly  cavity  with  gauze  pads.     If  the  gall-bladder  is  sufiiciently 


s68 


OPERATIOMS    ON    THE    BILIARY    PASSAGES 


large,  pull  it  up  into  the  abdominal  wound, 
volsellae. 


Seize  the  fundus  with  two  small 


If  the  organ  is  tensely  filled  with  fluid,  it  is  usually  advised  to  empty  it  by  means  of  an 
aspirator.  When  the  contents  are  thick,  and  they  usually  are  so,  a  small  aspirating  needle 
is  useless,  and  a  large  needle  puncture,  it  seems  to  the  writer,  possesses  no  advantages  over  a 
cut.     The  advantage  of  aspiration  is  avoidance  of  soiling  the  wound. 

Make  a  small  incision  into  the  viscus.  Mop  away  all  fluid  which  escapes. 
Enlarge  the  opening.  Remove  with  the  scoop  (Fig.  696)  any  calculi  which 
may  be  present  in  the  bladder  or  adjacent  portion  of  cystic  duct.     A  finger 


Fig.  696. — Finney's  block  tin  scoop. 

outside  the  gall-bladder  greatly  aids.  Often  stones  lying  in  the  cystic  and 
rarely  the  common  ducts  may  be  coaxed  by  the  finger  (outside  the  bladder) 
up  into  the  bladder  and  so  removed.  Too  much  time  must  not  be  expended 
in  trying  to  coax  such  stones  into  the  bladder,  as  other  and  surer  means  of 
extracting  them  are  available.  Once  more  explore  the  interior  of  the  gall- 
bladder with  the  linger.  When  exploring  the  gall-bladder  after  it  has  been 
opened,  much  information  may  be  obtained  by  palpating  with  a  finger  of  one 
hand  inside  the  viscus  and  the  fingers  of  the  other  hand  outside  it,  but  inside  the 
belly.     Occasionally  one  finds  the  gall-bladder  apparently  divided  into  two 


ItiVfR5>0N  5uTji>e 


'&.-;  /    PcmreitcAi ■  cul  eiAMe* 


f^. 


Fig.  697. — Jones'  cholecystostomy. 

cavities,  both  containing  calculi.  The  septa  between  such  cavities  require 
division  before  the  stones  can  be  removed.  The  methods  of  establishing  a 
temporary  fistula  into  the  gall-bladder  have  undergone  a  number  of  changes. 
The  edges  of  the  wound  in  the  viscus  were  at  first  sutured  to  the  skin,  later 
to  the  aponeurosis  or  to  the  peritoneum.  The  resulting  fistula  was  almost 
always  slow  to  close  and  sometimes  failed  do  so;  hence  surgeons  sought  to 
invert  the  edges  of  the  gall-bladder  wound  so  that  on  removal  of  the  drainage 


CHOLECYSTOSTOMY 


569 


tube,  which  was  and  is  always  used,  peritoneal  surfaces  would  be  left  in 
contact  and  healing  be  rapid.  W.  D.  Jones  devised  a  suture  for  inverting 
the  edges  of  the  gall-bladder  wound  and  attaching  it  to  the  parietes.  He 
pulled  the  viscus  well  out  of  the  abdomen  and  sutured  it  to  the  parietal 
peritoneum  at  a  distance  from  the  wound  in  it  (Fig.  697).  He  next  passed 
a  catgut  suture  through  the  abdominal  aponeuroses  and  muscles  into  the  gall- 
bladder near  the  line  of  stitches  already  in  place;  with  this  catgut  suture  he 
caught  up  the  edges  of  the  wound  in  the  gall-bladder  and  brought  it  out  through 
the  parietes  in  the  reverse  direction  to  that  in  which  it  was  introduced.  When 
several   such  sutures  have  been  inserted  and  tied  the  cystostomy  wound  is 

properly  inverted. 

J.  E.  Summers'  method  of  securing  inversion 

and   suspension  is  sufficiently   shown  in  Figs. 

698,  699. 

The  Mayos  attain  the  same  end  as  follows: 

Prepare  a  drainage-tube  by  surrounding  it  with 

a  few  layers  of  gauze  covered  by  rubber  tissue. 


Purae-5trir\S 
Suture 


Fig.  698. 


Figs.  698  and  699.- 


FiG.  699. 
-Cholecystostomy. 


Theend  of  the  tube  should  be  bevelled  or  trimmed  in  the  "fishtail"  fashion.  In- 
troduce this  "dressed  tube"  a  short  distance  into  the  gall-bladder.  With 
plain  catgut  suture  the  edges  of  the  gall-bladder  wound  snugly  to  the  tube. 
Push  the  tube  a  little  further  into  the  gall-bladder,  thus  inverting  that  portion 
of  the  gall-bladder  around  the  tube  and  the  original  line  of  suture.  With  a 
Lembert  suture  of  catgut  attach  the  surface  of  the  gall-bladder  all  around 
the  tube  to  the  tube.  Leave  the  ends  of  this  last  suture  long,  and  with  a  needle 
attach  them  to  the  parietal  peritoneum. 

The  advantages  of  this  procedure  are :  (a)  The  purse-string  suture  prevents 
leakage  of  bile  around  the  drainage-tube,  (b)  When  the  tube  is  withdrawn, 
the  inversion  of  the  bladder  wound  leaves  serous  surfaces  in  contact,  there  is 
no  prolapse  of  mucous  membrane,  and  hence  closure  of  the  fistula  is  hastened. 
When  numerous  small  calculi  and  much  biliary  "sand"  have  been  removed,  it  is 
wise  not  to  invert  the  edges  of  the  wound  in  the  gall-bladder,  since  by  so  doing 
a  trap  is  formed  which  will  prevent  the  discharge  of  any  "sand"  or  small  stones 
which  may  have  been  overlooked. 

When  the  gall-bladder  could  not  be  brought,  without  tension,  into  contact 
with  the  parietes  it  was  found  that  if  the  tube  was  well  sutured  into  the  viscus 
the  latter  could  be  safely  dropped  back  into  the  abdomen  and  the  tube  brought 


.->/' 


OPERATION'S    ON    THE   BILIARY   PASSAGES 


out  through  the  parietes  exactly  as  is  done  in  drainage  of  the  cystic  or  common 

ducts.     As  a  precautionary  measure  it  may  be  well  to  surround  the  tube,  in  its 

passage  through  the  peritoneal  cavity,  with  a  little  gauze  protected  by  rubber 

tissue.     This  precaution  is  probably  entirely  unnecessary  as  the  omentum,  that 

most  efficient  "abdominal  policeman,"  will  certainly  surround  and  isolate  the 

tube.     At  present  the  best  method  of  performing  cholecystostomy  seems  to  be: 

(i)  Evacuate  the  contents  of  the  gall-bladder  by  aspiration,  incision  or  both. 

(2)  Surround  the  cystotomy  wound  by  a  continuous 

catgut  suture  penetrating  all  the  coats  of  the  viscus. 

Introduce  a  "dressed  tube"  into  the  gall-bladder  and 

tie    the    catgut    suture,    already    in    place,    snugly 

around  it.     Introduce  a  purse-string  suture  of  catgut, 

in  the  Lembert  fashion,  into  the  walls  of   the  gall- 

t-  ^  n  uu      ^  V    bladder,  around  and  a  short  distance  awav  from  the 

Fig.  700. — Rubber    tube  ' 

tube.  Push  the  tube  farther  into  the  gall-bladder 
thus  causing  invertion  of  the  original  line  of  suture. 
Tighten  and  tie  the  purse-string  suture.  With  a 
needle  make  the  purse-string  suture  take  one  or  two 
bites  in  the  drainage  tube  to  anchor  the  latter.  Instead  of  a  "dressed  tube" 
one  may  use  a  rubber  tube,  the  end  of  which  has  been  turned  back  on 
itself  twice  in  a  double  revere.  If  this  tube  is  used  the  purse-string  suture 
snugly  tied  round  it  just  above  the  revere,  which  is  in  the  bladder,  will  prevent 
it  escaping  (Fig.  700).  (3)  Permit  the  gall-bladder  to  assume  whatever  position 
it  pleases,  in  the  abdomen.  Bring  the  end  of  the  drainage  tube  out  through 
the  parietes.  (4)  Close  the  abdominal  vvound  with  or  without  further  drainage. 
The  tube  mav  be  removed  whenever  it  becomes  loose. 


with  a  double  revere  intro 
duced  into  gall-bladder. 

X-X.  Suture  around  wound 
in  gall-bladder;  Y— Y,  purse- 
string  suture. 


Fig.  701. — Shaw's  inversion  suture. 

Shaw's  inversion  suture  is  good  (Surg.,  Gyn.  and  Obst.,  June,  1916). 

Introduce  suture  .1  (Fig.  701)  at  A'  about  ^i  inch  from  the  edge  of  the 
opening  in  the  \'iscus,  let  it  emerge  a  0  about  }i  inch  from  the  edge  of  the 
opening.  Continue  the  suture  from  0  to  M  each  bite  penetrating  the  whole 
thickness  of  the  wall  of  the  gall  bladder.  Let  the  last  stitch  emerge  at  A'  a 
point  corresponding  to  A'.     Continue  the  suture  BA  on  the  opposite  side  of 


CHOLECYSTECTOMY  57 1 

the  opening.  Cut  the  loop  BB.  Introduce  the  drain.  Pull  upon  and  tie 
.l.-l  while  the  assistant  at  the  same  lime  tightens  and  ties  BB.  Easy  inversion 
results. 

Cholecystectomy. — Is  called  for  under  several  conditions  such  as  the  pres 
ence  of  neoplasms,  lithiasis,  and  inflammation,  but  the  indications  necessitating 
it  will  be  discussed  later. 

Step  I. — Exposure  and  exploration  of  the  gall-bladder  and  ducts. 

Step  2. — -Aspiration  or  incision  of  the  gall  bladder  is  necessary  under  the 
following  circumstanges  (Monod  and  Vanverts):  (i)  When  the  viscus  is  so 
distended  that  it  is  liable  to  rupture  during  the  necessary  manipulations.  (2) 
When  external  exploration  of  the  common  duct  leaves  doubt  as  to  its  permea- 
bility and  one  desires  to  catheterize  the  ducts  through  the  bladder.  One  must 
remember,  however,  that  the  valvular  construction  of  the  upper  part  of  the 
cystic  duct  does  not  lend  itself  to  easy  catheterization. 

In  the  absence  of  the  above  conditions  it  is  better  not  to  open  the  viscus 
so  as  to  avoid  possible  contamination  of  the  wound. 

Step  3. — When,  as  exceptionally  happens,  the  gall-bladder  is  provided  with 
a  "meson,"  divide  this  between  ligatures  or  forceps.  As  a  rule,  the  viscus 
is  applied  directly  to  the  undersurface  of  the  liver  and  held  there  by  the  peri- 
toneum, and  one  operates  as  follows:  Incise  the  peritoneal  covering  of  the 
gall-bladder  and  by  blunt  dissection  separate  the  organ  from  the  liver.  Bleed- 
ing from  the  liver  may  be  controlled  by  suture,  by  the  use  of  the  Paquelin 
cautery,  or  by  the  sponge  pressure.  Isolate  and  ligate  the  cystic  branches  of  the 
hepatic  artery;  ligate  and  divide  the  cystic  duct.  If  it  is  desired  to  drain  the 
biliary  passages,  only  one  ligature  or  clamp  may  be  applied  between  the  gall- 
bladder and  the  point  of  section  of  the  duct;  if  complete  closure  of  the  passage 
is  sought,  then  the  duct  should  be  divided  between  two  ligatures.  Riedel  under 
the  latter  circumstances  closes  the  abdominal  wound  without  drainage,  but 
most  surgeons  prefer  to  drain  with  a  small  roll  of  rubber  tissue  or  dental  dam. 
The  peritoneal  flaps  left  after  removing  the  gall-bladder  ought  to  be  sutured. 
If  drainage  of  the  duct  is  required  or  desired,  leave  the  stump  of  the  duct  open 
and  suture  over  it  or  to  it  a  rubber  drainage-tube  with  a  stitch  of  fine  plain 
catgut.  This  stitch  will  be  absorbed  before  it  is  time  to  remove  the  tube,  and 
in  the  meantime  will  hold  it  in  place. 

Undoubtedly  cholecystectomy  is  best  accomplished  from  below  upwards — 
i.e.,  beginning  by  dividing  the  duct.  There  are  two  principal  reasons  for  this: 
(a)  The  dissection  is  easier;  {b)  the  cystic  artery  (generally  two  branches) 
is  ligated  at  the  same  time  as  the  duct  and  thus  hemorrhage  is  completely  con- 
trolled at  the  earliest  possible  moment.  The  only  objection  to  this  method  of 
removal  is  that  the  operator  may  fear  mistaking  the  common  for  the  cystic 
duct. 

The  Operation. — Step  1. — Expose  the  gall-bladder  by  any  convenient  inci- 
sion; the  author  prefers  one  more  or  less  transverse.  E.  S.  Judd  writes:  "The 
abdominal  incision,  instead  of  being  made  over  the  normal  location  of  the  gall- 
bladder, is  made  high  and  close  to  the  mid-line,  usually  extending  to  the  ensi- 
form.  Through  this  high  incision,  in  most  cases,  much  of  the  right  lobe  of  the 
liver  .can  be  rolled  out  by  using  the  gall-bladder  as  a  tractor.     If  the  liver 


572 


OPERATIONS    ON    THE    BILIARY    PASSAGES 


is  adherent  to  the  parietal  peritoneum,  the  adhesions  should  h>e  freed  before  pro- 
ceeding further,  as  the  operation  is  much  simpler  if  the  liver  can  be  displaced." 

Step  2. — Explore  the  common  duct,  the  head  of  the  pancreas  and  the  neigh- 
boring lymphatic  glands.  The  dissection  necessary  for  this  exploration  exposes 
the  cystic  duct. 

Step  3. — Apply  a  forceps  to  the  fundus  of  the  gall-bladder  and  gently  pull 
it  forwards  and  upwards.  Apply  a  second  forceps  to  the  neck  of  the  \ascus; 
traction  on  this  pulls  the  cystic  duct  away  from  the  liver.  By  blunt  dissection 
clear  away  any  fatty  and  cedematous  tissue  which  obsctires  the  duct.     Using 


Fig. 


(Judd,  Annals  of  Surgery.) 


the  cystic  duct  as  a  guide  expose  its  junction  with  the  common  duct.  "The 
neck  of  the  gall-bladder  and  the  lowest  part  of  the  body  of  the  gall-bladder 
frequently  lie  along  side  the  cystic  duct,  so  that  when  this  is  dissected  out 
and  pulled  up,  the  cystic  duct  is  easily  separated  from  the  surface  of  the  liver 
(Fig.  702)." 

Step  4. — Isolate  the  cystic  duct  and  the  cystic  artery  together  for  about  ^ 
or  I  inch  and  doubly  clamp  them  together.     Divide  between  the  clamps. 

Step  5." — Make  traction  on  the  forceps  applied  to  the  cystic  duct  beside 
the  gall-bladder  and  so  make  prominent  the  peritoneal  folds  attaching  the 


CHOLECYSTECTOMY  573 

bladder  to  the  liver  as  well  as  the  communicating  vessels  which  are  now  easily 
controlled.  Dissect  the  gall-bladder  from  the  liver,  leaving  however  enough  of 
its  fundus  attached  so  that  it  can  be  used  as  a  tractor  during  the  next  step  of  the 
operation  (Fig.  703). 


Fig.   ■]o^.—{Jud(l,  Annals  oj  Surgery.) 

Step  6. — ^Ligate  the  Stump.  This  can  be  done  without  tension  and  without 
danger  to  the  common  duct  because  of  the  thorough  dissection.  Suture  the 
cut  edges  of  the  peritoneal  folds  from  beside  the  stump  up  to  the  edge  of  the 
liver,  removing  the  gall-bladder  little  by  little  as  the  sutures  are  being  inserted. 
Place  a  small  cigarette  drain  or  roll  of  rubber  dam  down  to  the  stump  of  the 
cystic  duct  and  along  the  fissure  from  which  the  gall-bladder  was  removed 
(Fig.  704). 


5  74 


OPERATIONS    ON    THE   BILIARY    PASSAGES 


Cholecystenterostomy. — When  the  common  duct  is  irreparably  occluded, 
e.g.,  by  malignant  disease,  or  when  it  is  desirable  to  drain  the  ducts  in  chronic 
pancreatitis,  the  formation  of  a  fistula  between  the  gall-bladder  and  the  gut 
permits  the  escape  of  bile.     This  operation  is  cholecystenterostomy. 

(A)  Antero-colic  method.  When  possible,  it  is  best  to  unite  the  gall-bladder 
to  the  duodenum  but  under  stress  of  circumstances  that  portion  of  the  intestine 
(even  the  colon)  which  is  most  readily  brought  up  against  the  gall-bladder  is 
the  best  portion  to  use.     The  operation  itself  is  practically  identical  with  that 


I'lG.   704. — {Judd,  Annals  of  Surgery.) 


of  entero-enterostomy  (intestinal  anastomosis)  and  requires  no  special  descrip- 
tion. It  may  be  accomplished  by  the  method  of  suture,  by  McGraw's  elastic 
suture,  or  by  the  Murphy  button.  Probably  the  oldest  patient  ever  submitted 
to  this  operation  was  a  woman  eighty  years  of  age,  in  whom  the  author  success- 
fully used  the  Murphy  button.  Before  the  operation  of  choledochotomy  was 
as  safe  as  it  is  to-day,  cholecystenterostomy  was  much  more  frequently  resorted 
to  than  at  present;  it  averted  the  evils  from  obstruction  of  the  common  duct  by 
stones,  but  it  did  not  rid  the  patient  of  the  obstruction  itself  or  of  the  late  effects 
of  the  irritation  from  the  obstructing  calculus. 


CYSTICOTOMY  575 

When  the  gall-bladder  is  anastomosed  to  a  segment  of  small  intestine,  it 
has  been  suggested  that  an  anastomosis  between  the  afferent  and  efferent 
segments  of  the  gut  would  prevent  all  possibility  of  intestinal  contents  gaining, 
access  to  the  gall-bladder.  This  precaution  seems,  to  the  author,  superfluous, 
as  it  would  not  prevent  the  passage  of  the  ever-present  infection  from  the 
intestine  into  the  gall-bladder,  even  if  it  did  keep  the  gross  contents  of  the  in- 
testine from  entrance  into  that  viscus.  The  increased  danger  of  the  extra 
operation  seems  out  of  proportion  to  the  benefit  to  be  obtained. 

(B)  Retro-colic  Method.  (Brentano,  "  Zentralblatt  fur  Chir.,"  1907,  No. 
24.     Lotheisen,  idem.,  No.  31.) 

Step  I. — Open  the  abdomen.     Explore  the  gall-bladder  and  ducts. 

Step  2. — Pull  the  transverse  colon  and  great  omentum  out  of  the  wound 
and  turn  them  upwards  exactly  as  in  posterior  gastro-enterostomy.  Find 
the  duodeno-jejunal  junction;  select  a  portion  of  jejunum  about  j2  inches 
below  the  junction;  select  a  bloodless  portion  of  the  transverse  mesocolon 
close  to  the  gall-bladder  and  tear  a  hole  in  it  as  in  gastro-enterostomy.  Pull 
the  selected  loop  of  jejunum,  from  below  upwards  through  the  rent  in  the 
mesocolon.  Apply  an  intestinal  clamp  {e.g.,  Doyen's)  to  the  jejunum.  Return 
the  colon  and  omentum  into  the  belly. 

Step  3. — If  the  gall-bladder  is  distended  empty  it  by  means  of  a  trocar 
and  cannula  introduced  at  its  dome.     Close  the  puncture. 

Step  4. — Choose  a  suitable  portion  of  the  undersurface  of  the  gall-bladder 
and  to  it  apply  an  intestinal  clamp.  Lay  the  clamped  loop  of  jejunum  against 
the  clamped  loop  of  gall-bladder  and  make  an  anastomosis.  If  the  Murphy 
button  is  used  it  is  unnecessary  to  clamp  the  gall-bladder. 

Step  5. — Once  more  pull  the  colon  and  omentum  upwards  so  as  to  expose 
the  transverse  mesocolon.  Pull  the  jejunum  downwards  until  the  line  of  the 
anastomosis  becomes  visible  below  the  rent  in  the  mesocolon.  With  a  few 
stitches  tack  the  edges  of  the  rent  in  the  mesocolon  to  the  line  of  anastomosis. 
Return  the  colon  and  omentum  to  the  abdomen. 

No  argument  is  necessary  to  show  the  superiority  of  the  retrocolic  method 
of  cholecystenterostomybover  the  older  method. 

Cysticotomy— Incision  into  the  Cystic  Duct. — When  calculi  are  present  in 
the  cystic  duct,  it  is  often  possible  to  ej#l:act  them  through  the  gall-bladder. 
If  this  is  not  easy  to  accomplish,  one  should  not  waste  much  time  in  such 
endeavors,  but  should  carefully  locate  the  stones,  incise  the  duct  longitudinally 
over  them,  and  extract  them.  The  wound  in  the  duct  may  be  closed  by  sutures. 
The  sutures,  if  of  silk  or  hemp,  must  not  penetrate  the  mucosa  lest  they  form 
the  nuclei  of  more  calculi.  Catgut  sutures  are  excellent  and  have  not  this 
disadvantage.  Many  surgeons  insert  but  do  not  tie  the  sutures  before  the 
stones  are  removed.  The  suturing  is  not  so  difficult  as  might  be  imagined, 
because  from  disease  the  ducts  are  dilated  and  their  walls  thickened.  It  is 
important  to  remember  that  not  much  time  should  be  devoted  to  attempts 
at  suturing  (the  writer  has  seen  death  result  from  such  waste  of  time),  since 
really  quite  as  good  results  are  obtained  by  drainage  of  the  unsutured  passages. 
The  Mayo's  suggestion  of  suturing  (with  plain  catgut)  a  rubber  drain  to  the 
open  duct  and  surrounding  this  with  a  gauze  pack  is  a  most  excellent  practice, 


576  OPERATIONS    ON    THE   BILIARY    PASSAGES 

and  is  eminently  safe.  On  the  whole,  the  inexperienced  operator  is  advised 
to  avoid  attempts  at  suturing  the  ducts. 

Instead  of  making  a  separate  incision  into  the  duct  one  may  follow  Del- 
ageniere's  plan  of  continuing  the  incision,  already  existing  in  the  gall-bladder, 
downwards  so  as  to  split  the  cystic  duct  until  the  stone  is  exposed.  If  necessary 
the  whole  length  of  the  duct  may  be  split  in  the  above  fashion.  Terrier, 
Hartmann  and  others,  when  dealing  with  stones  in  the  common  duct,  split 
the  gall-bladder,  cystic  duct  and  as  much  of  the  common  duct  as  may  be  neces- 
sary to  expose  and  remove  the  stone,  after  which  they  remove  the  gall-bladder, 
pass  a  rubber  drain  far  up  the  hepatic  duct  (Kehr's  "hepaticus  drainage") 
and  pack  a  little  gauze  around  the  tube.  The  tube  and  pack  are  brought 
out  of  the  abdominal  wound,  the  excess  of  which  is  closed.  It  is  a  wise  pre- 
caution to  anchor  the  drain  and  pack  to  the  ducts  by  fine  catgut  sutures. 

The  advantages  of  splitting  the  gall-bladder  and  ducts  are  that  they  form 
an  infallible  guide  to  the  stone  and  the  wide  opening  permits  of  very  free 
exploration.  The  disadvantages  are  the  difficulty  of  doing  the  work  when 
many  adhesions  are  present,  and  the  extent  of  the  wound  inflicted.  On  several 
occasions  the  author  has  found  the  procedure  very  useful. 

Choledochotomy — Incision  into  the  Common  Bile-duct. — The  common 
bile-duct  may  be  considered  as  consisting  of  two  parts:  one,  supraduodenal, 
stretching  from  the  junction  of  the  cystic  and  hepatic  ducts  to  the  union  of 
the  first  and  second  segments  of  the  duodenum;  the  other  part,  retroduodenal, 
stretching  the  remainder  of  the  distance  to  the  ampulla  of  Vater. 

The  supraduodenal  portion  of  the  choledochus  is  about  ^  to  i  inch  in 
length  and  occupies  the  right  margin  of  the  gastro-hepatic  omentum.  To 
the  left  and  behind  the  duct  lies  the  portal  vein — further  to  the  left  is  the  hepatic 
artery.  When  the  duct  is  dilated  by  disease,  the  portal  vein  may  lie  in  front 
of  it.  The  dangers  from  this  source  have  been  grossly  exaggerated.  In 
operations  the  portal  vein  and  hepatic  artery  are  rarely  seen.  The  line  of 
safe  incision  is  along  the  anterior  and  right  side  of  the  duct.  The  foramen 
of  Winslow  is  the  guide  to  the  duct.  A  finger  passed  into  the  foramen  and 
hooked  forwards  inevitably  brings  the  duct  forwards  also.  Unfortunately, 
the  foramen  of  Winslow  is  sometimes  hidden  or  obliterated  by  adhesions. 
Several  lymphatic  glands  exist  in  the  gastro-hepatic  omentum,  and  when 
enlarged  may  lead  to  error.  The  retroduodenal  portion  of  the  choledochus 
runs  for  a  distance  of  about  2  inches  along  the  posterior-internal  border  of 
the  second  part  of  the  duodenum.  The  duct  for  about  i^^  inches  before 
it  reaches  the  ampulla  of  Vater  lies  on  or  in  the  pancreas.  It  is  evident  that 
the  retroduodenal  portion  of  the  duct  covered  by  intestine  and  pancreas  is 
out  of  reach  of  palpation  by  ordinary  means.  To  add  to  the  difficulties,  several 
lymphatic  glands,  prone  to  enlargement,  exist  along  this  tract  and  render 
a  positive  diagnosis  as  to  the  presence  or  absence  of  stone  impossible  without 
further  exposure.  Vautrin  ("Revue  de  Chirurgie,"  June,  1896)  has  made 
an  extremely  exhaustive  and  important  study  on  the  anatomy  and  surgery 
of  the  retroduodenal  choledochus,  and  the  following  is  based  on  his  writings: 

Exposure  of  the  Retroduodenal  Choledochus  {Vautrin' s  Operation). — Make 
traction  on  the  second  or  descending  portion  of  the  duodenum.     This  makes 


CHOLEDOCHOrOMY  577 

prominent  the  junction  of  the  intestine  and  the  gastro-hepatic  omentum. 
Beginning  at  this  prominent  point,  incise  the  peritoneum  parallel  to  the  con- 
vexity of  the  duodenal  angle,  and  prolong  the  incision  along  the  external 
border  of  the  second  segment  of  the  duodenum,  so  as  to  free  it  from  its  ex- 
ternal serous  attachments.  This  soon  exposes  that  portion  of  the  duct  which 
lies  in  a  groove  on  the  anterior  surface  of  the  pancreas.  Lower  down  the 
duct  is  embedded  in  the  pancreas  and  the  exposure  is  more  difficult,  as  various 
lobules  of  the  gland  lying  between  the  duct  and  the  intestine  are  closely  adherent 
to  the  muscular  coats  of  the  latter.  Blunt  dissection  alone  no  longer  avails; 
the  scissors  must  be  employed  and  portions  of  pancreatic  tissues  must  be  sac- 
rificed rather  than  intestinal  wall.  One  and  one-fourth  inches  of  the  duct 
may  be  exposed  as  above.  A  further  exposure  may  be  made,  but  to  do  this 
the  thermocautery  ought  to  be  employed  because  of  the  numerous  veins  present. 
By  the  above  measures  the  duct  can  be  exposed  to  a  point  about  ^^  inch  from 
the  ampulla  of  Vater. 

Without  previous  knowledge  of  Vautrin's  researches  Cooper,  of  San  Fran- 
cisco, came  to  almost  identical  conclusions  from  his  studies  on  the  cadaver 
("Annals  of  Surgery,"  vol.  ii,  1903).     Abbe  also  describes  a  similar  method. 

Jurasz  (Arch.  f.  klin.  Chir.,  civ,  11 18)  reviews  the  104  operations  in  Payr's 
clinic  in  which  Vautrin's  method  was  used.  The  mortality  was  8.5  per  cent. 
In  18  there  was  dilatation  of  the  choledochus  from  chronic  pancreatitis  with- 
out stone  and  in  one  cancer  of  the  pancreas.  In  26  cases  of  stone  in  the  ampulla 
of  Vater  or  in  the  retro-duodenal  choledochus  it  was  possible  to  coax  the  stone 
into  the  upper  parts  of  the  common  duct  except  in  one  instance  when  duo- 
denotomy  was  done.  In  30  cases  having  a  history  of  previous  icterus  the 
permeability  of  the  duct  was  verified  and  in  23  this  exploration  was  made  in 
the  presence  of  jaundice. 

When  the  finger,  passed  through  the  foramen  of  Winslow,  palpates  stones  in 
the  upper  portion  of  the  common  duct  and  the  stones  cannot  easily  be  coaxed 
back  into  the  gall-bladder  for  removal — -how  should  they  be  treated?  In  the 
earlier  days  of  the  surgery  of  this  region  several  plans  were  devised,  and  under 
exceptional  circumstances  might,  even  to-day,  be  practised. 

1.  The  stones  can  be  crushed  in  situ  between  the  blades  of  forceps  pro- 
tected by  rubber  tubing.  This  treatment  is,  of  course,  liable  to  injure  the 
duct-walls,  and  in  spite  of  careful  cleansing  of  the  duct  through  the  gall- 
bladder is  certain  to  leave  detritus  which  may  or  may  not  be  passed  per  vias 
naturales. 

2.  Needles  may  be  passed  through  the  duct- walls  and  into  the  stones  so 
as  to  facilitate  their  fragmentation.  The  same  objections  apply  here  as  to 
the  cholelithotrity  by  forceps. 

3.  The  stones  may  be  left  in  situ,  and,  the  cystic  duct  and  gall-bladder 
being  free,  the  operation  of  cholecystenterostomy  may  be  performed.  This 
overcomes  the  dangers  of  biliary  obstruction,  but  does  not  obviate  the  dangers 
inherent  to  the  presence  of  retained  duct  stones,  viz.,  irritation  leading  to 
inflammation  and  malignant  disease. 

The    operation    of    choice   is    choledochotomy,  or  incision  into  the  duct 

directly  over    the   stone.     The   portion    of   the    duct   affected,    exposed    as 
37 


578  OPERATIONS    ON    THE   BILIARY    PASSAGES 

described,  is  grasped  or  steadied  by  tiie  fingers,  and  an  incision  is  made  along 
it,  over  the  stone,  of  size  sufficient  to  permit  of  the  easy  extraction  of  the  cal- 
culus. If  it  is  desired  to  close  the  duct  wound  with  sutures,  such  should  be 
introduced  but  not  tightened  before  the  stone  is  removed.  The  stitches, 
if  of  silk,  include  the  serous  and  muscular  coats  of  the  duct,  but  not  the  mucous. 
Comparatively  few  surgeons  use  sutures,  preferring  to  rely  on  drainage  until 
such  time  as  closure  of  the  duct  takes  place  naturally.  Having  opened  the  duct 
and  removed  the  calculi  present  at  the  site  of  incision,  pass  a  probe  down- 
wards to  the  duodenum  to  insure  the  patency  of  the  duct  below,  and  upwards 
into  the  hepatic  duct  to  explore  for  any  calculi  there  present.  This  is  the 
advice  usually  given,  but  it  is,  in  fact,  impossible  by  means  of  the  probe  posi- 
tively to  exclude  the  presence  of  stones;  only  by  palpation  with  the  finger 
inside  the  duct  can  positive  knowledge  be  attained.  Kehr  strongly  recom- 
mends that  a  rubber  drain  be  passed  up  into  the  hepatic  duct  so  as  to  provide 
exact  drainage.  Most  surgeons  pass  a  rubber  drain  down  to  the  duct,  fix 
it  there  with  a  stitch  of  plan  catgut,  surround  it  with  a  pack  of  gauze  covered 
by  rubber  tissue,  and  close  the  external  wound  except  where  the  drain  and 
pack  emerge. 

Even  if  the  wound  in  the  duct  be  sutured,  drainage  is  essential.  When 
the  gall-bladder  has  been  opened,  it  may  be  treated  in  various  ways:  (a)  It 
may  be  excised — cholecystectomy,  (b)  The  opening  in  it  may  be  sutured 
to  the  parietes — cholecystostomy.  (c)  It  may  be  drained  in  the  same  fashion 
as  the  common  duct  is  drained. 

The  Mayo  brothers  have  systematized  the  operation  of  choledochotomy 
in  the  following  manner: 

Step  I. — Open  the  belly  by  the  Robson  incision.  Separate  adhesions  and 
explore  the  gall-bladder  and  ducts.  If  the  gall-bladder  is  distended  remove 
part  or  all  of  its  fluid  contents  by  the  trocar  and  cannula  or  by  incision.  The 
gall-bladder  in  case  of  common-duct  stone  is  commonly  much  shrunken. 

Step  2. — Pull  part  of  the  liver  out  of  the  wound  and  towards  the  right. 
This  exposes  the  ducts  and  brings  them  within  reach.  Protect  the  belly 
cavity  with  gauze  packs.  With  the  fingers  palpate  the  stone  in  the  duct, 
and  steady  it  so  that  it  can  act  to  the  duct  the  part  of  a  ball  thurst  into  a  stock- 
ing that  is  being  darned.  (Elliot.)  Introduce,  longittidUmlly ,  two  fine  plain 
gut  sutures  into  the  duct  (Fig.  705).  These  penetrate  the  whole  thickness 
of  the  duct-wall,  if  such  is  necessary  to  get  a  firm  hold.  Using  the  sutures 
as  tractors,  make  an  incision  into  the  duct  over  the  stone.  Extract  the  stone. 
Explore  the  duct  with  the  finger  in  it.  The  finger  passed  up  the  duct  and 
pulled  out  again  (slightly  crooked  when  being  pulled  out)  acts  as  the  piston 
of  a  pump  and  sucks  down  any  small  stones  which  may  be  in  the  upper  part 
of  the  common  or  in  the  hepatic  ducts.  In  the  large  majority  of  cases  the 
finger  can  and  must  be  passed  up  to  the  division  of  the  hepatic  duct  and  down 
to  the  papilla;  this  can  be  much  simplified  by  exerting  counterpressure  on 
the  duodenum  and  pancreas.  Ducts  not  large  enough  to  admit  the  finger 
are  usually  thin-walled,  not  much  adherent,  and  hence  palpable  from  the 
outside.  It  is  only  in  difficult  cases,  i.e.,  where  many  adhesions  are  present 
and  the  duct-walls  are  thickened,  that  finger  exploration  inside  the  duct  be- 


cholp:i)ochotomy 


579 


comes  absolutely  necessary.  In  all  cases  when  it  is  possible,  this  method 
of  exploration  should  be  used.  Diverticula  hide  stones  from  the  probe  or 
scoop,  as  the  nature  of  the  calculi  lets  them  give  no  feeling  of  "grit"  when 
touched  by  metal;  only  the  finger  can  recognize  them. 

Step  3. — Treatment  of  the  wound  in  the  duct. 

(A)  If  it  is  possible  to  do  a  cholecystostomy,  and  the  cystic  duct  is  sufliciently 
patent  to  permit  of  biliary  drainage,  the  wound  in  the  duct  may  be  treated 
as  follows:  Cross  the  one  end  of  suture  x  with  that  of  suture  y  (Fig.  706), 
and  the  end  of  suture  x^  with  that  of  suture  y^  but  do  not  tie  them.     Place 


Fig.  705. — Choledochotomy.     {Mayo.)     From  sketches  by  the  author. 


the  strip  of  gauze  G  (Fig.  707)  longitudinally  over  the  wound  in  the  duct  and 
over  the  crossed  sutures.  Tie  the  sutures  around  the  gauze  strip,  the  free 
side  of  which  is  covered  by  a  layer  of  rubber  tissue.  This  closes  the  wound 
and  fixes  the  gauze  over  it,  so  that  should  bile  escape  it  cannot  wash  away 
the  gauze  and,  an  eflScient  drain  is  provided.  Bring  the  end  of  the  gauze  out 
through  the  abdominal  wound.  A  folded  strip  of  rubber  dam  or  gutta-percha 
tissue  is  preferable  to  the  gauze.  Establish  a  cholecystostomy.  Close  the 
excess  of  abdominal  wound. 

^)  If  owing  to  the  small  size  or  the  diseased  condition  of  the  gall-bladder 
a  cholecystostomy  is  impossible  or  improper,  proceed  as  follows:  Prepare 
a  3^-inch  tubular  drain  wrapped  with  gauze  to  within  a  distance  of  3^-inch 
of  its  end.  Introduce  the  bared  end  of  the  tube  into  the  common  duct;  the 
covering  of  gauze  prevents  its  going  in  too  far.     Thread  one  end  of  the  suture 


58o 


OPERATIONS    ON    THE   BILIARY    PASSAGES 


x-x^  on  a  needle,  pass  it  through  the  tube  and  tie  it  to  the  other  end  of  the 
same  suture.  Do  the  same  with  suture  y-y^  Bring  the  end  of  the  drain  out  of 
the  wound  and  close  the  excess  of  abdominal  wound  (Fig.  708).  The  end  of  the 
tube  introduced  into  the  duct  should  be  beveled  or  cut  in  the  "fishtail"  fashion. 
A  small  gauze  pack  around  the  above  and  tied  to  the  suture  y-y'  or  x-x^  is  an 


Fig.  706.  Fig.  707. 

Figs.  706  and  707. — Treatment  of  incision  in  common  duct. 


Fig.  708.— Drainage  of  common  duct.  Fig.  709.— Hepaticus  drainage. 


added  safety.  McArthur  introduces  a  rubber  tube  into  the  duct  but  directs  it 
towards  the  duodenum  instead  of  towards  the  liver.  The  caliber  of  the  tube  ijiust 
be  less  than  that  of  the  duct.  The  object  of  this  radical  change  in  method  is  that 
solutions  of  any  appropriate  kind  in  any  desired  quality  can  be  introduced 
practically  directly  into  the  duodenum.  In  cholemic  nephritis  with  anuria 
the  introduction  of  i,  2  or  even  3  liters  of  hypotonic  salt  solution  has  saved  a 


HEPATICUS    DRAINAGE 


581 


number  of  otherwise  hopeless  patients.  In  acute  septic  nephritis  Matas  has 
performed  cholecystostomy  on  the  normal  gall-bladder  and  saved  his  patient 
by  instilling  much  warm  Vichy  Celestin. 

(C)  Hepaticus  drainage.  Through  the  wound  in  the  common  duct  in- 
troduce a  drainage  tube  upwards  to  beyond  the  opening  of  the  cystic  duct. 
The  best  tube  to  use  is  a  soft-rubber  catheter  (No.  25  to  30  F.),  with  its  end 
cut  off  and  a  lateral  opening  made  about  ^  inch  from  its  extremity.  Fix 
the  tube  to  the  wound  by  a  catgut  stitch  (Fig.  709).  Close  the  excess  of  the 
wound  in  the  duct  and  the  hepato-colic  omentum  by  a  continuous  catgut 
stitch.  Drain  the  gall-bladder  with  a  dressed  rubber  draim  Between  the 
neck  of  the  gall-bladder  and  the  wound  in  the  common  duct,  place  a  strip 
of  iodoform  gauze.  With  fine  catgut  stitch  the  end  of  a  large  spUt  rubber 
tube  to  the  common  duct  immediately  below  the  exit  of  the  drain.     (The 


Fig.  710. — Cholecystostomy  and  hepaticus  drainage. 

same  suture  used  for  closing  the  duct  wound  is  suitable  for  fixing  the  large 
split  tube.)  Make  the  split  tube  embrace  or  almost  embrace  the  common  duct 
drain,  the  gall-bladder  drain  the  strip  of  gauze  and  any  other  drain  which 
may  be  required  (Fig.  710).  Tie  a  thread  of  catgut  round  the  spht  tube  so 
as  to  hold  all  these  drains  together,  and  let  them  all  protrude,  as  one,  through 
the  abdominal  wound. 

Another  method  of  reaching  the  calculus,  viz.,  by  splitting  the  gall-bladder 
and  both  the  cystic  and  common  ducts,  is  described  under  cysticotomy. 

When  the  obstructing  calculus  exists  very  low  down  in  the  common  duct, 
one  may  reach  it  by  the  transduodenal  route.  McBurney  ("Annals  of  Sur- 
gery," Oct.,  1893)  was  the  first  to  perform  this  operation  of  duodeno-choledo- 
chotoniy.  Kocher  is  a  supporter  of  the  method.  Mayo  Robson  thus  describes 
the  procedure: 

"The  termination  of  the  common  duct,  including  the  duodenum,  should 
be  grasped  between  the  finger  and  the  thumb  of  the  left  hand  and  the  anterior 


582  OPERATIONS    ON    THK   BILIARY    PASSAGES 

wall  of  the  gut  cut  through,  thus  exposing  the  interior  of  the  posterior  wall 
of  the  intestine  with  the  termination  of  the  common  duct  running  in  it.  Either 
the  duct  can  be  laid  open  from  the  papilla,  or  the  stone  may  be  cut  down  on, 
through  the  posterior  wall  of  the  duodenum.  Bile  flows  freely  as  soon  as 
the  obstruction  is  removed,  and  it  must  be  mopped  away  as  it  flows,  since 
it  always  contains  pyogenic  microbes  and  is  therefore  infective.  As  a  rule, 
there  will  be  no  trouble  with  bleeding  and  no  sutures  need  be  placed  in  the 
posterior  wall  of  the  duodenum.  The  incision  through  which  the  duodenum 
has  been  opened  should  be  sutured  by  a  continuous  catgut  suture  for  the 
mucous  membrane  and  a  continuous  silk  suture  for  the  peritoneum.  No 
drainage  is  required.  For  calculi  situated  in  the  lower  third  of  the  common 
duct,  especially  if  impacted  in  the  diverticulum  of  Vater,  the  operation  is 
decidedly  preferable  to  the  ordinary  choledochotomy,  as  not  only  is  it  easier, 
but  an  incision  of  the  narrow  orifice  of  the  bile-duct  in  the  duodenum  leaves 
a  patent  opening,  which  will  allow  any  other  concretions  that  may  have  es- 
caped observation  to  pass  without  difficulty."  ("Dis.  Gall-bladder  and  Bile- 
ducts,"  1901,  p.  269.) 

Sencert  ("Revue  de  Gynecologie  et  de  Chir.  Abdom.,"  x,  47)  gives  the 
following  anatomical  rules  for  finding  the  ampulla  of  Vater  by  the  duodenal 
route,  (c)  Observe  whether  the  ascending  colon  is  fixed  or  is  provided  with 
a  mesocolon,  (b)  If  the  ascending  colon  is  fixed  (80  per  cent.),  incise  the 
duodenum  transversely  immediately  above  that  portion  or  angle  of  the  colon 
which  lies  on  its  anterior  surface,  (c)  If  the  ascending  colon  has  a  meson 
(20  per  cent.),  find  the  root  of  the  transverse  mesocolon  and  incise  the  duo- 
denum immediately  above  this.     This  leads  directly  to  the  ampulla  of  Vater. 

J.  C.  Hancock  ("Annals  of  Surg.,"  Jan.,  1906)  has  collected  62  cases  in 
which  the  common  duct  has  been  reached  through  the  duodenum.  The 
death  rate  was  12.6  per  cent.  In  57  of  the  cases  operation  was  for  the  removal 
of  gall-stones,  in  2  for  the  relief  of  neoplastic  obstruction  of  the  papilla  and 
in  2  for  the  removal  of  pancreatic  calculi. 

Kehr  and  Mayo  have  supplemented  the  operation  by  opening  the  common 
duct  high  up  and  pulling  strips  of  gauze  through  the  duct  from  one  opening 
to  the  other,  thus  insuring  the  removal  of  all  fragments  of  stone. 

Hepato-cholangio-enterostomy.— This  operation  consists  in  efifecting  an 
anastomosis  between  the  gut  and  the  smaller  hepatic  ducts.  It  is  indicated 
in  those  cases  in  which  there  is  present  permanent  obstruction  of  the  common 
and  main  hepatic  ducts  or  of  the  common  and  cystic  ducts.  Under  the  above 
circumstances  a  cholecystenterostomy  would  be  useless,  and  a  cholangiostomy 
{i.e.,  a  union  01  the  opened  small  bile-ducts  to  the  skin)  as  practised  by  Kocher 
and  Langenbuch  is  objectionable,  as  it  establishes  a  permanent  biliary  fistula. 
Hepato-cholangio-enterostomy  was  suggested  by  Baudouin,  and  Langenbuch, 
but  first  practised  by  Hans  Kehr.     ("Centralblatt  f.  Chir.,"  1904,  No.  7.) 

The  Operation. — Step  i. — Exposure  of  gall-bladder  region,  preferably  by 
Mayo  Robson's  incision.     If  necessary,  excise  the  gall-bladder. 

Step  2. — From  a  convenient  part  of  the  lower  margin  of  the  liver  excise  a 
strip  of  liver  tissue  about  two  and  one-half  inches  long  by  about  one  inch  wide. 
With  the  thermocautery  stop  the  hemorrhage  and  at  the  same  time  burn  a  hole 
in  the  liver  of  such  a  depth  that  several  moderate-sized  bile-ducts  are  opened. 


RECONSTRUCTION    BILK    DUCTS  583 

Step  3.- — Choose  a  segment  of  gut,  preferably  duodenum,  which  can  l)e 
brought  up  to  the  hepatic  wound  without  tension.  In  this  gut  make  an  opening 
2^4  inches  long,  and  suture  it  to  the  margins  of  the  liver  wound.  In  Kehr's 
case  only  a  few  sutures  cut  loose  while  l)cing  tied,  and  he  was  able  to  close  the 
belly  without  packing  the  wound.  In  most  cases  one  imagines  that  packing 
with  iodoform  gauze,  or  at  least  the  use  of  one  or  more  cigarette  drains,  would 
be  of  much  value.  In  the  case  operated  upon  recovery  ensued  and  the  liver 
tissue  seemed  to  tolerate  the  necessary  direct  contact  with  intestinal  contents. 

Sullivan  ("Trans.  Surg.,"  Sect.  A.M. A.,  191 2)  has  excised  the  common  duct 
in  dogs  and  restored  the  continuity  of  passage  in  the  following  manner:  Push  a 
soft-rubber  tube  not  less  than  ^  inch  in  inside  diameter  into  the  hepatic  duct 
and  fix  it  there  by  two  or  three  non-absorbable  sutures.  Push  the  other  end  of 
the  tube  through  the  stump  of  the  common  duct  into  the  duodenum  for  not 
more  than  i  inch.  If  the  stump  of  the  duct  is  not  available,  close  its  remnant 
with  suture  or  ligature;  puncture  the  duodenum,  introduce  the  tube  through  the 
puncture  and  fix  it  there  with  sutures,  inverting  the  edges  of  the  duodenal 
wound  round  the  tube.  Lay  the  exposed  portion  of  the  tube  along  the  surface 
of  the  duodenum  and  by  means  of  sutures  bury  it  in  the  duodenal  wall  exactly 
as  is  done  in  Witzel's  gastrostomy  or  in  cgecostomy.  Unite  that  portion  of 
the  tube  between  the  hepatic  duct  and  the  duodenum  to  the  edge  of  the  gastro- 
hepatic  omentum.  Pull  up  the  great  omentum  and  completely  cover  the  rubber 
tube  with  it.     Fix  the  omentum  in  place  with  sutures. 

Remark. — Is  it  not  very  probable  that  infolding  of  the  duodenal  wall  might 
cause  such  diminution  of  the  lumen  that  a  gastro-enterostomy  might  be 
necessary? 

Wilms  ("Berliner  klin.  Woch,"  1912,  No.  12)  reports  five  cases  in  which  he 
substituted  a  rubber  tube  for  the  common  duct  with  good  results.  His  method 
is  similar  to  that  of  Sullivan. 

W.  J.  Mayo  finds  that  jaundice  recurs  in  the  course  of  a  year  or  two  after 
an  apparently  successful  operation  of  this  kind,  due  presumably  to  stenosis 
of  the  rather  unnatural  new  passageway." 

When  the  common  duct  has  become  closed  and  a  cholecystenterostomy 
is  not  available  the  common  or  the  hepatic  duct  may  be  anastomosed  to  the 
duodenum.  If  the  duct  is  much  dilated  it  may  be  united  to  the  gut  by  lateral 
anastomosis.  If  this  is  impossible J:he  duct  may  be  divided  transversely;  the 
duodenum,  mobihzed  after  the  manner  of  Vautrin,  Cooper,  Finney  or  Kocher, 
is  easily  lifted  up  to  lie  without  tension  near  the  open  duct  and  united  by  a  few 
catgut  stitches  to  the  tissues  beside  the  duct.  It  is  now  possible  to  make  an 
end-to-side  anastomosis  between  the  duct  and  the  duodenum  (W.  J.  Mayo, 
Annals  of  Surg.,  July,  1905). 

L.  L.  Mc Arthur  in  1908  performed  an  operation  which  has  been  subsequently 
and  independently  devised  by  Wilms  and  others.  Expose  and  divide  the 
duct  at  the  site  of  stricture;  ligate  its  duodenal  end.  Insert  into  the  open 
hepatic  end  of  the  duct  a  small  rubber  drainage  tube  the  end  of  which  has 
been  twice  turned  back  on  itself,  making  a  double  revere.  Pass  3  or  4  inches 
of  the  other  end  of  the  tube  into  the  duodenum  through  a  small  opening  around 
which  a  purse-string  suture  has  been  inserted.  Tie  the  suture  snugly  around 
the  tube.     Suture     the  stump  of  the  duct  covering  the  rubber  drain,  to  the 


584  OPERATIONS    ON    THE    BILIARY    PASSAGES 

duodenum.     The    result    is    an    end-to-side    anastomosis.     The    ruhhcr    tube 
when  it  has  served  its  purpose  escapes  per  rectum  in  a  few  weeks. 

A.  J.  Walton  (Surg.,  Gyn.,  Obst.,  Sept.,  1915)  where  direct  anastomosis 
was  impossible,  performed  a  plastic  operation  successfully  as  follows:  Insert 
a  rubber  tube  into  the  duct  and  fix  it  there  with  a  catgut  suture  (if  the  tube  has 
been  soaked  for  a  few  days  in  liquid  paraffin,  as  advised  by  McArthur,  it  will 
not  permit  coagulation  of  the  bile  in  it).  From  the  anterior  surface  of  the 
duodenum  reflect  a  flap  downwards,  long  enough  to  reach  to  the  duct  and  wide 
enough  to  surround  it  without  tension.  Close  the  wound  in  the  duodenum 
leaving  enough  of  it  open,  beside  the  pedicle  of  the  flap  to  admit  the  end  of  the 
tube.  Insert  the  end  of  the  tube  into  the  duodenum.  Pull  the  duodenum  as 
near  to  the  duct  as  possible  and  anchor  it  with  sutures  to  any  convenient 
tissues.  Suture  the  flap  around  the  tube  and  to  the  duct.  This  operation 
is  very  similar  to  one  of  v.  Stubenrauch's  but  the  flap  has  its  pedicle  below  and 
the  end  of  the  tube  is  not  brought  out  through  a  second  puncture  in  the  gut. 

V.  Stuhcnrauclis  Methods. — Very  rare  cases  occasionally  arise  in  which 
owing  to  a  small  size  of  gall-bladder,  adhesions  in  the  operative  territory,  im- 
mobility of  the  omentum  {e.g.,  because  of  herniae,  etc.)  it  is  impossible  to  per- 
form any  of  the  ordinary  direct  anastomoses 
between  the  gall-bladder  or  ducts  and  the  ali- 
mentary canal,  and  yet  it  is  absolutely  neces- 
sary to  short  circuit  an  obstructed  duct. 

V.  Stubenrauch  ("Archiv  fiir  klin.  Chir.," 
Ixxix,  1015)  endeavored  to  solve  the  above 
puzzle  in  a  case  of  chronic  pancreatitis  with 
complications  in  the  following  fashion:  At  a 
previous  operation  the  shrunken  gall-bladder 
and  the  common  duct  were  both  drained,  leav- 
ing a  fistula  leading  from  the  skin  to  the  duct. 

^'''"  ^"."^^/.'i^'"'^"'^'"'  Method  /.—Make  an  incision  through  the 

operation.  ° 

skin  around  the  fistulous  orifice.  Separate  the 
fistulous  tract  from  its  surroundings,  leaving  it  connected  with  the  common 
duct  like  a  vermiform  appendix.  Make  an  incision  into  a  convenient  portion 
of  the  stomach  or  duodenum  and  implant  the  distal  end  of  the  fistulous  tract 
into  this.  In  v.  Stubenrauch's  case  the,  implantation  into  the  duodenum 
caused  narrowing  of  the  pylorus,  so  gastro-enterostomy  was  done.  Result 
was  failure  due  to  necrosis  of  fistulous  tract. 

Method  II. — Expose  the  openings  in  gall-bladder  and  common  duct.  Pack 
the  common  duct  with  gauze  and  see  if  the  bile  will  flow  into  the  gall-blad- 
der; if  it  will,  use  the  gall-bladder  for  the  anastomosis;  if  it  will  not,  then  use  the 
duct  for  this  purpose.  Expose  the  duodenum  and  pyloric  portion  of  the  stomach. 
From  the  duodenum  and  stomach  reflect  a  flap  with  pedicle  above,  about  i 
inch  wide  and  long  enough  to  reach  without  tension  to  the  opening  in  the  gall- 
bladder or  duct.  This  flap  consists  of  all  the  coats  of  the  viscus  (peritoneal, 
muscular  and  mucous)  (Fig.  711).  Turn  the  flap  upwards.  Occlude  the 
opening  in  the  common  duct  by  laying  the  serous  surface  of  the  flap  over  it. 
Unite    the  distal  end  of  the  flap  to  the  opening  in  the  gall-bladder  with  a  few 


RECONSTRUCTION    HILE    DUCTS 


58: 


catgut  sutures.  Close  the  wound  in  the  stomach  and  duodenum,  leaving  room 
for  a  drainage-tube  at  the  base  of  the  flap.  Introduce  a  drain  between  the  gut 
and  the  gall-bladder.     Partially  close  the  external  wound.     Pack  and  drain. 

Result. — Complete  immediate  success.  About  six  months  afterwards 
there  was  slight  and  temporary  evidence  of  local  trouble. 

V.  Stubenrauch  suggests  an  improvement  of  Method  II  and  also  an  alternate 
procedure. 

Method  III. — Make  the  gastro-duodenal  flap  as  above,  but  unite  its  lateral 
edges  over  a  drainge-tube  (Fig.  712)  so  as  to  form  a  tube  lined  with  mucous 
membrane.  Unite  the  free  end  of  the  flap  to  the  opening  in  the  gall-bladder 
(or  in  the  common  duct  as  the  case  may  demand)  (Fig.  713).  Make  a  small 
opening  into  the  duodenum  a  short  distance  distal  to  the  flap  and  through 
this  make  the  end  of  the  drainage-tube  emerge.  Unite,  with  sutures,  two 
folds  of  duodenal  wall  over  the  drainage-tube  for  a  short  distance  exactly 


Fig.  712.  Fig.  713. 

Figs.  712  and  713. — Stubenrauch's  operation. 


as  in  Witzel's  operation  for  gastrostomy  (Fig.  713).  Bring  the  end  of  the  drain- 
age-tube out  through  the  abdominal  wound.  Close  the  wound  in  the  stomach 
and  duodenum.  Pack  and  drain  the  operative  area.  Close  the  excess  of  ab- 
dominal wound.  By  this  method  drainage  by  a  rubber  tube  is  provided  from 
the  gall-bladder  (or  common  duct)  through  the  new-formed  bile-duct,  through 
the  duodenum,  through  the  duodenal  wall  by  an  oblique  canal  out  to  the  skin. 
When  repair  is  complete  the  tube  is  easily  drawn  out  and  the  oblique  duodenal 
fistula  quickly  closes.  If  any  stenosis  is  threatened  by  the  operation  a  gastro- 
enterostomy must  be  done.* 

Method  IV. — A  biliary  fistula  is  present.  It  is  believed  that  any  ordinary 
method  of  cholecystenterostomy  is  impossible.  It  is  desired  to  make  the 
cutaneous  opening  of  the  fistula  empty  itself  into  the  intestine. 

Open  the  abdomen  immediately  to  the  right  of  the  middle  line.  Choose 
a  freely  mobile  loop  of  small  intestine  (one  which  may  be  made  to  reach  the 
region  of  the  fistula).  Divide  the  upper  end  of  this  loop  and  anastomose  the 
open  end  of  the  proximal  gut  to  the  side  of  the  lower  portion  of  gut  at  a  point 

*  It  will  probably  be  wise  to  perform  a  gastro-enterostomy  in  any  of  these  complicated 
plastic  operations  because  there  is  certain  to  be  some  stenosis  and  if  any  of  the  sutures  cut 
loose  there  will  be  a  iistula  which,  even  if  onlj'  temporary,  will  permit  of  the  escape  of  the 
gastric  contents  and  lead  to  starvation. 


586 


OPERATIONS    ON    THE    BILIARY    PASSAGES 


about  4}^  inches  below  the  line  of  section  (Fig.  714.)  Make  an  incision  through 
the  skin  alone,  immediately  below  the  biliary  fistula.  Introduce  a  forceps 
into  this  wound  and  burrow  a  canal  between  the  skin  and  aponeurosis  down 
to  the  laparotomy  wound.  With  the  forceps  pull  the  end  of  the  lower  segment 
of  gut  (temporarily  closed  by  a  ligature)  through  the  subcutaneous  tunnel 
and  unite  it  to  the  cutaneous  opening  of  the  biliary  fistula.  (It  may  be  nec- 
essary to  mobilize  the  end  of  the  fistula  slightly).  Close  the  laparotomy 
wound,  being  careful  not  to  constrict  the  portion  of  gut  where  it  passes  through 


Fig.  714. 

i4.  Anastomosis  between  end  upper  segment  gut  and  side  lower  segment.  F.  Biliary  fistula  and  in- 
cision through  which  forceps  is  passed  subcutaneously  to  grasp  and  pull  up  to  F  the  segregated  portion  of 
lower  segment  of  gut  L. 


the  deep  structures  of  the  belly-wall.  It  might  be  wise  to  supplement  the  longi- 
tudinal laparotomy  wound  by  a  small  transverse  incision  through  the  rectus 
and  aponeurosis  at  the  point  where  the  segment  of  gut  passes  through  these 
structures. 

The  author  used  this  method  in  one  case  (reported  by  Sutton,  "Annals  of 
Surg.,"  Sept.,  1910).  The  segment  of  intestine  passing  under  the  skin  to  the 
fistula  retained  its  vitality  but  acted  as  a  faecal  fistula. 

These  methods  of  v.  Stubenrauch  have  been  suggested  for  certain  rare  and 
very  difficult  cases.  Only  one  of  the  methods  has  been  used  with  success. 
They  are  described  here  as  they  are  worthy  of  consideration  and  may  be  help- 
ful in  an  emergency. 

INDICATIONS   FOR   AND    CHOICE   OF   OPERATION 

It  is  undoubtedly  true  that  in  at  least  one-half  of  all  cases  of  gall-stone 
disease  in  which  diagnosis  has  been  made,  an  apparent  cure  may  result  from 
medicinal  treatment.     Scientifically  such  a  "  cure  "  is  generally  merely  apparent. 


IXDICATIONS  587 

as  the  calculi  remain  in  situ,  but  are  at  rest  and  give  rise  to  no  evident  trouble. 
The  patient  considers  himself  well,  but  he  is  always  exposed  to  relapse,  and 
the  continued  presence  of  the  stones  is  to-day  believed  to  be  conducive  to  malig- 
nant disease.  Some  surgeons  believe  that  every  case  of  gall-stone  disease 
ought  to  be  submitted  to  early  operation.  Winiwarter  was  the  first  to  pro- 
mulgate this  dictum  and  Riedel  takes  much  the  same  ground.  W.  J.  Mayo 
says  that  the  successful  passage  of  the  calculus  per  vias  natiirales  is  not  a  con- 
traindication but  a  positive  indication  for  operation,  as  there  are  always  more 
calculi  to  follow,  and  the  next  ones  may  become  impacted  in  the  common  duct, 
thus  necessitating  a  grave  instead  of  a  safe  operation.  Few  modern  surgeons 
advise  much  loss  of  time  before  operation  is  decided  on.  In  the  writer's  ex- 
perience there  have  been  a  number  of  cases  where  the  symptoms  were  ap- 
parently trifling,  and  yet  exploration  showed  advanced  disease.  There  is  great 
dijficulty  and  danger  in  operating  upon  many  of  the  old  cases;  adhesions  and 
contractions  alter  the  anatomy  most  confusingly,  and  all  conceivable  difficulties 
arise.  Early  operation,  before  the  common  duct  is  involved,  is  easy,  and  on 
the  whole  very  safe. 

Whether  cholecystostomy  or  cholecystectomy  should  be  ihe  operation  of 
choice  is  not  entirely  easy  to  answer.  If  the  operation  has  been  rendered 
difl&cult  owing  to  adhesions  from  old  inflammation,  etc.,  and  if  the  surgeon  has 
not  had  much  experience,  then  undoubtedly  cholecystostomy  is  the  preferable 
method.  The  same  is  true  in  cases  of  phlegmonous  cholecystitis  or  gangrene 
when  the  patient  is  too  ill  to  bear  cholecystectomy. 

In  discussing  the  treatment  of  interstitial  pancreatitis,  Robson  ("Surg., 
Gyn.,  Obstetrics,"  Jan.,  1908)  writes:  "This  brings  into  prominence  the  un- 
desirability  of  removing  the  gall-bladder  as  a  routine  procedure  in  operating 
for  gall-stones,  for  unless  it  is  seriously  damaged  or  ulcerated,  or  is  the  seat  of 
malignant  disease,  or  unless  there  is  ulceration  or  stricture  of  the  cystic  duct, 
removal  is  quite  unnecessary.  I  think  it  better  practice  to  drain  it  simply 
and  not  to  perform  cholecystectomy,  since  on  some  future  occasion,  should 
trouble  develop  in  the  deeper  ducts  or  in  the  pancreas,  and  the  gall-bladder  be 
absent,  it  will  be  impossible,  with  few  exceptions,  to  short-circuit  the  obstruc- 
tion. Moreover,  after  cholecystotomy  gall-stones  have  no  greater  tendency  to 
reform  than  they  have  after  cholecystectomy,  and  should  cholelithiasis  again 
develop,  it  will  be  in  the  common  duct,  a  much  more  serious  position  than  if 
in  the  gall-bladder." 

Cholecystectomy  "is  contraindicated  in  all  cases  of  non-patency  of  the  com- 
mon duct,  and  it  should  not  be  resorted  to  under  the  idea  that  it  will  prevent 
the  formation  of  gall-stones,  as  calculi  may  form  in  the  bile-duct,  within  the 
liver,  or  below  it." 

Roswell  Park,  S.  J.  Mixter  and  others  have  long  urged  that  all  diseased 
gall-bladders  should  be  treated  on  the  same  principle  that  leads  to  removal 
of  the  vermiform  appendix  when  diseased.  All  surgeons  are  widening  the 
indications  for  cholecystectomy  and  narrowing  those  for  cholecystostomy. 
The  fact  that  carcinoma  is  found  present  in  a  considerable  number  of  thick- 
ened gall-bladders  is  a  great  incentive  to  excision.  Mayo  finds  that  while 
chronic  pancreatitis  becomes  much  improved  after  cholecystostomy  yet  when 


588  OPERATIONS    ON    THE    BILIARY    PASSAGES 

the  fistula  closes  the  symptoms  often  recur  and  can  be  cured  only  by  removing 
the  gall-bladder. 

C.  A.  McWilliams  ("Presbyterian  Hospital  Reports,"  N.  Y.,  1906)  in  a  care- 
ful analysis  of  the  results  and  after-results  of  186  operations  upon  the  liver  and 
gall  passages  finds  the  immediate  danger  of  cholecystectomy  to  be  1.5  per  cent, 
greater  than  that  of  -ostomy,  but  that  the  permanent  results  of  the  -ectomy  are 
very  much  better  than  those  of  the  -ostomy. 

The  question  is  often  asked,  Are  gall-stones  liable  to  form  again  after  they 
have  been  removed  by  any  of  the  above  operations?  The  experience  of  Kehr, 
Robson,  the  Mayos,  Riedel,  and  others,  an  experience  amounting  to  many 
thousands  of  cases,  teaches  that  if  the  calculi  have  been  removed  there  is  no 
recurrence.  In  the  hands  of  less  experienced  operators  apparent  recurrences 
crop  up,  but  these  are  usually  cases  of  stones  overlooked  in  the  original  opera- 
tion. The  younger  practitioners  must  remember  that  operation  is  not  directed 
merely  against  the  gall-stones  themselves,  but  against  the  infective  processes 
which  give  rise  to  them  and  against  the  complications  which  they  occasion. 
The  author  remembers  well  one  case  in  which  a  complete  cure  attended  the 
purely  medicinal  treatment  of  gall-stone  disease,  but  the  patient  succumbed 
to  the  remote  results  of  the  lithiasis,  viz.,  an  extensive  adhesive  peritonitis 
causing  obstruction  of  the  first  portion  of  the  duodenum.  Operated  upon 
early,  this  case  would  have  been  easily  cured;  a  late  and  compulsory  operation 
was  fatal. 

Cholecystostomy  may  be  indicated  as  a  means  of  introducing  into  the 
duodenum  directly,  rapidly  and  repeatedly  larger  or  smaller  quantities  of  various 
liquids  in  the  treatment  of  anuria,  etc.  (McArthur;  Matas). 

The  indications  for  cholecystenterostomy  have  been  sufficiently  described 
in  earlier  paragraphs. 

COLOHEPATOPEXY   OR   COLON   SUBSTITUTION 

E.  W.  Andrews  ("  Journ.  Am.  Med.  Assoc,"  Sept.  16,  1905)  notes  the  severe 
gastric  disturbances  which  follow  wide  adhesion  between  the  liver  and  the 
anterior  surface  of  the  stomach.  If  these  adhesions  are  separated  they  neces- 
sarily reform.  Andrews  endeavors  to  arrange  matters  so  that  where  they  do 
reform  they  will  be  harmless. 

Step  I. — Exposure  through  a  free  right  rectus  incision. 

Step  2. — Note  the  shape,  position  and  mobility  of  the  stomach.  Usually 
numerous  short  bands  or  a  broad  adhesion  will  be  seen  between  the  liver  and 
a  large  part  of  the  pyloric  end  of  the  stomach.  Divide  or  separate  the  ad- 
hesions at  the  expense,  if  necessary,  of  the  liver  rather  than  of  the  stomach.  In- 
spect the  patency  of  the  pylorus  by  passing  the  finger  through  it  in  the  usual 
fashion. 

Step  3. — All  adhesions  having  been  freed  and  the  stomach  being  in  normal 
position,  pull  upwards  the  transverse  colon  and  with  it  some  omentum.  Thrust 
these  into  the  space  between  the  liver  and  pylorus.  Stitch  the  colonic  omentum 
to  the  gastro-hepatic  ligament.  The  more  loose  omentum  can  be  interposed 
the  better  it  is. 

Andrews  has  had  excellent  results  from  this  colonic  interposition  or  suspension. 


ECHINOCOCCIC    CYSTS    OF    THE    ABDOMEN  589 

OPERATION   FOR   ECHINOCOCCIC  CYSTS  OF  THE  ABDOMEN 

Echinococcic  cysts  are  composed  of  a  structureless  true  capsule  or  wall  on 
the  inner  surface  of  which  there  develop  the  young  heads  of  the  parasites. 
The  cavity  of  the  cyst  is  filled  with  thin  fluid  in  which  lie  numerous  subsidiary 
or  daughter  cysts.  The  whole  cyst  is  surrounded  by  a  firm  connective-tissue 
capsule  developed  from  the  liver  itself.  The  cysts  may  be  single  or  multiple, 
usually  the  former. 

Out  of  18  cysts  operated  on  by  Mabit  the  site  of  disease  was:  right  lobe  liver, 
8;  left  lobe,  3;  spleen,  2;  omentum,  3;  mesentery,  2.  The  liver  being  the  organ 
usually  affected,  the  operations  here  described  will  have  special  reference  to  it. 

Several  methods  of  operating  on  echinococcic  cysts  have  been  recommended, 
but  most  of  them  have  been  discarded  in  favor  of  more  radical  measures. 
Aspiration  is  ineffectual  and  dangerous.  Injection  of  antiseptics — e.g.,  bi- 
chloride of  mercury  or  formalin  solution — is  dangerous  and  indefinite.  The 
best  method  of  treatment  is  enucleation. 

According  to  the  site  of  the  disease  access  is  gained  to  it  by  one  of  two  routes: 

(A)  Abdominal  Route  .^ — When  the  disease  can  be  reached  by  this  route, 
and  it  usually  can,  it  is  the  preferable  one.  Open  the  abdomen  by  a  vertical 
or  oblique  incision  over  the  most  prominent  part  of  the  tumor.  Explore  the 
liver,  etc.,  to  make  sure  of  the  diagnosis,  to  ascertain  whether  the  disease  is 
single  or  multiple  and  to  satisfy  one's  self  as  to  anatomical  relations.  With 
gauze  packs  thoroughly  isolate  the  field  of  operation  from  the  peritoneal  cavity. 
Protect  the  edges  of  the  abdominal  wound  with  gauze.  The  firm  false  capsule 
of  the  cyst  will  usually  show  prominently  on  the  surface  of  the  liver.  Seize 
the  false  capsule  with  a  stitch  or  a  volsella.  With  a  trocar  and  cannula  empty 
the  cyst  of  its  fluid  contents,  thus  rendering  its  walls  flaccid.  Pull  the  cyst- 
wall  as  far  as  possible  out  through  the  abdominal  wound  and  incise  it  freely. 
With  fingers,  strips  of  gauze,  and  salt  solution  gently  evacuate  all  daughter 
cysts.  If  possible,  peel  the  true  cyst- wall  from  the  false  fibrous  capsule,  but 
do  not  endeavor  to  excise  the  latter. 

Prepare  a  rubber  tube  by  surrounding  it  with  a  few  layers  of  gauze  and  cover 
the  gauze  with  rubber  tissue.  Introduce  this  "dressed  tube"  into  the  cyst, 
and  with  plain  catgut  suture  the  opening  in  the  cyst  around  and  to  the  tube. 
Cleanse  the  field  of  operation  and  remove  the  gauze  pads  from  the  peritoneal 
cavity.  Suture  the  cyst-wall,  around  the  drainage-tube,  to  the  parietal  peri- 
toneum.    Close  the  excess  of  abdominal  wound. 

If  secondary  cysts  are  present  and  lie  close  to  that  first  opened,  they  may  be 
penetrated  from  it.  Sometimes  several  cysts  may  require  to  be  opened  through 
several  abdominal  incisions.  The  advantage  of  sewing,  with  catgut,  the  open- 
ing in  the  cyst  around  and  to  the  drain  is  that  all  leakage  into  the  belly  is  abso- 
lutely avoided.  The  catgut  remains  effective  until  union  is  so  far  advanced 
that  there  is  no  danger  of  the  peritoneum  becoming  soiled. 

Some  surgeons  perform  the  above  operation  in  two  stages.  At  the  first 
operation  they  expose  the  diseased  portion  of  liver,  pack  the  wound,  and  wait 
ten  days  or  more  for  adhesions  to  form  and  protect  the  peritoneum.  At  the 
second  sitting  they  open  the  cyst  and  treat  it  as  already  described.     There  is 


590 


HERNIA 


practically  no  greater  danger  in  completing  the  operation  at  one  sitting  than  in 
waiting  for  adhesions  to  take  place,  and  if  the  cysts  are  multiple,  the  operation 
in  two  stages  is  entirely  unsuitable. 

The  method  of  treatment  outlined  is  known  as  marsupialization;  its  ob- 
jectionable features  are:  long  convalescence;  the  dangers  of  suppuration,  and 
the  persistence  of  biliary  fistulae.  Marsupialization  is  an  eminently  safe 
operation. 

Bond  suggested  that  the  cyst  cavity  might  be  obliterated  by  means  of  buried 
sutures,  and  the  abdomen  closed  without  danger.  Other  surgeons,  after 
evacuating  all  the  cyst  contents,  advise  filling  the  cavity  with  iodoform  emulsion 
or  with  saline  solution,  and  closing  it  completely  with  suture.  There  is  too 
much  danger  involved  in  this  method  to  render  it  advisable.  The  experience 
of  John  O'Conor,  Mabit,  and  others  shows  that  the  sutured  false  capsule  of  a 
hydatid  cyst  is  very  prone  to  suppuration,  and  that  Bond's  operation,  however 
modified,  is  exceedingly  dangerous.  Mabit  finds  that  if  much  of  the  cyst-wall 
protrudes  beyond  the  parenchyma  of  the  liver,  spleen,  or  whatever  organ  it 
affects,  such  free  cyst-wall  may  be  excised  and  the  remainder  after  being  thor- 
oughly dried,  may  be  left  with  safety  in  the  belly  cavity.  The  operation  of 
Mabit  is  improper  unless  at  least  3^-^  of  the  cyst-wall  is  free,  and  unless  the 
contents  are  sterile  as  regards  pyogenic  organisms. 

(B)  Transpleural  Route. — When  the  disease  is  situated  far  back  on  the 
dorsum  of  the  liver,  presses  into  the  subphrenic  region,  and  cannot  be  con- 
veniently reached  from  in  front,  one  gains  access  to  it  by  the  transpleural  route. 

The  Operation. — Excise  about  three  inches  of  the  eighth  or  ninth  rib  in  the 
anterior  axillary  line.  Suture,  with  catgut,  the  parietal  to  the  diaphragmatic 
pleura.  Of  course,  in  inserting  these  sutures  one  aims  at  uniting  the  two 
pleural  surfaces  alone,  i.e.,  without  other  tissues,  but  one  never  succeeds  in 
so  doing.  The  stitch,  if  effective,  always  includes  in  its  loop  other  tissues  than 
the  pleura.  Incise  the  diaphragm  and  expose  the  liver.  Pack  gauze  all  around 
the  area  of  liver  to  be  opened.     Treat  the  disease  as  already  described. 


CHAPTER   XLV 
HERNIA 


Hemiotomy. — ^Formerly  herniotomy  was  considered  one  of  the  most  beau- 
tiful and  satisfactory  operations  in  surgery;  now,  however,  it  is  rarely  thought  of 
as  a  complete  procedure,  but  merely  as  a  preliminary  to  some  one  of  the  opera- 
tions for  the  radical  cure  of  the  hernia.  Under  the  caption  "herniotomy"  it 
will  be  convenient  to  describe  the  methods  of  combating  some  of  the  complica- 
tions met  in  cases  of  irreducible  and  of  strangulated  hernia?. 

I.  Incision. — (A)  Inguinal  hernia:  (a)  Bassini's  incision  (page  605).  (b) 
Macewen's  incision  (Fig.  715  and  page  591).  (c)  Any  more  or  less  vertical 
incision  over  the  hernial  swelling  and  following  its  long  axis,  (d)  Ferguson's 
incision  (page  608). 

(B)  Femoral  hernia:  {a)  Bassini's  incision  (page  5q6).     {b)  Vertical  incision. 

(C)  Umbilical  and  ventral  hernicB:     Vertical  or  transverse  incision. 


HERNIOTOMY 


591 


2.  The  skin  having  been  divided,  one  picks  up  the  subjacent  tissues  layer 
by  layer  and  divides  them  between  forceps*  (Fig.  716).  By  this  method  the 
hernial  sac  is  soon  reached.  How  may  the  sac  be  recognized?  Bull  says  the 
sac  "may  be  recognized,  first,  by  the  presence  of  the  subperitoneal  fat  im- 
mediately outside  it;  second,  by  its  lead  or  bluish  color;  third,  by  its  gliding  over 
the  contents  of  the  sac  beneath  it. 


Fig.  71 ■ 


—Herniotomy.     (Esmarch 
and  Kowalzig.) 


Fig.  716. 


While  the  sac  in  inguinal  and  femoral  hernias  is  being  freed  from  its  sur- 
roundings, especially  when  its  neck  is  being  isolated  and  dragged  upon,  it  is 
not  rare  to  pull  the  urinary  bladder  into  the  hernial  canal.  The  bladder  may 
be  recognized  by  its  musculature,  and  must  of  course  be  avoided.  Brunner 
("Deutsche  Zeitsch.  fiir  Chir.,"  ci,  p.  562)  has  observed  this  dragging  down 
of  the  bladder  in  44  out  of  775  operations  for  inguinal  and  femoral  herniae. 

Especially  in  a  small  hernia,  the  finding  of  the  sac  is  sometimes  a  matter 
of  difficulty.  Remember  that  the  sac  is  a 
protruding  pouch  of  peritoneum,  hence  to 
find  it,  e.g.,  in  an  inguinal  hernia,  examine 
the  internal  abdominal  ring  and  the  sac 
will  always  be  found  as  a  continuation  of 
the  parietal  peritoneum. 

3.  A  portion  of  the  sac  which  is  non- 
adherent to  its  contents  is  picked  up  by 
forceps  and  cautiously  opened  with  knife 
or  scissors.  The  first  opening  is  made 
exceedingly  small  and  is  cautiously  enlarged 
until  the  finger  can  be  introduced  and  dis- 
cover the  condition  of  the  contents,  after  which  the  sac  is  widely  opened. 

4.  Examination  in  cases  of  irreducible  and  strangulated  herniae  almost  al- 
ways shows  stricture  of  the  neck  by  firm  surrounding  tissues.  Division  of 
stricture:  (A)  The  classical  method  is  to  introduce  the  finger-nail  of  the  left 
fore-finger  into  the  stricture,  the  back  of  the  finger  being  against  the 
hernia,  keeping  it  out  of  the  way   (Fig.    717).     A  hernia  knife   is  laid  flat 

*  The  layers  spoken  of  are  not  layers  described  by  anatomists;  such  are  rarely  recog- 
nized and  never  sought,  but  are  such  thin  sheets  of  tissue  as  happen  to  be  picked  up  by  the 
forceps. 


Fig. 


717 . — Herniotomy. 

and  Kowalzig.) 


{Esmarch 


592 


HERNIA 


on  the  palm  of  the  finger  and  pushed  along  until  its  blunt  nose  has  got 
beyond  the  constricting  band.  The  edge  of  the  knife  is  now  turned  and 
pressed  against  the  stricture  in  such  a  way  as  to  make  a  number  of  small 
nicks  instead  of  any  definite  cut.  No  sawing  motion  should  be  given  to 
the  knife  and  its  edge  should  always  be  blunt.  In  inguinal  hernia  if 
these  precautions  are  adhered  to,  it  makes  little  difference  whether  one 
cuts  upwards  and  outwards,  upwards  and  inwards,  or  only  generally 
upwards,  since  such  a  knife,  so  used,  would  be  extremely  unlikely  to  injure 
any  vessel.  Should  any  vessel  be  divided  and  bleeding  occur,  it  is  easy  to 
enlarge  the  wound  and  ligate  the  bleeding  point.  A  herniotomy  knife,  while 
convenient,  is  not  necessary — its  work  can  be  done  by  a  pair  of  blunt-pointed 
scissors.  (B)  Most  surgeons  now  advocate  the  division  of  the  constricting 
tissues  from  without  inwards,  exactly  as  the  canal  is  opened  during  a  radical 
operation.     This  is  the  easiest,  safest  and  best  method  to  follow. 


Fig.  718. 


-Chain  ligatures  applied  to 
omentum. 


Fig.  719. — Repair  gangrenous  gut. 
{Guibe.) 


5.  Contents  of  the  Sac. — If  the  contents  consist  of  healthy  gut  or  healthy  non- 
adherent or  non-redundant  omentum,  they  are  to  be  reduced  at  once.  If 
adhesions  are  present,  they  must  be  gently  torn  through  or  divided  between 
ligatures.  Sometimes  adhesion  between  gut  and  sac  is  so  firm  that  a  thin 
portion  of  sac  has  to  be  cut  away  and  left  attached  to  the  gut.  If  the  omentum 
is  redundant,  inflamed  or  much  lacerated  from  the  division  of  adhesions  most  of 
it  should  be  removed.  This  is  done  by  placing  a  chain  of  ligatures  across  it 
(Fig.  718)  and  cutting  away  the  peripheral  portion  at  a  distance  of  at  least  one 
inch  from  the  ligatures. 

Remove  as  little  omentum  as  possible;  omentum  is  most  valuable. 

Should  the  gut  be  gangrenous,  it  may  be  dealt  with  in  several  ways: 

(a)  Only  a  small  spot  on  the  free  surface  of  the  gut  is  gangrenous,  the  rest 
of  the  gut  is  healthy.  Invaginate  the  gangrenous  patch  by  a  few  Lembert 
sutures  (Fig.  719).  Examine  to  see  if  the  invagination  produces  too  much 
narrowing  of  the  gut. 

If  the  gangrene  affects  all  or  nearly  all  the  circumference  of  the  gut,  but 
affects  little  of  its  long  axis,  use  Summer's  operation  (p.  451). 


COMPLICATIONS 


593 


(b)  Gangrene  is  extensive.  Pull  down  healthy  gut  from  beyond  the  stric- 
tures caused  by  the  constricting  abdominal  opening  (Fig.  720).  Doubly  clamp 
both  the  afferent  and  efferent  loops  of  gut.     If  an  end-to-end  union  is  to  be 


Fig.  720.— Examination  of  constricted  gut.     (Veau.) 


Fig.   721. — Excision  gangrenous"'gut. 

made,  the  clamps  nearest  the  body  must  be  protected  with  rubber  tubing  and 
must  not  crush.  If  a  lateral  anastomosis  is  contemplated,  crushing  forceps  are 
best.  Divide  between  the  forceps,  Fig.  721.  Ligate  and  divide  the  mesentery. 
Remove  the  excised  gut  and  mesentery. 


594  HERNIA 

With  through-and-through  catgut  sutures,  close  the  ends  of  both  segments 
of  gut  protruding  from  the  clamps.  Insert  a  purse-string  suture  (Fig.  721)  on 
the  body  side  of  each  clamp.  Remove  the  clamps.  Invaginate  the  ends  of 
the  guts,  tighten  and  tie  the  purse-string  sutures.  Unite  the  afferent  and 
efiferent  loops  of  gut  by  lateral  anastomosis.  (Instead  of  lateral  anastomosis, 
end-to-end  or  end-to-side  anastomosis  may  be  practised.)  If  there  is  doubt  as 
to  the  viability  of  the  gut  or  as  to  the  cleanliness  of  the  field  of  operation  fix  the 
united  segments  of  gut  near  the  wound  in  the  parietes  by  means  of  a  well-placed 
cigarette  or  oiled-silk  drain. 

(c)  The  general  condition  of  the  patient  renders  a  complete  operation  haz- 
ardous. Excise  the  gangrenous  segment  of  gut.  Unite  the  open  ends  of  the 
healthy  gut  to  the  wound,  thus  providing  an  artificial  anus  which  may  be  closed 
subsequently.  This  is  probably  the  safest  plan  for  inexperienced  surgeons  to 
adopt. 

(d)  The  general  condition  of  the  patient  is  poor;  the  temperature  is  about 
normal  or  even  subnormal;  the  pulse  is  120  or  more;  the  abdomen  is  tense  and 
distended.  Relieve  the  constriction,  pull  down  healthy  gut  and  fix  it  to  the 
wound,  the  diseased  segment  being  placed  outside  the  belly  wall.  Incise  the 
gut  to  obtain  intestinal  drainage.  Do  not  remove  any  tissue.  Drain  the 
whole  wound  freely  and  endeavor  to  keep  the  patient  alive  by  suitable  food 
and  stimulants. 

(e)  In  strangulated  femoral  hernia  it  is  wise  to  recognize  the  fact  that  the 
small  size  of  the  femoral  canal  hinders  or  prevents  the  proper  treatment  of  the 
gut.  One,  therefore,  opens  the  abdomen  immediately  above  Poupart's  liga- 
ment; protects  the  belly  cavity  with  pads;  reduces  the  hernia  (working  from 
the  abdominal  side);  excises  the  gangrenous  segment;  repairs  the  bowel;  pro- 
vides drainage  from  below  and  closes  the  abdominal  wound. 

Unless  contraindicated  by  the  weak  state  of  the  patient  or  by  the  necessity 
of  deep  drainage,  herniotomy  ought  always  to  be  followed  by  an  effort  after 
radical  cure.     (Vide  "Special  Operations.") 

Retrograde  Strangulation  of  Intestine. — When  operating  for  strangulated 
hernia  remember  that  two  portions  of  a  loop  of  intestine  may  protrude  into  the 
sac  while  an  intermediary  portion  of  the  same  loop  may  remain  in  the  abdomen 
(Fig.  727).  When  this  is  the  case  it  is  quite  possible  for  the  blood-vessels  of  the 
intermediary  portion  to  be  caught  and  obstructed  in  the  hernial  ring,  thus 
causing  gangrene  of  the  intra-abdominal  loop  of  gut  while  the  two  portions 
actually  in  the  hernia  remain  unaffected.  In  two  cases  (Lorenz)  the  strangu- 
lation was  due  not  to  inclusion  in  the  ring  of  the  affected,  but  to  acute 
flexion  of  the  vessels  caused  by  the  dragging  on  them  of  the  two  herniated 
segments  of  intestine.  Of  course  the  intra-abdominal  strangulation  demands 
laparotomy. 

SLIDING   HERNIA 

Sliding  Hernia. — When  large  intestine  is  present  in  the  hernia  that  part 
of  the  parietal  peritoneum  to  which  it  is  attached  (with  or  without  meson)  may 
slide  down  and  form  part  of  the  sac.     This  must  be  remembered  when  a  portion 


SLIDING    HERNIA 


595 


of  large  intestine  appears  to  he  adherent  to  the  sac.  Figs.  722,  723,  724,  725, 
726,  explain  sufficiently  how  the  sac  may  be  used  to  reconstitute  the  meson  and 
protect  the  intestinal  blood-supply. 

Bull  and  Coley  have  had  relapses  in  one  out  of  eight  cases  of  sliding  hernia 
operated  on  by  them.     Fiaschi   ("Australasian  Med.  Gaz.,"  Nov.  20,  1907) 


Fig.  722.  Fig.  723. — Reconstruction  of  meson. 

Figs.  722  and  723. — Sliding  hernia.     (Giiihe.) 


Fig.  724. — Meson  reconstructed.  Fig.  725 

Figs.  724  and  725. — Sliding  hernia.     {GuiM.) 


Fig.  726. — Sliding  hernia,  meson  re- 
constructed.    {Giiibe.) 


Fig.  727. — Retrograde  strangulation. 


has  had  considerable  experience  with  sliding  hernia  and  considers  relapse  to 
be  due  to  "the  vicious  habit  of  sliding  down  acquired  by  that  portion  of  intes- 
tine which  formed  the  sliding  hernia." 

To  counteract  the  above  tendency  he  supplements  the  ordinary  operation 
on  the  hernia  by  anchoring  the  offending  portion  of  the  colon  to  the  belly-wall 
(colopexy)  through  a  muscle-splitting  (gridiron)  incision. 


596 


HERNIA 


FEMOR.\L   HERNIA 

Bassini's  Operation. — Step  i. — Make  an  incision  3  inches  long,  parallel  to 
and  below  Poupart's  ligament  (Fig.  728).  The  center  of  this  incision  cor- 
responds to  the  centre  of  the  hernial  swelling.  Div-ide  the  tissues  layer  by 
layer  between  forceps  until  the  sac  is  reached.  The  superficial  fascia  may  be 
surprisingly  thick  and  fatty. 

Step  2. — By  blunt  dissection  free  the  sac  from  its  surroundings. 
Step  3. — Open  the  sac  and  reduce  its  contents.     (For  treatment  of  compli- 
cations see  page  592.) 

Step  4. — (A)  Bassini,  having  separated  the  sac  from  its  surroundings  up  to 
its  junction  with  the  parietal  peritoneum  (of  which  it  is  a  mere  process),  trans- 
fixes and  ligates  it  at  this  point  and  cuts  away  the  peripheral  portion.  Many 
surgeons  close  the  external  wound  and  terminate  the  operation  at  this  point. 
(B)  Macewen,  having  separated  all  the  sac  from  its  surrounding,  pushes  his 
finger  through  the  femoral  opening  outside  the  sac  and  separates  the  parietal 
peritoneum  from  the  parietes  for  a  distance  of  ^  inch  above  the  opening. 
He  then  treats  the  sac  exactly  as  in  his  operation  for  inguinal  hernia,  making 
it  into  an  intra-abdominal  pad.     (See  page  604.) 

Step  5. — Make  a  careful  survey  as  to  the  position  of  Gimbernat's  ligament, 
Poupart's  ligament,  the  plica  falciformis,  and  the  pectineal  fascia.  Retract 
the  pUca  falciformis  upwards  and  outwards.  With  a  full  curved  needle  intro- 
duce the  suture  a-a  (Fig.  729)  through  the  inferior  and  posterior  part  of  Pou- 
part's ligament  and  the  pectineal  fascia  close  to  the  pubic  spine.     About  3^  inch 

external  to  a-a  introduce  the  suture  b-b.  In 
the  same  way  the  suture  c  is  introduced  and 
ought  to  lie  about  3^  inch  internal  to  the 
femoral  vein.  The  sutures  a,  b,  and  c  are 
left  for  the  present  without  being  tied. 

Step  6. — The  plica  falciformis  is  stitched 

to  that  portion  of  the  pectineal  fascia  which 

1 

I' 


Fig.  728. — Incision  femoral  hernia. 


Fig.  729. — Bassini's  operation. 


normally  forms  the  posterior  wall  of  the  femoral  funnel.     The  insertion  of 
these  stitches  is  shown  in  Fig.  730  (x-x,  y-y,  z-z). 

Step  7. — The  sutures  a-a,  b-b,  c-c,  are  tied.  This  approximates  Poupart's 
ligament  to  the  fascia  covering  the  horizontal  ramus  of  the  pubis.  The  sutures 
x-x,  Y-Y,  z-z  are  tied.  This  slides  the  plica  falciformis  inwards  to  its  normal 
position  or  to  an  exaggeration  of  its  normal  position,  and  completes  the  closure 


FEMORAL   HERNIA 


597 


of  the  canal.  The  long  saphenous  vein  is  left  to  dip  unmolested  under  the  in- 
ferior end  of  the  plica  falciformis.  (N.  B. — Sutures  a-a,  b-b,  c-c  close  the  ab- 
dominal opening  into  the  femoral  canal.  Sutures  x-x,  y-y,  z-z  close  the  canal 
itself. 

Step  S. — Closure  of  the  skin-wound. 
A 


Fig.  730. — Bassini's  operation. 


Fig.  731. — Roux's  operation. 


Roux's  Operation: — The  hernia  is  exposed  and  its  sac  ligated  and  excised 
as  in  the  Bassini  operation.  The  peculiar  feature  of  the  operation  is  the  method 
of  closing  the  femoral  canal,  as  follows:  Pass  a  metal  staple  obliquely  through 
Poupart's  ligament  over  the  crural  canal  to  the  inside  of  the  femoral  vessels, 
carefully  avoiding  the  vein  (Fig.  731).  Gently  hammer  the  points  of  the 
staple  into  the  pubis.     The  staple  or  nail  must  not  be  inserted  too  tightly  lest 


Fig.  732. — {Bald-win. 


Fig.  733. — {Baldwin.) 


Poupart's  ligament  be  injured.  J.  Crawford  Renton  reports  that  Roux  has 
successfully  used  this  method  in  60  cases  and  he  himself  in  10.  The  superficial 
wound  is  closed  in  the  usual  manner. 

Aslett  Baldwin's  Operation-  ("Lancet,"  July  21,  1906). — Step  i. — Expose 
and  fully  isolate  the  hernial  sac.     Reduce  the  hernia. 

Step  2. — Introduce  a  slightly  curved  director  or  dissector  into  the  femoral 
canal  in  front  of  the  sac  and  with  it  dissect  a  path  upwards  between  the  parietal 


598 


HERNIA 


peritoneum  and  Pouparl"s  ligament  to  a  point  about  ]^  inch  above  Poupart's 
ligament  (Fig.  732).  At  this  point  tilt  the  end  of  the  director  forwards  so  that 
it  can  be  felt  through  th^  aponeurosis  of  the  external  oblique.  Make  a  short 
incision  through  the  aponeurosis,  parallel  to  its  fibres  and  protrude  the  director 
through  the  opening. 

Step  3. — Pass  a  forceps  (sinus  forceps  or  ha^mostat)  along  the  director  from 
above  downwards  (Fig.  733).  Remove  the  director.  Seize  the  distal  end  of  the 
sac  with  the  forceps  and  pull  it  through  the  tunnel  (Fig.  734).  Pull  the  sac 
as  far  as  possible  through  the  opening  in  the  external  oblique;  Ugate  the  neck 
of  the  sac. 

Step  4. — Fix  a  stout  stitch  of  catgut  to  the  fundus  of  the  sac.  Leave  both 
ends  of  the  stitch  long.     Pass  one  end  of  the  stitch  several  times  through  the 


Fig.  734. — {Baldwin.) 


Fig.  735. — (Baldwin.) 


Fig.  736. — (Baldwin.) 


sac  (Fig.  735)  and  then  make  it  take  the  following  course — through  the  opening 
in  the  aponeurosis  of  the  external  oblique,  through  the  neck  of  the  sac  down 
to  the  horizontal  ramus  of  the  pubis  which  it  must  hug,  then  downwards  and 
forwards  through  the  pectineus  muscle  and  fascia  to  emerge  through  the  inner 
part  of  the  saphenous  opening  (Fig.  735). 

Step  5. — Pulling  on  the  thread,  push  the  sac  back  through  the  opening  in 
the  aponeurosis  until  it  is  lost  to  sight.  The  tucking  away  of  the  sac  may  be 
aided  by  the  use  of  a  stout  probe  or  a  forceps. 

The  sac  now  lies  curled  up  behind  Poupart's  ligament;  from  it  one  end  of 
a  suture  hangs  out  through  the  small  opening  in  the  aponeurosis;  the  other 
end  of  the  suture  passes  through  the  tissues  on  the  deep  side  of  the  femoral 
canal  (Fig.  736).  Tie  the  two  ends  of  the  suture  together;  this  closes  the 
femoral  canal. 

Baldwin's  operation  seems  better  suited  to  the  female  than  to  the  male 
because  of  anatomical  considerations. 

Dujarier's  Operation. — (''Journal  de  Chir.,"  Feb.,  191 2.) 

Step  I. — Open  the  inguinal  canal  as  in  Bassini's  operation  for  inguinal 


FEMORAL    HERNIA 


599 

Note 


hernia.     Retract  the  cord  or  the  round  hgament  upwards  (Fig.  737). 
the  deep  epigastric  vessels  and  protect  them  from  injury. 

Step  2. — Separate  the  contents  of  the  inguinal  canal  from  the  abdominal 
surface  of  Poupart's  ligament  and  thus  push  the  parietal  peritoneum  upwards 
until  the  subperitoneal  fat  is  exposed  near  the  femoral  canal.    Note  the  position 


Fig.  7s7.—{Diijaricr.) 

O.T.   Internal  oblique  and  transversalis  muscles  retracted.     H.   Incision  in  peritoneum. 

Poupart's  ligament. 


C.  Cord. 


of  the  femoral  vein  and  protect  it.  Pick  up  the  peritoneum  immediately  above 
the  femoral  canal  and  incise  it.  Through  the  peritoneal  wound  see  if  any 
omentum  or  viscus  enters  the  hernial  sac. 

A.  If  the  sac  is  empty  and  if  there  has  not  been  much  inflammation  it  is 
usually  easy,  by  traction  on  the  peritoneum,  to  pull  the  sac  out  of  the  femoral 
canal  into  the  inguinal  canal  where  it  may  be  treated  as  if  it  belonged  to  an  in- 


6oo 


HERNIA 


guinal  hernia  (Fig.  738).  Sometimes  reduction  of  ih€  sac  as  above  is  impossible. 
If  the  ditTiculty  is  due  to  narrowness  of  the  fibrous  ring  constituting  the  femoral 
canal  this  is  easily  overcome  by  cutting  the  inner  edge  of  the  ring,  i.e.,  Gim- 
bernat's  ligament. 


Fig.  738. — {Dujaricr.) 
F.  Poupart's'ligament.    L.C.  Cooper's  ligament.    H.  Neck  of  sac  ligated. 


If  the  difficulty  in  reduction  is  due  to  adhesion  of  the  sac  to  the  tissues  of 
Scarpa's  triangle,  dissect  the  sac  free  from  these  adhesions  or  if  this  is  too 
difficult,  divide  the  sac  as  close  as  possible  to  the  adhesions  leaving  the  adherent 
portion  of  the  sac  buried  in  Scarpa's  triangle  and  treating  the  mobilized  sac 
secundum  arlem. 

' B.  If  the  sac  has  contents  which  are  reducible,  reduce  them  and  treat  the 
sac  as  in  .4. 


FEMORAL    HERNIA 


60 1 


If  the  contents  are  not  reducible  or  are  strangulated  treat  them  according  to 
the  rules  laid  down  on  page  592.     Dislocate  the  sac  into  the  inguinal  canal. 

^Igp  3.— By  traction  on  the  sac  try  to  pull  forwards  as  much  peritoneum  as 
possible  from  above  the  neck  of  the  sac.  Note  that  the  bladder  is  liable  to  be 
dragged  into  the  wound.  Ligate  the  sac  as  high  up  as  possible  (Fig.  738) 
and  cut  it  awav  distal  to  the  Hgature. 


L.C.   Cooper's  ligament. 


Fig.  739.- 

F.   Poupart's   ligament. 


-\  Dujaricr.) 
O.T.   Internal   oblique   and   transversalis. 


C.    Cord. 


Step  4.— Closure  of  the  femoral  canal.  Insert  two  or  more  sutures 
through  the  fascia  covering  the  horizontal  ramus  of  the  pubes  just  internal  to  the 
femoral  vein  fFig.  739).  Pass  the  lower  end  of  each  of  these  sutures  through  the 
deep  part  of  Poupart's  ligament  and  the  upper  end  through  the  internal  obhque 
and    transversalis.     The    spermatic    cord   lies    behind    these    sutures.     When 


6o2 


HERNIA 


these  sutures  are  tied  the  femoral  canal  and  the  deep  part  of  the  inguinal 
canal  are  closed.  Reich  (Beitr.  z.  klin.  chir.,  Ixxiii,  iioj  closes  the  inguinal 
by  suturing  the  internal  oblique  and  transversalis  to  Cooper's  ligament  and  the 
pubic  periosteum  without  including  Poupart's  ligament.  Thus  the  cord  lies  in 
front  of  the  sutures. 

Step  5. — Suture  the  wound  in  the  external  oblique.     Suture  the  skin. 

Seelig  and  Tuholske  (Surg.,  Gyn.  and  Obst.,  xviii,  page  58)  describe  an 
operation  almost  the  same  as  Dujarier's.  One  of  their  illustrations  (Fig.  740) 
shows  the  relations  of  the  sac  most  admirably. 


Fig.  740. — {Seelig  and  Tuholske.  Surg.,  Gyn.,  and  Obst.) 


Femoral  Hernia. — Chaput  (Rev.  de  Gyn.  et  Chir.  Abdom.^  Nov.,  191 5) 
finds  that  ordinary  suture  is  insufficient  in  femoral  hernia  when  the  opening  is 
large.  He  therefore  plugs  the  opening  with  a  mass  of  fat.  In  subjects  over 
35  or  40  years  of  age  non-pedunculated  implants  of  fat  are  very  subject  to  asep- 
tic necroses  and  absorption  hence  a  pedunculated  flap  is  preferable.  Chaput 
operates  as  follows: 

Step  I. — Open  the  inguinal  canal;  mobilize  and  remove  the  hernial  sac  as 
in  Dujarier's  operation  (p.  598). 

Step  2. — With  a  scalpel  trace  out  a  rectangular  flap,  10  cm.  long,  two  fingers- 
breadth  wide,  with  its  base  at  the  pubis  and  its  inner  border  corresponding 


INGUINAL   HERNIA  603 

to  the  median  line.  Remo\'e  all  the  skin  in  this  tiap  without  encroaching  on 
the  subcutaneous  fat. 

Step  3. — Along  the  lines  of  the  original  incision  penetrate  through  the  fat 
to  the  aponeurosis  and  elevate  a  tlap  of  fat  with  its  pedicle  below.  Make  a 
cut  2  cm.  long  through  the  middle  of  the  distal  end  of  the  flap. 

Step  4. — About  3  cm.  from  the  middle  line  make  a  4  cm.  vertical  incision 
through  the  rectus  muscle  down  to,  but  not  through  the  peritoneum.  Separate 
the  peritoneum  from  the  parietes  outward  until  the  inguinal  canal  and  femoral 
ring  are  reached.  Pull  the  end  of  the  fat-flap  through  the  tunnel  thus  formed 
and  suture  the  posterior  half  of  the  distal  end  of  the  split  fat-flap  to  Cooper's 
ligament  behind  the  femoral  vein  and  the  anterior  half  of  the  flap  to  Poupart's 
ligament  in  front  of  and  external  to  the  vein. 

Step  5. — Close  the  inguinal  canal  as  in  Dujarier's  operation.  In  closing  the 
wound  in  the  rectus  through  which  the  fat-flap  passes  insert  one  thread  of 
catgut  through  the  adjacent  borders  of  the  muscle  and  the  upper  edge  of  the 
flap.     Insert  a  similar  suture  below  the  flap. 

Step  6. — Mobilize  the  skin  around  the  vertical  wound  and  close  it. 

The  above  closely  follows  Chaput's  description  but  the  writer  fails  to  see 
any  excuse  for  excising  the  skin.  A  vertical  incision  through  the  skin  ought 
to  give  plenty  opportunity  to  form  an  efficient  flap  of  fat. 

RADICAL   CURE   OF   INGUINAL  HERNIA 

The  older  operations  for  the  radical  cure  of  inguinal  hernia  were  faulty  and 
unsuccessful  because  they  were  based  on  the  idea  that  the  hernia  escaped  from 
the  abdomen  through  a  ring,  and  that  if  the  edges  of  the  ring  were  brought  to- 
gether, a  cure  w^ould  be  obtained.  The  scar  left  by  such  edge-to-edge  closure 
of  the  ring  can  never  offer  any  great  opposition  to  recurrence  of  the  hernia. 
All  the  good  modern  operations  are  based  on  the  idea  that  the  hernia  has  origi- 
nally passed  through  a  more  or  less  oblique  canal,  which  it  has  converted 
into  a  ring-like  opening,  and  that  to  effect  a  cure  it  is  necessary  to  reverse 
the  process  and  convert  the  ring  into  an  oblique  canal — narrower  and  more 
resistant  to  abdominal  pressure  than  the  original  canal  had  been.  All  operations 
which  carry  out  the  above  principle  are  successful  in  effecting  cures. 

Macewen's  Operation. — i.  Make  an  oblique  incision  about  3  inches  in 
length  over  the  external  abdominal  ring.  Practically  a  good  rule  is  to  begin 
the  cut  I  inch  above  and  to  the  outer  side  of  the  upper  limit  of  the  hernial 
swelling  and  continue  the  incision  downwards  and  inwards  over  the  hernial 
neck.     Expose  the  upper  part  of  the  sac  of  the  hernia. 

2.  By  blunt  dissection  free  the  sac  from  its  surroundings  and  from  the 
spermatic  cord,  which  lies  posteriorly.     This  must  be  done  thoroughly. 

3.  Reduce  the  contents  of  the  sac  and  then  open  and  inspect  it.  It  is  often 
necessary  to  open  the  sac  before  the  hernia  can  or  ought  to  be  reduced.  (For 
treatment  of  complications  see  page  592.) 

4.  Pass  the  finger  outside  the  sac  through  the  opening  in  the  parietes  and 
separate  the  peritoneum  (of  which  the  sac  is  a  mere  continuation)  from  the 
parietes  for  a  space  of  ^^  inch  on  every  side  of  the  opening  (Fig.  741). 


6o4 


HERNIA 


5.  Should  the  sac  be  too  voluminous,  cut  oflf  its  distal  end,  which  may  be 
removed  or  left  in  the  scrotum.  Every  time  it  is  necessary  to  make  an  incision 
in  the  sac  the  position  of  the  cord  should  be  ascertained. 

6.  A  stitch  of  chromicized  catgut  is  taken  through  the  distal  extremity  of 
the  sac,  which  is  now  hanging  loosely  throucrh  the  abdominal  wall  (Fig.  742), 


Fig.  741. — Macewen's      I'IG.  742. — Treatment  of  sac.       Fig,  743. — ^lacewen's  opera- 
operation.     {Esmarck     and  tion. 
Kowalzig.) 

and  is  there  tied.  The  long  end  of  the  suture  is  passed  three  or  four  times  from 
side  to  side  through  the  sac,  so  that  when  pulled  upon  it  throws  the  sac  into 
folds.  The  loose  end  of  the  thread  is  threaded  on  a  Macewen  hernia  needle. 
The  needle,  guided  by  the  finger,  is  passed  up  external  to  the  sac  through  the 
abdominal  opening,  and  thrust  outwards  through  the  whole  thickness  of  the 
pariet£s  (with  the  exception  of  peritoneum  and  skin)  (Fig.  742).     If  the  thread  is 


Fig.  744. — Closure  of  canal.     Macewen's  operation.     {Esmarch  and  Kouahig.) 

now  pulled,  the  sac  will  be  reduced  into  the  belly  cavity  (external  to  the  peri- 
toneum), and  will  form  a  firm,  puckered-up  pad  lying  between  the  peritoneum 
and  the  parietes  (Fig.  743).  The  end  of  the  thread  is  caught  by  a  hemostat 
and  temporarily  thrown  aside. 

7.  A  Macewen  hernia  needle  is  passed  through  the  conjoined  tendon  from 
without  inwards,  and  its  point,  guided  by  the  finger  in  the  abdominal  opening, 


INGUINAL   HERNIA  605 

is  carried  upwards  for  about  ^-^  of  an  inch  and  once  more  passed  through  the 
conjoined  tendon,  this  time  from  within  outwards  (Fig.  744  a  and  h).  By  this 
means  a  strong  chromicized  catgut  thread  is  placed  in  position  through  the  inner 
wall  of  the  ring. 

8.  The  lower  end  of  the  suture  is  now  threaded  on  an  appropriate  needle 
and  passed  through  Poupart's  ligament  from  within  outwards  a  short  distance 
above  the  spermatic  cord  (Fig.  744  c).  The  upper  end  of  the  suture  is  passed 
from  within  outwards  through  the  aponeurosis  of  the  external  oblique.  We 
now  have  a  single  thread  which  takes  the  course  seen  in  Fig.  744  d.  If  one 
pulls  upon  the  ends  of  the  suture,  the  tissues  external  and  inferior  to  the  open- 
ing (viz.,  Poupart's  ligament  and  the  aponeurosis  of  the  external  oblique) 
must  slide  over  those  internal  and  superior  (viz.,  the  conjoined  tendon),  and 
when  the  suture  is  firmly  tied,  the  obliquity  of  the  inguinal  canal  is  restored. 
The  anterior  surface  of  the  conjoined  tendon  is  in  apposition  with  the  posterior 
surface  of  Poupart's  ligament.  Before  the  suture  is  definitely  tied  the  spermatic 
cord  is  examined  lest  too  much  pressure  be  exerted  on  it. 


Fig.  745. — Bassini's  operation. 

9.  The  end  of  the  suture  used  for  puckering  the  sac  is  now  pulled  tight 
and  fixed  in  the  belly-wall  subcutaneously. 

10.  The  skin-wound  is  closed, 

Macewen  makes  use  of  special  handled  needles,  but  these  are  not  really 
necessary.  The  author  has  frequently  used  common  full-curved  needles 
gasped  in  a  needle-holder  and  found  them  absolutely  satisfactory. 

Bassini's  Operation. — i .  An  incision  is  made  parallel  to  and  3>^  inch  above 
Poupart's  ligament.  It  begins  external  to  the  region  of  the  internal  abdominal 
ring  and  ends  internal  to  the  external  ring. 

2,  A  firm  aponeurotic  sheet  (aponeurosis  of  external  oblique)  covering 
the  hernia  is  exposed  and  divided  in  the  direction  of  the  wound  with  scissors 
or  on  a  director  (Fig.  745).  Thus  are  formed  a  superior  and  inferior  aponeurotic 
flap.  The  superior  flap  is  separated  from  the  subjacent  tissues  for  a  distance 
of  I  or  1 3-^  inches. 

3.  The  hernial  sac  now  lies  exposed  from  its  peritoneal  origin  to  the  point 
where  it  disappears  into  the  scrotum,  and  is  recognized  according  to  the  rules 


6o6 


HERNIA 


described  on  paj^e  5yi.  With  hlunl  disseclion  ihe  sac  is  separated  from  its 
surroundings  and  from  the  spermatic  cord.  This  must  be  done  thoroughly 
and  carefully.  The  sac  should  be  opened  and  its  contents  reduced  or  treated 
as  described  on  page  592. 

4.  Downward  traction  being  exerted  on  the  sac,  its  neck  is  transfixed  and 
ligated  as  high  up  as  possible,  and  the  distal  portion  cut  ofT.  The  stump 
should  retract  into  the  belly  cavity  and  be  lost  to  sight.  Sometimes  the  neck 
of  the  sac  is  so  bulky  or  of  such  a  shape  that  ligation  is  impossible.  In  these 
cases  the  neck  of  the  sac  is  sewed  up  and  the  distal  portion  removed.  By 
whatever  method  the  neck  is  closed  and  divided,  special  attention  ought  to  be 
paid  to  the  position  of  the  spermatic  cord,  as  this  important  structure  has 
frequently  been  injured.  Separation  of  the  sac  from  its  surroundings  has 
freshened  all  the  tissues  so  that  if  placed  in  apposition  they  will  unite.  It  is  not 
always  necessary  to  excise  the  distal  portion  of  the  sac.  After  isolation,  liga- 
tion and  division  of  the  neck  the  remainder  of  the  sac  may  be  permitted  to  drop 
into  the  scrotum.  The  author  has  occasionally  seen  this  procedure  followed  by 
the  development  of  a  hydrocele,  but  if  the  cord  and  testicle  are  pulled  out  of 
the  scrotum  and  the  remnants  of  the  sac  turned  outside-in  over  them  no  hydro- 
cele can  develop  and  considerable  dissection  may  be  avoided.  (See  Eversion 
of  Hydrocele  Sac,  Jaboulay's  Operation.) 


Fig.  746.  Fig.  747. 

Figs.  746,  747  and  748. — Bassini's  operation, 


Fig.  74S. 


5.  The  spermatic  cord  is  raised  from  its  bed  and  held  out  of  the  way  by 
a  blunt  hook.  Review  of  the  wound  now  shows  that  its  upper  edge  consists  of 
three  layers;  (A)  A  deep  thick  layer,  marked  muscular  flap  (Fig.  746). 
(Internal  oblique  and  transversalis  muscles,  transversalis  fascia,  and  external 
margin  of  the  rectus.)  (B)  Superior  aponeurotic  flap.  (Aponeurosis  of  external 
oblique.)  (C)  The  skin.  The  lower  edge  of  the  wound  consists  of  the  deep 
layer  of  Poupart's  ligament  on  which  the  spermatic  cord  normally  lies,  the 
inferior  aponeurotic  flap,  and  the  skin. 

6.  A  suture  is  now  passed  through  the  muscular  flap  (Figs.  746,  747)  close 
to  the  exit  of  the  cord  from  the  abdomen,  and  unites  it  to  the  deeper  layer  of 
Poupart's  ligament.  This  suture  must  be  so  placed  as  to  close  the  wound 
beside  the  cord,  but  yet  not  interfere  with  its  circulation.  Some  surgeons 
place  a  suture  external  to  the  cord  at  the  point  marked  x,  Fig.  747.  This  is 
important.  The  whole  edge  of  the  muscular  flap  (Figs.  746,  747)  is  stitched 
to  the  deep  layer  of  Poupart's  ligament. 

7.  The  cord  is  now  laid  on  the  top  of  the  line  of  suture  and  the  superior  and 
inferior  aponeurotic  flaps  united  over  it  (Fig.  748). 

8.  The  skin-wound  is  closed. 


INGUINAL   HERNIA 


607 


La  Roque's  Operation  (Surg.,  Gyn.  and  OIjsI.,  Nov.,  1Q19)  has  much  to 
recommend  it,  as  it  facihtates  the  exposure  and  safe  mobilization  of  the  sac 
and  ensures  good  closure  of  the  internal  ring. 

Step  I. — Expose  and  split  the  aponeurosis  of  the  external  oblique  as  in 
Bassini's  method.  Along  a  line  about  i  inch  above  their  lower  margin,  pene- 
trate the  internal  oblique  and  transversalis  muscles  by  separation  of  their 
muscle  bundles  and  open  the  peritoneum  above  the  neck  of  the  sac.  (If  the 
muscles  are  attenuated  they  may  be  retracted  upwards  and  thus  the  proper 
place  for  opening  the  peritoneum  may  be  reached  without  muscle  splitting.) 


Fig.   749. — La  Roque's  Operation.     (Surg.  Gyn.  6°  Ohst.) 


Step  2. — Treat  the  hernial  contents  from  the  abdominal  side.  Pass  a 
finger  into  the  sac  and  thus  guided,  separate  the  sac  from  its  surroundings. 

Step  3.— With  a  hemostat  grasp  the  apex  of  the  sac  and  inverting  the  sac 
pull  it,  along  with  any  redundant  peritoneum,  out  through  the  peritoneal  open- 
ing. Guided  by  the  eye  pass  sutures  through  the  redundant  peritoneum  well 
above  the  neck  of  the  sac  thus  closing  the  opening  into  the  sac.  Let  each  of 
these  stitches  take  a  bite  in  the  upper  edge  of  the  original  peritoneal  wound. 
Cut  away  the  excess  of  sac.     Close  the  split  in  the  muscles. 

Step  4. — Close  the  inguinal  canal  in  the  usual  fashion. 

HidVs  Operation  (Brit.  Med.  J.  Oct.  27,  191 7). 

I.  One-half  inch  above  the  center  of  Poupart's  ligament  make  a  one-inch 
incision  parallel  to  the  Hgament  and  expose  the  aponeurosis  of  the  external 
oblique  directly  over  the  spermatic  cord.  Split  the  aponeurosis  for  about  one- 
half  inch. 


6o8 


HERNIA 


2.  Expose  the  cremasteric  and  fascial  coverings  of  the  cord  and  pull  them 
through  the  wound.  Separate  the  cremasteric  fibres  and  incise  the  spermatic 
fascia.     This  exposes  the  sac. 

3.  Pick  up  the  sac  with  two  fme  hemostats.  Open  the  sac  between  the 
forceps.  Apply  two  more  forceps  to  the  edges  of  the  opening  in  the  sac  to 
expose  the  interior.  The  interior  of  the  sac  shows  two  openings  one  leading 
into  the  abdomen  the  other  into  the  scrotum.  These  openings  are  separated 
by  a  ridge  of  peritoneum  (the  crista)  (Fig.  750).  Pick  up  the  crista  in  one  or 
two  places  with  forceps.  Complete  the  transverse  division  of  the  sac  distal 
to  the  forceps.  By  lifting  up  the  forceps  the  neck  of  the  sac  can  be  easily 
separated  from  its  surroundings.  Transfix  the  sac  with  a  needle  armed  with 
catgut,  ligate  it  and  permit  it  to  retract  inside  the  abdominal  wall.  Unless 
transfixion  is  used  the  ligature  may  slip  off  the  sac. 


Fig.  750. 


4.  Suture  the  skin  and  the  wound  in  the  aponeurosis  with  silkworm  gut 
(most  surgeons  would  suture  the  aponeurosis  with  catgut  and  the  skin  with 
any  material  preferred.) 

In  90  per  cent,  of  cases  this  is  all  that  is  necessary.  In  cases  where  the  in- 
ternal ring  is  very  large  or  the  peritoneum  is  thin  the  conjoined  tendon  is  drawn 
over  the  cord  and  sutured  to  Poupart's  ligament  without  enlarging  the  wound. 

Ferguson's  Operation. — A.  H.  Ferguson  has  noticed  that  a  deficient  origin 
of  the  internal  oblique  and  transversalis  muscles  at  Poupart's  ligament  is  a 
fruitful  cause  of  recurrence  after  operations  for  the  cure  of  inguinal  hernia. 
To  expose  and  correct  such  deficiency  he  has  devised  the  following  operation: 

Step  I. — Make  a  semilunar  incision,  with  convexity  upwards,  from  a  point 
in  Poupart's  ligament  i)-^  inches  below  the  anterior  superior  spine  to  a  point 
on  the  conjoined  tendon  near  the  pubis  (Fig.  751).  Reflect  the  flap  thus 
outlined,  exposing  the  aponeurosis  of  the  external  oblique  and  the  hernia. 

Step  2. — Cut  through  the  external  abdominal  ring  and  intercolumnar 
fascia;  separate  the  longitudinal  fibres  of  the  aponeurosis  of  the  external  oblique 
directly  over  the  inguinal  canal,  far  beyond  the  internal  ring,  over  the  surface 


INGUINAL    HERNIA  609 

of  the  internal  oblique,  and  up  under  the  skin  to  a  point  nearly  opposite  the 
anterior  superior  spine  (Fig.  751 ).  This  exposes  all  the  contents  of  the  inguinal 
canal,  and  any  deficiency  in  the  origin  of  the  internal  oblique  and  transversalis 
muscles  is  seen. 

Step  3. — Attend  to  the  hernial  contents  and  sac  in  the  manner  already 
described. 


Fig.  751. — {A.  H.  Ferguson.) 

Step  4. — ^Lessen  the  size  of  the  dilated  internal  ring  by  means  of  a  few 
stitches  (Fig.  752).  Suture  the  internal  oblique  and  transversalis  muscles 
to  the  inner  aspect  of  Poupart's  ligament  and  restore  their  normal  origin 
(Fig.  753).  The  line  of  suture  extends  fully  two-thirds  down  the  ligament. 
Take  care  not  to  split  the  ligament  by  grasping  with  the  needle  the  same  longi- 
tudinal fibres  each  time.  In  this  step  the  Mayos  suture  the  upper  edge  of 
the  wound  in  the  external  oblique  fascia  along  with  the  internal  oblique  muscle 
to  the  inner  aspect  of  Poupart's  ligament  and  thep  make  the  lower  portion 
of  the  fascia  (continuous  with  Poupart's  ligament)  overlap  the  line  of  suture 
and  fix  it  in  position  by  means  of  a  few  stitches.  Close  the  wound  in  the 
aponeurosis  of  the  external  oblique.  Restore  the  external  abdominal  ring. 
Replace  and  suture  the  semilunar  skin-flap. 

39 


6io 


HERNIA 


AJler-treatment. — Bassifii  permits  his  patients  to  leave  their  beds  and  go 
to  work  after  the  lapse  of  two  weeks.  Macewen  believes  that  no  wound 
is  firmly  healed  after  such  a  short  time.  \\'hen  it  is  possible  to  carry  out  the 
following  rules,  they  will  be  found  exceedingly  satisfactory: 

For  a  period  of  three  or  four  weeks  after  operation,  rest  in  bed. 

For  a  period  of  six  weeks  after  operation,  when  the  bowels  are  being  moved , 
the  patient  should  be  in  the  recumbent  posture  so  as  to  avoid  strain  on  the 
wound.  The  squatting  posture  with  thighs  flexed  on  and  supporting  the 
abdomen  is  as  good  and  more  humane. 


Fig.  752. — {A.  H.  Ferguson.) 

For  a  period  of  three  months  after  operation  there  should  be  no  hard  manual 
work. 

The  Johns  Hopkins  Operation  for  Hernia. — This  operation  is  the  result 
of  the  experience  and  ingenuity  of  the  surgical  staff  in  the  Johns  Hopkins 
Hospital.  It  is  based  on  the  original  operation  of  Halsted,  modified  by  him- 
self and  Bloodgood.     ("Johns  Hopkins  Bulletin,"  August,  1903.; 

Step  I. — Divide  the  skin  and  the  aponeurosis  of  the  external  obhque  as 
in  the  Bassini  operation.     Reflect  the  aponeurotic  flaps. 

Step  2. — Split  the  cremaster  muscle  and  fascia  along  a  line  a  little  above 
the  centre  of  the  cord. 


INGUINAL   HERNIA 


6ii 


Step  3. — Expose  clearly  the  internal  oblique  muscle  beside  the  canal. 

Step  4. — Examine  the  hernia  and  the  cord.  If  the  veins  are  large,  and 
this  is  usually  the  case,  excise  them  with  very  great  care  to  avoid  even  the 
slightest  extravasation  of  blood  into  the  tissues  about  the  smaller  veins  and 
about  the  vas  deferens  which  they  accompany.  Do  not  raise  the  vas  deferens 
from  its  bed;  do  not  handle  or  even  touch  it,  if  possible,  lest  thrombosis  of 
its  veins  occur  (Fig.  754).  Ligate  the  veins  as  high  up  in  the  abdomen  as 
possible,  pulling  them  quite  firmly  just  before  the  ligature  (in  a  needle  with 


Fig.  753. — {A.  H.  Ferguson.) 


the  blunt  end  first)  is  passed  between  them.  Ligate  the  lower  portions  of 
the  veins  at  a  point  as  high  above  the  testicle  as  possible,  the  stump  being, 
of  course,  outside  the  external  abdominal  ring. 

Step  5. — ^Ligate  the  sac  by  transfixion  or  purse-string  suture  at  the  highest 
possible  point.  After  tying  this  suture  thread  its  ends  on  long  curved  needles 
and  pass  them  outwards  under  the  internal  oblique  muscle  to  penetrate  the 
muscle  from  within  outwards  at  two  points  about  5  mm.  (^^  inch)  apart.  Tie 
the  ligatures.  This  step  dislocates  the  neck  of  the  sac  in  a  manner  essentially 
the  same  as  is  recommended  by  Kocher. 

Step  6. — Draw  the  lower  flap  of  cremaster  muscle  and  fascia  up  under  the 


6l2 


HERNIA 


k... , 

flffi 

m 

Fig.  754. — {Halsted.) 


iG.  755. — (Hoisted.) 


INGUINAL   HERNIA 


613 


internal  oblique  muscle,  and  fix  it  there  by  fine  sutures  which,  having  engaged 
firmly  a  few  bundles  of  the  cremaster,  perforate  the  internal  oblique,  pref- 
erably where  it  is  becoming  aponeurotic,  and  are  lied  on  the  external  surface  of 
the  latter  (Fig.  755). 


Fig.  756. — (Halstcd.) 


Fig.   757. — {Halsted.) 


Step  7. — Stitch  the  internal  oblique  muscle,  mobihzed  and  possibly  further 
released  by  incising  the  anterior  sheath  of  the  rectus  muscle  (along  with  its 
conjoined  tendon)  to  Poupart's  ligament  (Fig.  756).  Do  this  in  such  a  manner 
that  the  lower  edge  of  the  internal  oblique  is  tucked  under  Poupart's  ligament. 

Step  8. — Suture  the  aponeurotic  flaps  of  the  external  oblique  by  the  An- 
drews-Halsted  method,  which  makes  them  overlap  (Figs.  757,  758). 

Step  g.- — Close  the  skin-wound. 


6i4 


HERNIA 


Where  the  hernial  opening  is  very  large  and  the  conjoined  tendon  atrophied, 
a  flap  of  the  anterior  sheath  of  the  rectus  muscle  may  be  reflected  outwards 
and  downwards  and  sutured  to  the  under  surface  of  Poupart's  ligament  (Fig. 
759).     This  llap  of  fascia  aids  in  closing  the  canal  by  the  usual  means. 

/ 


Fig.  758. — (Halsted.) 


Fig.  759. — {Halsted.) 

Kirschner  ('•  Archiv  fur  klin.  Chir.,"  xcii,  896)  supports  the  line  of  suture  as 
follows:  Make  an  incision  through  the  skin  of  the  thigh  and  expose  a  sufficient 
area  of  fascia  lata;  excise  a  strip  of  fascia  lata  longer  than  the  hernial  wound  and 
about  two  to  two  and  one-half  inches  wide;  spread  this  "free"  fascial  flap  over 
the  line  of  suture  closing  the  inguinal  canal  and  suture  it  there. 


INGUINAL   EVENTRATION  615 

In  an  inguinal  hernia  which  had  recurred  after  operation  by  two  excellent 
surgeons,  the  author  adopted  Kirschner's  method  with  gratifying  results.  He 
has  found  the  free  transplantation  of  fascia  of  much  value  for  many  purposes. 

Instead  of  using  a  flap  of  rectus  sheath  to  aid  in  closing  the  inguinal  canal 
when  the  conjoined  tendon  is  insufficient,  Bloodgood  splits  the  outer  margin 
of  the  rectus  sheath  from  the  pubic  insertion  upwards  for  2  inches  (5  cm.). 
The  muscle  bulges  from  the  cut  and  is  sutured  to  Poupart's  ligament. 

When  Poupart's  Ugament  has  been  destroyed  or  greatly  weakened  the  same 
surgeon  (Annals  of  Surg.,  July,  191 9,  p.  86)  has  repaired  the  defect  by  dividing 
the  Sartorius  in  the  middle  of  the  thigh,  isolating  it  except  at  its  upper  attach- 
ment, placing  it  over  the  inguinal  canal  and  suturing  it  in  place. 

En  resume. — The  special  features  of  the  Johns  Hopkins  methods  of  operating  are: 

1.  Excision  of  the  veins  of  the  cord  and  avoidance  of  injury  to  the  vas  deferens. 

2.  Use  of  the  cremaster  muscle  and  fascia  to  strengthen  the  closure. 

3.  Overlapping  of  the  various  structures  brought  into  apposition. 

4.  Reinforcement  of  the  lower  part  of  the  wound  when  necessary  by  a  flap  of  rectus  fascia, 
or  by  rectus  transplantation. 

Inguinal  Eventration.  Chaput  (La  Pr.  Med.,  June  19,  1919)  has  given  this 
name  to  those  inguinal  herniae  where  not  only  is  the  ring  very  large  but  where 
the  parietes  above  and  external  to  the  ring  are  thin  and  weak  and  in  which 
the  ordinary  operations  such  as  Bassini's  are  insufficient.  Several  methods 
of  muscle  transplantation  may  be  used  to  give  material  with  which  to  occlude 
the  canal. 

Method  A.  Step  1. — Expose  and  tieat  the  hernial  contents  and  sac  as  in  the 
Bassini  operation. 

Step  2. — Continue  the  incision  up  to  the  anterior  superior  iliac  spine.  From 
this  point  make  a  cut  downwards  and  inwards  along  the  Sartorius  for  a  distance 
of  about  four  or  five  inches.  Divide  the  muscle  transversely  at  the  lower  end 
of  the  wound  and  mobilize  it  (along  with  the  fascia  covering  it)  up  to  its  origin. 

Step  3. — Suture  the  upper  end  of  the  lower  segment  of  the  muscle  to  the 
neighboring  fascia. 

Step  4. — Insert  the  mobile  muscle  flap  into  the  inguinal  canal.  Suture  its 
distal  end  to  the  pubes  and  its  sides  to  Poupart's  ligament  and  the  boundaries 
of  the  inguinal  canal. 

Step  5.— Close  the  wounds. 

This  operation  has  been  practiced  by  Bloodgood;  Streissler;  Salva  Mercede 
and  Chaput. 

Objections  to  the  operation  are  that,  (a)  The  Sartorius  is  sometimes  not 
large  enough  to  serve,  (b)  along  the  site  from  which  the  muscle  was  taken  a 
fibrous  tissue  cord  may  form  which  may  cause  pain  and  interference  with  ex- 
tension of  the  thigh  while  loss  of  part  of  the  muscle  may  weaken  flexion  (Chaput) 

Method  B.     Step  i. — As  in  Method  .4. 

Step  2. — Extend  the  primary  incision  to  the  anterior  superior  iliac  spine 
and  continue  it  downwards  and  backwards  to  the  middle  of  the  trochanter 
major.     Freely  expose  the  anterior  part  of  the  gluteus  medius  and  from  it 


6l6  HERNIA 

fashion  a  llap  vvilh  pedicle  above.     The  llap  should  be  about  >^'4  inch  (2  cm.) 
thick,  two  finger  breadths  wide  and  long  enough  to  easily  reach  the  pubes.  • 

Step  3. — Place  the  ilaj)  in  the  inguinal  canal;  suture  its  free  end  to  the  pubes 
and  its  sides  to  the  fascias  bounding  the  canal.  Remarks — it  is  always  possible 
to  secure  enough  muscle  to  form  a  satisfactory  flap  except  sometimes  as  regards 
length,  and  there  is  little  or  no  interference  with  function,  but  the  wound  is 
very  large  and  there  is  much  trauma  which  naturally  favors  infection. 

Method  C. — Chaput  (loc.  cit.)  favors  this  method. 

Step  I. — As  in  preceding  methods. 

Step  2.- — Continue  the  skin  incision  upwards  and  outwards  parallel  to  the 
iliac  crest  to  a  point  two  finger  breadths  posterior  to  the  anterior  superior  spine. 

Step.  3. — From  a  point  on  the  incision  one  finger  breadth  posterior  to 
the  anterior  superior  spine  make  a  cut  vertically  down  the  thigh  for  a  dis- 
tance of  6  or  7  inches  (15  to  18  cm.),  along  the  course  of  the  tensor  vaginae 
femoris.     Reflect  the  skin  along  this  incision  so  as  to  freely  expose  the  muscle. 

Step  4. — Divide  the  muscle  transversely  at  the  lower  end  of  the  wound  and 
mobihze  it  from  below  up,  along  with  its  fascial  envelope.  Preserve  the  attach- 
ments to  the  ihac  crest. 

Step  5. — Suture  the  free  end  of  the  flap  to  the  pubes  and  its  sides  to  the  ap- 
propriate structures  bounding  the  inguinal  canal. 

Diastases  or  weaknesses  of  the  lower  lateral  abdominal  walls  above  the 
inguinal  region  may  be  closed  by  muscular  flaps  as  described  above,  the  free 
ends  of  the  flaps  being  sutured  to  the  rectus  abdominalis  muscles.  Sometimes 
flaps  from  all  three  sources  may  be  used,  one  to  supplement  the  other. 

Obturator  Hernia.— This  hernia  is  rarely  diagnosed  before  symptoms  of 
strangulation  have  appeared. 

Method  A. — ^Place  the  patient  in  the  Trendelenburg  position.  Open  the 
abdomen.  Look  for  the  hernia  at  the  site  of  the  obturator  foramen  which  is 
directly  posterior  to  the  femoral  canal.  Reduce  the  hernia  treating  the  strangu- 
lated gut  secundum  art  em.  The  constricting  hernial  ring  may  be  nicked  back- 
wards to  permit  reduction.  Extirpate  the  sac  or  its  neck.  Close  the  hernial 
opening  with  a  few  sutures. 

Method  B. — When  obturator  hernia  is  suspected  the  obturator  foramen  may 
be  explored  through  the  inguinal  canal.  E.  T.  C.  Milligan  (Brit.  Med.  Jour., 
Aug.  2,  1919)  operated  as  follows:  Open  the  inguinal  canal  as  in  Bassini's 
operation.  Retract  the  spermatic  cord  upwards.  Recognize  the  external  iliac 
vein  and  the  femoral  canal.  With  deep  retractors  push  the  peritoneum  up- 
wards from  the  pubic  bone  until  the  obturator  canal  is  reached  about  i  inch 
behind  the  femoral  ring.  This  method  is  not  suitable  when  strangulation  is 
present. 

Umbilical  Hernia. — The  classical  method  of  operating  in  cases  of  umbilical 
hernia  was  to  make  a  vertical  incision  more  or  less  over  the  center  of  the 
swelling,  open  the  sac,  free  the  contents,  reducing  intestine  and  excising  re- 
dundant omentum.  Ransohofif  has  shown  that  much  time  is  lost  and  danger 
to  viscera  incurred  by  this  method  of  attack,  and  has  laid  down  the  principle 
that  the  incision  should  always  be  made  into  the  free  abdominal  cavity  at  the 
neck  of  the  sac. 


UMBILICAL   HERNIA  617 

Modified  as  above,  the  classical  operation  may  be  described  as  follows: 

Step  I. — Make  a  vertical  incision  from  a  point  well  above  the  hernia  to 
a  similar  point  below.  When  passing  the  hernia,  the  incision  should  be  deflected 
to  one  side  or  the  other  of  the  umbilicus  (Fig.  760). 

Step  2. — Through  the  above  incision  without  opening  the  sac  dissect  down 
to  and  freely  expose  the  aponeurotic  structures  at  one  side  of  the  neck  of  the 
hernia. 

Step  3. — Open  the  sac  at  its  neck;  reduce  any  extruded  gut.  Ligate  and 
divide  redundant  omentum  and  reduce  the  omental  stump.  Place  a  gauze  pad 
against  the  opening  into  the  abdomen  and  excise  the  hernial  sac,  the  remains  of 
omentum  which  it  may  contain,  and  such  redundant  skin  as  may  require  re- 
moval. This  excision  may  be  done  rapidly,  as  all  danger  of  injury  to  gut,  etc., 
has  been  avoided  by  its  early  isolation  and  reduction. 

Step  4.— Close  the  peritoneal  wound  by  a  row  of  catgut  sutures. 

Step  5. — By  sharp  and  blunt  dissection  open  the  rectus  sheath  on  both  sides 
of  the  wound  and  expose  the  edge  of  both  recti  muscles. 

Step  6. — Unite  the  posterior  layer  of  rectus  fascia  or  sheath  by  sutures. 
Suture   together  the  rectus  muscles.     Unite   the  an- 
terior layer  of  rectus  fascia.     Close  the  skin-wound. 

The  above  is  a  good  operation  in  cases  of  small 
hernia;  but,  as  the  Mayos  have  shown,  when  the 
hernia  is  large,  and,  as  is  usually  the  case,  the  patient     /       x.  ^/ 

is  fat,  there  is  a  wide  separation  between  the  recti  and    '  ^^^fc-^^-^-i^ 

these  muscles  are  themselves  atrophied.  The  classical 
operation  has  therefore  proved  ineflacient,  in  the  very 
cases  where  success  is  most  to  be  desired.     The  Mayos'  pj^,    -^^ 

operation  has   become   the  recognized  procedure.     It 

does  not  seek  to  obtain  muscular  apposition  but  depends  for  success  on  the 
formation  of  a  strong  aponeurotic  barrier. 

The  Mayos'  Operation  (Figs.  761,  762,  763). — Step  i. — Make  transverse 
elliptical  incisions  around  the  umbilicus  and  the  hernia.  Deepen  these  to  the 
base  of  the  hernial  protrusion. 

Step  2. — For  an  inch  and  a  half  in  all  directions  from  the  neck  of  the  sac 
carefully  expose  the  aponeurotic  structures. 

Step  3. — Divide,  in  a  circular  manner,  the  fibrous  and  peritoneal  coverings 
of  the  hernia  at  the  neck.  Expose  the  hernial  contents.  If  viscera  are  present, 
separate  the  adhesions  and  reduce.  Ligate  the  contained  omentum  and  remove 
it  with  the  entire  sac  of  the  hernia. 

Step  4. — Grasp  with  forceps  and  approximate  the  margins  of  the  ring.  In 
whatever  direction  overlapping  proves  easiest  lies  the  proper  direction  for 
closure. 

Step  5. — ^Incise  the  aponeurotic  and  peritoneal  structures  of  the  ring  for  a 
distance  of  one  inch  or  more  transversely  to  each  side.  Separate  the  peritoneum 
from  the  under  surface  of  the  upper  of  the  two  flaps  thus  formed. 

Step  6. — Beginning  one  inch  or  more  above  the  margin  of  the  upper  flap, 
introduce  three  or  four  mattress  sutures,  the  loop  firmly  grasping  the  upper 
margin  of  the  lower  flap.     Make  sufficient  traction  on  these  sutures  to  permit 


6i8 


HERNIA 


of  closure  of  the  peritoneum  with  a  continuous  catgut  suture.  Tie  the  mattress 
sutures,  sliding  or  pulling  the  entire  lower  aponeurotic  flap  into  the  space 
between  the  peritoneum  and  aponeurosis  above. 

Step  7. — With  catgut,  suture  the  lower  edge  of  the  upper  aponeurotic  flap 
to  the  aponeurosis  below.     Close  the  superficial  wound. 

Kelly's  modification  of  the  Mayos'  operation.  ("Annals  of  Surg.,"  May, 
1910.) 


Fig.  761. — Mayo's  operation.     Umbilical  hernia.     {Mayo.) 


Step  I. — Make  a  curved  transverse  incision  across  the  hernia  from  a  point 
slightly  external  to  the  right  rectus  to  a  point  slightly  external  to  the  left  rectus 
muscle.  The  concavity  of  the  curve  is  directed  upwards.  Expose  the  fascia 
over  both  recti. 

Step  2. — Divide  the  fascia  over  both  recti  and  separate  it,  from  the  muscles, 
upwards  and  downwards  for  a  distance  of  2  or  3  cm.  (^'i-iji  inches)  so  as  to 
form  fascial  flaps  (Fig.  764). 

Step  3. — Isolate  and  open  the  hernial  sac.  Treat  its  contents  in  the  usual 
fashion. 

Step  4. — Close  the  peritoneal  wound  with  catgut  sutures. 

Step  5. — "Haul  up  and  sew  the  free  margin  of  the  lower  under  the  upper 
flap  from  side  to  side  with  four  to  six  interrupted  silk  sutures,  using,  if  needs  be. 


UMBILICAL   HERNIA 


619 


catgut  between  them.  If  the  transrectal  incision  is  angled  a  little  upwards 
and  the  overlapping  of  the  recti  is  well  done,  there  may  be  little  tension;  there 
is  always  a  greatly  diminished  tension  in  the  overlapping  at  the  ring  itself." 


Fig.  762. — Mayo's  operation.     Umbilical  hernia.     (Mayo.) 


Fig.  763. — Mayo's  operation.     Umbilical  hernia.     (Mayo.) 

Suture  the  free  overhanging  margin  of  the  upper  flap  to  the  fibrous  tissues  by  a 
continuous  catgut  suture. 

Step  6. — Close  the  skin  wound. 

When  a  large  defect  in  the  abdominal  wall  cannot  be  closed  in  the  above 
manner  or  in  some  modification  thereof,  closure  has  been  effected  by  means  of 
a  perforated  celluloid  plate  (McCosh)  or  of  a  silver  wire  meshwork  (Phelps, 


620 


HERNIA 


Willy  Meyer,  Bartlett).  Meyer  and  A.  E.  Barker  are  very  urgent  in  the  praise 
of  this  method  of  closure.  The  meshwork  or  fence  of  silver  wire  seems  to  be 
well  borne  In'  the  tissues  and  to  form  the  nucleus  of  a  strong  mass  of  connective 
tissue. 

The  author  has  used  Bartlett's  wire  mesh  with  great  satisfaction  in  a  case 
of  hernia  resulting  from  loss  of  much  of  the  upper  end  of  the  right  rectus  ab- 
dominis muscle.  Kirschner's  plan  (p.  614)  of  the  "free"  transplantation  of  a 
flap  of  fascia  lata  may  possibly  supplant  the  use  of  foreign  materials. 

Ventral  herniae  of  all  varieties  are  to  be  treated  on  the  same  principles  as 
are  advocated  for  umbilical  herniae.  Undoubtedly  the  best  treatment  for  post- 
operative ventral  herniae  is,  to  use  an  Irishism,  not  to  have  them.     For  this 


Fig.  764. — Umbilical  hernia.     (Kelly.) 


purpose  nothing  is  better  than  attention  to  cleanliness,  careful  closure  of  the 
parietes  in  their  anatomic  layers,  and  absolute  avoidance  of  strain  until  the 
embryonic  tissues  necessary  for  the  repair  of  abdominal  wounds  have  had  time 
to  become  mature. 

Rutherford  Morison's  Operation. — (i)  Make  long  transverse  incisions  in- 
cluding the  hernia  in  an  ellipse.  (2)  Expose  the  rectus  sheath  above,  below  and 
on  each  side  of  the  hernia.  (3)  Open  the  sac  and  the  abdomen  through  the 
linea  alba  below  the  hernia.  (4)  Reduce  the  hernial  contents,  never  cutting 
away  omentum  unless  absolutely  necessary.  Cut  away  sac.  (5)  With  fingers 
in  the  abdomen  introduce  thick  catgut  mattress  sutures  through  the  aponeurosis 
and  rectus  muscle  on  either  side  but  do  not  tighten  them.  Separate  and  hold 
up  the  mattress  sutures  so  as  to  expose  the  peritoneal  wound.  Suture  the  peri- 
toneal wound.  Infold  the  aponeurosis  by  tightening  and  tying  the  mattress 
sutures,  making  a  keel  towards  the  abdominal  cavity  and  bringing  broad  sur- 
faces of  aponeurosis  into  apposition.  Draw  surfaces  of  aponeurosis  still  more 
together  by  thick  interrupted  catgut  sutures  above,  below  and  between  the 
mattress  sutures.     (6)  Drain  cavity  with  a  tube  introduced  by  small  incision 


VENTRAL   HERNIA 


621 


through  the  upper  flap.  (The  skin  of  the  lower  flap  is  often  moist  and  infected.) 
(7)  Apply  dressings  and  support  the  abdomen  with  adhesive  straps. 

Hayncs'  operation  (N.  Y.  Med.  Jour.,  Vol.  cv,  o.  107,  1917)  is  very  similar 
to  Rutherford  Morison's. 

WuUstein's  operation  for  ventral  hernia  is  sufficiently  described  by  Fig.  765. 
(Zentralblatt  fiir  Chir.,  Sept.  22,  1906,  p.  153.) 

When  a  patient  with  umbihcal  hernia  is  atrociously  fat  it  is  often  wise  to 
operate  as  follows: 

1.  Make  a  transverse  curved  incision  across  the  abdomen  a  short  distance 
above  the  hernia.  Make  a  similar  incision,  beginning  and  ending  at  the  same 
points,  below  the  hernia  running  in  the  fold  between  the  pendulous  abdominal 
fat  and  the  supra-pubic  region.     Incise  deeply  enough  to  expose  the  aponeurosis. 

2.  Through  both  incisions  separate  the  fat  from  the  aponeurosis  towards  the 
hernia.     When  the  neck  of  the  hernial  sac  is  exposed  open  it  and  treat  its  con- 


FiG.  765. — WuUstein's  operation  for  ventral  hernia. 


tents  as  described  in  Step  3  of  the  classical  operation  (page  617).  Remove  the 
skin  and  fat  included  between  the  primary  incision.  Complete  the  operation  by 
the  Mayo  method. 

Congenital  eventration  or  evisceration  is  an  extremely  fatal  deformity.  The 
difficulty  in  replacing  the  viscera  is  due  to  the  fact  that  the  usual  infantile 
"pot  belly"  is  absent,  the  recti  muscles  pass  straight  down  from  costal  margin  to 
pubis;  the  intestines,  though  distended  with  meconium,  not  having  pushed 
them  forwards  in  the  usual  fashion. 

Charles  G.  Mixter  has  operated  (personal  communication)  as  follows:  If 
the  prolapsed  viscera  are  covered  with  peritoneum  excise  this  but  leave  a  margin 
of  peritoneum  3^  inch  wide  around  the  opening  at  the  umbilicus.  Enlarge  the 
hernial  opening  by  a  transverse  incision  on  each  side.  Lift  up  the  lower  margin 
of  the  wound  so  as  to  expose  the  peritoneal  surface  of  the  lower  anterior  abdomi- 
nal wall.  Working  from  the  inside  of  the  abdomen  make  a  transverse  incision 
from  the  middle  line  outwards  to  the  flank  dividing  all  the  structures  of  the 
abdominal  wall  except  the  skin  and  superficial  fascia.     Make  a  corresponding 


622 


RETRO-PERITONEAL    AXU    DIAPHRAGMATIC    HERNIA 


incision  at  a  slightly  different  level  on  the  opposite  side  of  the  lower  abdomen. 
Make  similar  incisions  in  the  upper  part  of  the  abdominal  wall.  Attend  to 
hemostasis.  Empty  the  bowel  by  multiple  punctures  and  replace  it  in  the 
abdomen.     Close  the  wound. 


CHAPTER   XLVr 

RETRO -PERITONEAL,  LARGE  AND  DIAPHRAGMATIC  HERNIA 

RETRO-PERITONEAL  OR  INTERNAL  HERNIA 

Normally  the  peritoneal  cavity  is  provided  with  a  number  of  apertures  or 
fossae  which,  under  ordinary  circumstances,  are  entirely  harmless,  but  which 
may  become  dangerous  owing  to  various  anomalies  of  development  and  to 
adverse  circumstances.  The  following  are  the  most  important  of  these 
structures: 

I.  The  foramen  of  Winslow.  In  a  few  cases  small  intestine  has  entered 
the  lesser  peritoneal  sac  through  this  opening.  The  condition,  if  found  during 
life,  demands  that  the  herniated  intestine  be  reduced  into  its  proper  location 
and  that  the  foramen  be  lessened  in  size  or  obliterated.     Probably  the  trauma 


Plica  duodeno- 
mesocolica 


Kidney 


Duo 


Jnferior  mesenteric  vein  Left  colic  artery 

Fig.  766. — {Ziickcrkandl.) 

due  to  the  hernia  and  its  reduction  will  produce  enough  plastic  peritonitis  to 
effect  obliteration;  a  gauze  or  cigarette  pack  introduced  into  the  foramen  would 
act  similarly,  or  one  or  two  catgut  sutures  may  be  judiciously  introduced. 

2.  Recessus  duodenojejunalis.  At  the  point  where  the  duodenum  passes 
into  the  jejunum  a  fold  of  peritoneum,  containing  the  inferior  mesenteric  vein, 
forms  a  semilunar  opening  to  the  left  of  the  origin  of  the  jejunum  (Fig.  766). 
Usually  this  opening  or  recess  is  shallow  and  not  wider  than  a  man's  thumb. 


INTERNAL   HERNIA 


623 


Jonnesco  and  others  have  described  several  varieties  of  recess  in  this  situation, 
but  for  our  purposes  the  recognition  of  its  existence  and  of  its  proneness  to  vary, 
suffices.  Intestine  may  bore  its  way  into  the  recess  described,  enlarging  the 
opening  and  forming  a  retro-peritoneal  hernia  (Treitz's  hernia).  The  pouch 
formed  by  the  herniated  gut  may  stretch  to  the  left  under  the  descending  colon 
and  downwards  to  the  pelvis.  Upwards  the  hernia  may  pass  under  the  root 
of  the  transverse  mesocolon  to  a  position  behind  the  stomach  and  spleen. 
Strangulation  is  rare.  It  is  commonly  supposed  that  small  intestine  alone  is 
involved,  but  Freeman  ("Transactions  American  Surg.  Assoc,"  1903)  describes 
a  case  in  which  the  sac  contained  the  entire  small  intestine,  the  caecum  and  a 
portion  of  the  colon,  which  was  strangulated.  A.  Narath  ("Archiv  f.  klin. 
Chir.,"  Ixxi,  911)  reports  a  case  in  which  prior  to  operation  the  diagnosis  was 
pyloric  or  gall-bladder  tumor.     When  the  abdomen  was  opened  above  the  um- 


Superior  ileo-caecal  fossa 


Inferior  ileo-caecal  fossa 


Fig.   767. — {Zuckerkandl.} 


bilicus,  the  small  intestines  presented  in  front  of  the  great  omentum,  the  trans- 
verse colon,  and  the  stomach.  When  the  small  intestine  was  pulled  out  of  the 
belly  cavity  for  inspection,  the  caecum  and  vermiform  appendix  followed,  ap- 
pearing above  the  lesser  curvature  of  the  stomach.  The  case  was  one  of  hernia 
through  the  recessus  duodenojejunalis;  the  gut  passed  up  behind  the  stomach 
and  then  forwards  through  the  gastro-hepatic  omentum.  Reduction  was  easy, 
and  the  duodenojejunal  opening  was  closed  by  a  few  stitches  of  catgut.* 

3.  Pericaecal  fossse.  Three  fossae  exist  in  the  neighborhood  of  the  ileo-caecal 
junction  (Fig.  767):  (o)  Ileo-colic  fossa,  which  lies  above  the  ileum  and  below 
the  ileo-colic  fold  containing  the  colic  branch  of  the  ileo-colic  artery.  (6)  Ileo- 
caecal  fossa.  The  orifice  of  this  fossa  is  situated  below  the  ileum,  where  it  joins 
the  caecum.     The  fossa  may  be  large  and  extend  upwards  posterior  to  ascend- 

*  For  extended  information  on  this  subject  the  reader  is  referred  to  Freeman's  paper 
already  mentioned,  to  Moynihan's  work,  "Retroperitoneal  Hernia,"  London,  1906,  to  Jon- 
nesco's  "Hernies  internes  retro-peritoneales,"  Paris,  1890.  Vautrin,  "Les  Hernies  Paraduo- 
denales,"  Rev.  de  Chir.,  Jan.,  1907.     Desjardins  "Mayo  Clinics.  1917." 


624 


RETRO -PERITONEAL   AND    DIAPHRAGMATIC    HERNIA 


ing  colon  as  far  as  the  right  kidney,  (c)  Subcecal  fossa.  This  fossa  Hes  be- 
neath the  cascum  and  external  to  the  meso-appendix  and  meso-ca;cum.  Any 
one  of  the  pericaecal  fossae  may  be  the  site  of  an  internal  hernia,  especially  if  its 
normal  relations  have  been  altered  by  attacks  of  appendicitis.  The  fossae  are 
also  of  surgical  importance,  as  they  may  be  filled  with  the  products  of  inflamma- 
tion in  appendicitis,  and  into  one  of  them  the  appendix  itself  may  be  herniated, 
4.  The  intersigmoid  fossa  (Fig.  768).  On  the  lower  or  left  surface  of  the 
meso-sigmoid  a  fossa  may  exist  which  is  variable  in  size.  A  few  cases  of  hernia 
have  been  described  in  which  this  fossa  formed  the  sac. 

Sigmoid 


tersigmoid  fossa 


1^  Drs  ending  colon 


Ureter 


Fig.  768. — (Zuckerkandl.) 

Many  operations  have  been  undertaken  for  the  treatment  of  obscure  in- 
testinal obstruction,  chronic  or  acute,  and  in  many  of  these,  symptomatic 
recovery  has  ensued,  although  no  cause  was  discovered  during  the  operation. 
Undoubtedly  in  many  of  these  cases  an  internal  hernia  has  been  overlooked  or 
has  been  reduced,  unknown  to  the  operator,  by  the  manipulations  necessary 
in  exploration. 

This  short  chapter  has  been  written  to  direct  the  attention  of  the  junior 
surgeon  to  the  probable  sites  of  internal  herniae.  The  author  believes  that 
internal  herniae  are  very  much  more  common  than  statistics  would  indicate. 

LARGE  HERNIA 

Occasionally  herniae  become  so  large  and  contain  so  many  organs  that  these 
organs  may  be  said  to  have  lost  their  right  of  domicile  in  the  abdomen,  and 
hence  reduction,  whether  operative  or  non-operative,  becomes  impossible  or 
unjustifiable.  In  other  cases  adhesions  uniting  the  hernial  contents  to  each 
other  and  to  the  sac  constitute  a  condition  which,  either  alone  or  in  combination 
with  a  poor  state  of  the  general  health,  contraindicate  any  attempt  at  reduction. 
In  such  cases  when  strangulation  or  obstruction  becomes  evident,  what  means 
have  we  to  overcome  their  disastrous  results? 


DIAPHRAGMATIC    HERNIA  625 

If  the  strangulation  is  due  to  constriction  at  the  hernial  orifice,  common 
sense  tells  us  to  divide  the  constriction  by  free,  open  incision,  and,  contrary  to 
the  practice  in  "radical  cure,"  to  endeavor  to  retain  the  increased  patency  of 
the  opening  between  the  abdominal  cavity  and  the  hernial  sac.  In  other  words, 
our  aim  ought  to  be  to  make  the  abdominal  cavity  and  hernial  sac  as  nearly 
as  possible  one.  ^ 

Usually  in  large  herniie  nature  has  so  dilated  the  abdominal  orifice  that 
strangulation  at  this  point  is  rare.  It  is  more  common  to  find  that  adhesions, 
bands,  diverticula,  etc.,  in  the  hernial  sac  itself  are  the  cause  of  strangulation. 
As  Madelung  ("Archiv  f.  klin.  Chir.,"  Ixxiv,  60)  points  out,  gangrene  may  be 
far  advanced  in  herniae  of  this  class,  and  symptoms  be  almost  absent;  thus 
during  operation  one  may  be  compelled  to  excise  a  considerable  amount  of 
diseased  gut,  joining  the  afferent  and  efi'erent  sections  by  anastomosis  or 
enterorrhaphy,  or  may  establish  a  faecal  fistula.  Some  surgeons  have,  on 
general  principles,  excised  a  mass  of  herniated  gut,  so  that  reduction  of  the 
remainder  became  possible  and  a  radical  cure  could  be  effected. 

In  very  large  hernias  there  is  always  some  obstruction  to  the  onward  passage 
of  faeces;  this  obstruction  varies  from  time  to  time.  Mild  exacerbations  are 
usually  successfully  treated  by  purgation,  enemata,  rest  in  bed,  massage,  etc., 
but  occasionally  operative  interference  becomes  necessary.  Madelung  writes: 
"In  many  cases,  especially  the  old  and  feeble,  when  coprostasis  has  continued 
for  a  long  time,  it  is  very  proper  to  establish  a  fistula  in  the  afferent  gut.  Under 
local  anesthesia  this  is  absolutely  without  danger  even  in  the  most  debilitated. 
The  fistula  should  be  small,  about  the  size  of  a  medium-sized  Paquelin  cautery 
point.  It  should  drain  only  part  of  the  intestinal  contents,  acting  as  a  kind  of 
safety-valve."  When  the  patient  is  strong  enough  to  withstand  a  more  severe 
operation,  intra-abdominal  anastomosis  between  the  afferent  and  efferent  loops 
of  gut  serves  to  segregate  or  exclude  the  affected  viscera  (see  "Intestinal 
Exclusion").  It  is,  of  course,  impossible  to  formulate  precise  rules  for  the 
operative  treatment  of  irreducible  herniae,  but  it  is  hoped  the  above  brief  re- 
marks may  aid  the  inexperienced  practitioner  in  an  emergency. 

DIAPHRAGMATIC   HERNIA  1 

The  diaphragm  is  the  site  of  several  actual  or  potential  openings,  the  prin- 
cipal one  being  that  between  the  costal  and  sternal  origins  of  the  muscle  and 
known  as  the  foramen  of  Morgagni.  Hernia  through  Morgagni's  foramen  is 
known  as  parasternal  hernia,  and  is  provided  with  a  double  sac,  of  pleura  and 
peritoneum.  For  our  purpose  it  is  useless  to  differentiate  between  the  so-called 
true  hernia  and  the  false,  where,  owing  to  injury,  there  is  a  prolapse  of  abdominal 
organs  into  the  thorax.  Few  diaphragmatic  herniae  present  marked  symptoms 
prior  to  strangulation.  Berard  and  Dunet  (Lyon  Chirurg.,  XV,  509)  think  the 
only  striking  early  symptom  is  painful  thoracic  tension  with  gurgling  especially 
noted  when  the  patient  is  lying  down  after  a  meal.  Until  the  advent  of  the 
a;-ray  the  diagnosis  of  diaphragmatic  hernia  was  a  rarity  and  its  discovery 
usually  dependent  on  operation  or  autopsy.  The  commonest  cause  of  dia- 
phragmatic hernia  is  trauma,  usually  from  knife  or  bullet,  and  the  proper 

40] 


626  RETRO -PERITONEAL    AND    DLAPHRAGMATIC    HERNIA 

treatment  is  immediate  operation.  In  Lacher's  statistics  of  36  traumatic 
cases  not  submitted  to  operation,  15  died  from  hernia  after  periods  varying 
from  a  few  days  to  a  month,  and  10  died  in  from  five  to  twenty  years  from  the 
same  cause.  A  wound  of  the  diaphragm  when  left  to  itself  may  heal,  but  the 
scar  remains  weak  and  hernia  is  the  common  result.  This  being  true,  the  best 
treatment  for  traumatic  diaphragmatic  hernia  is  prophylactic.  The  wound  of 
entrance  is  almost  always  in  the  thorax.  Enlarge  the  wound,  excise  two  inches 
or  more  of  one  or  two  ribs,  as  may  be  required,  to  give  room.  Note  if  the  pleura 
is  or  is  not  injured.  In  a  case  operated  on  by  the  writer  the  pleura  was  unin- 
jured, though  the  diaphragm  was  penetrated  and  omentum  was  present  in  the 
thorax.  Expose  and  examine  the  diaphragm.  If  the  diaphragm  has  been 
penetrated  and  omentum  or  hollow  \dscera  present,  examine  and  repair  any 
injury  thay  may  have  sustained.  Open  the  abdomen  either  by  a  median  or 
lateral  incision,  or,  as  Xeugebauer  ("Archiv  f.  klin.  Chir.,"  Ixxiii,  1014)  did,  by 
a  cut  dividing  the  costal  arch.  It  is  usually  easier  to  reduce  the  prolapsed 
organs  after  the  abdomen  has  been  opened,  and  it  is  necessary  to  explore  the 
abdomen  in  search  for  further  injuries.  If  no  abdominal  contents  are  prolapsed 
through  the  diaphragmatic  wound,  open  the  abdomen  and  search  for  any  inju- 
ries to  its  contents.  If  the  liver  is  injured,  treat  such  injuries  secundum  artem. 
Close  the  wound  in  the  diaphragm  with  sutures  introduced  by  the  transthoracic 
route.  Close  the  wound  in  the  abdomen  and  thorax  with  or  without  drainage. 
In  52  cases  of  diaphragmatic  suture  (where  there  was  no  strangulated  hernia) 
the  mortality  was  9.6  per  cent,  when  the  transthoracic  route  was  adopted;  in 
10  similar  cases  when  the  abdominal  route  was  used  the  mortality  was  50  per 
cent.  Of  the  cases  of  strangulated  diaphragmatic  hernia  collected  by  Xeuge- 
bauer, all  those  operated  on  through  the  abdominal  route  died;  one  out  of  two 
operated  on  through  the  thorax  lived.  Two  cases  of  non-strangulated  dia- 
phragmatic hernia  submitted  to  radical  cure  (Llobet's  and  Cranwell's)  lived 
after  a  transthoracic  operation. 

Donald  Balfour  (personal  communication)  has  operated  successfully  by  the 
abdominal  route. 

WTien  operation  is  performed  for  obscure  abdominal  lesions,  one  ought  to 
remember  and  look  for  diaphragmatic  hernia,  and  if  such  is  found,  one  ought 
not  to  waste  time  endeavoring  to  reduce  it  from  the  abdominal  side,  but  proceed 
at  once  to  open  the  chest.  Suture  of  the  diaphragm  from  below  is  extremely 
difiScult  and  necessitates  very  much  disturbance  in  a  region  rich  in  important 
nerves.  Prolapsed  masses  which  it  is  impossible  to  reduce  from  the  abdomen 
alone  are  easUy  reduced  or  slip  back  of  themselves  as  soon  as  the  chest  is  well 
opened.  That  the  dangers  from  pneumothorax  are  not  so  great  as  is  usually 
imagined  is  shown  by  the  small  mortality  (9.6  per  cent.)  after  recent  wounds 
of  the  thorax.  Furthermore,  if  the  hernia  is  reduced  through  the  abdominal 
route,  pneumothorax  must  occur  immediately  the  hernia  ceases  to  plug  the 
diaphragmatic  wound,  while  the  establishment  of  pneumothorax  prior  to  reduc- 
tion aids  marvelously  in  obtaining  this  reduction. 

Cranwell  ("Rev.  de  Chir.,"  Jan.,  1908)  recognized  the  presence  of  a  dia- 
phragmatic hernia  before  he  operated.  His  patient  was  placed  on  his  side  in 
the  reversed  Trendelenburg  posture.     The  lower  and  lateral  part  of  the  thorax 


DIAPHRAGMATIC   HERNIA 


627 


Fig.  769. — Cranwell's  operation  for  diaphragmatic  hernia. 
P.  Pleura.     D.  Diaphragm.     O.  Omentum.     C.  Colon. 


^earf^ 


Fig.  770. — (Carson,  Interstate  Med.  Joiirn.) 


628  RETRO-PERITONEAL    AND    DIAPHRAGMATIC   HERNIA 

was  opened  by  a  flap  having  its  base  above,  consisting  of  the  whole  thickness 
of  the  chest-wall  and  containing  about  5  inches  of  the  ninth  and  eighth  ribs 
(Fig.  769).  In  spite  of  numerous  adhesions  the  prolapsed  omentum  and  colon 
were  reduced,  the  openings  in  the  diaphragm  and  in  the  pleura  were  sutured 
and  the  external  wound  closed.  The  patient  recovered.  The  hernia  was  due 
to  an  old  stab-wound  which  had  healed. 

N.  B.  Carson  ("Interstate  Med.  Journ.,"  April,  191 2)  reports  a  successful 
operation  for  diaphragmatic  hernia  (supposed  to  be  of  congenital  origin),  in 
which  a  correct  diagnosis  was  made  prior  to  operation.  Insufflation  anesthesia 
was  used  and  the  intrathoracic  structures  were  prevented  from  drying  by  being 
smeared  with  vaseline.  The  use  of  Carrel's  vaselinized  silk  napkins  to  protect 
the  lungs,  etc.,  was  found  impracticable.  It  was  necessary  to  resect  several 
ribs  before  proper  access  was  obtained.  Fig.  770  shows  the  exposure  of  the 
hernia  which  consisted  of  small  intestines,  stomach,  colon  and  omentum.  Re- 
duction was  effected  only  after  the  abdomen  was  also  opened.  After  suture  of 
the  diaphragm  the  wound  in  the  chest  wall  was  closed  in  layers,  but  before 
closing,  the  pressure  was  raised  and  the  lung  fully  expanded. 

O.  J.  Seibert  (Surg.,  Gyn.  Obst.,  Oct.,  1916)  diagnosed  and  operated  upon 
a  hernia  of  the  stomach  into  the  posterior  mediastinum  directly  behind  the 
heart.  The  abdominal  route  was  chosen  (it  is  difficult  to  imagine  how  success 
could  have  been  attained  in  this  case  by  the  thoracic  route).  The  hernial 
opening  was  the  oesophageal  diaphragmatic  lacuna  and  the  pylorus  was  fixed 
to  this  by  dense  fibrous  bands  which  required  division  before  reduction  was 
possible.  After  reduction  the  opening  was  closed  sufficiently  with  chromicized 
catgut  sutures  and  the  stomach  was  fixed  to  the  anterior  parietes  by  a  couple 
of  stitches.     Recoverv  ensued. 


PART  IV.-THE  GENITO-URINARY  SYSTEM 


CHAPTER  XLVII 


OPERATIONS  UPON  THE  KIDNEY 
METHODS  OF  EXPOSING  THE  KIDNEY 

I.  Posterior  or  Lumbar  Route. — There  are  two  positions  in  which  the 
patient  may  be  placed: 

(a)  The  classical  or  lateral  posture.  Place  the  patient  upon  this  sound  side 
with  his  back  near  the  edge  of  the  operating  table  and  his  thighs  and  knees  well 
flexed.  To  increase  the  space  between  the  thorax  and  ilium,  place  a  roll- 
shaped,  firm  pillow  under  the  loin  of  the  sound  side.  The  surgeon  stands  at  the 
patient's  back. 

(b)  The  prone  position.  This  position  is  the  best  for  most  purposes.  Lay 
the  patient  prone  upon  the  table.     Place  a  large  pillow  (Edebohls'  air-cushion, 


n 

WKP 

^ 

1 

m 

5^ 

^^M 

^^^p 

*. 

Q 

■ 

1 

p.. 

M 

■ 

^ 

1 

H 

^^R.     ^^ 

m 

1 

P 

II 

I 

?^>ws6 

Mi 

1 

■ 

\ 

Fig.  771. — {Edebohls,  Annals  of  Surg.) 


1 2  inches  long  by  8  inches  in  diameter,  is  excellent)  beneath  his  abdomen  with  its 
long  axis  at  right  angles  to  the  long  axis  of  the  body.  This  lifts  the  kidneys 
into  the  field  of  operation  and  gives  the  widest  possible  costo-iliac  space.  The 
operating  table  referred  to  as  suitable  in  operations  on  the  bile  ducts  is  of  value 
here  to  replace  sand-bags  and  cushions  (see  p.  563). 

(A)  Vertical  Incision  (Simon). — Recognize  the  last  rib  and  the  erector 
spinae  muscle.  Make  a  vertical  incision  from  the  last  rib  downwards,  parallel 
and  close  to  the  outer  edge  of  the  erector  spinae  muscle.  This  penetrates  the 
skin  and  subcutaneous  tissue  and  extends  nearly  to  the  crest  of  the  ilium.     The 

629 


630 


OPERATIONS    UPON    THE    KIDNEY 


latissimus  dorsi  is  now  seen.  Separate  but  do  not  cut  its  muscular  fibres 
(Figs.  771  and  772).  The  erector  spina?  muscle  presents.  Retract  it  inward, 
but  do  not  open  its  sheath.  Expose  and  open  the  sheath  of  the  quadratus  lum- 
borum  along  its  outer  margin  for  the  full  length  of  the  wound.  As  the  pleura 
occasionally  extends  below  the  last  rib,  it  is  wise  to  avoid  the  neighborhood  of 
this  rib  while  making  deep  dissection.  By  keeping  one  inch  below  the  rib,  all 
danger  to  the  pleura  is  avoided  and  at  a  little  later  period  in  the  operation  the 
wound  can  be  safely  enlarged  upwards  under  guidance  of  the  finger.  As  soon  as 
the  fascia  lumborum  or  transversalis  fascia,  lying  in  front  of  the  quadratus  lum- 
borum,  is  divided,  perirenal  fat  bulges  into  the  wound.     Remember  that  the 

last  thoracic,  iliohypogastric,  and  ilio- 
inguinal nerves  lie  between  the  quad- 
ratus muscle  and  the  kidney.  These 
nerves,  when  met  with,  should  be  care- 
fully pulled  aside,  or  if  it  is  necessary 
to  divide  one  of  them,  the  severed  ends 
ought  to  be  caught  up  in  a  suture,  so 
that  when  the  operation  is  completed 
and  the  wound  is  being  closed,  they 
may  be  once  more  united  (Edebohls). 
Failure  to  attend  to  this  point  may 
lead  to  an  annoying  and  persistent  pain 
in  the  thigh  after  operation.  When  the 
perirenal  fat  is  exposed,  tear  through  it 
and  expose  the  kidney. 

If  the  above  incision  does  not  give 
sufficient  room,  make  a  small  transverse 
incision  through  the  outer  fibres  of  the  quadratus  muscle  near  the  ilium;  this 
simple  proceeding  is  of  great  aid.  To  gain  more  room,  some  surgeons  have 
recommended  excision  of  the  last  rib,  but  this  has  not  proved  of  much  value. 
A  better  suggestion  has  been  made,  namely,  to  fracture  the  last  rib  and 
turn  it  upwards.  It  is  easy  to  deliver  the  kidney  on  to  the  back  through  this 
incision. 

(B)  Oblique  Incision  (Bergmann). — From  the  outer  edge  of  thee  rector  spinae, 
at  the  level  of  the  twelfth  rib,  make  an  incision  downwards  and  outwards 
towards  the  junction  of  the  outer  and  middle  thirds  of  Poupart's  ligament. 
The  length  of  the  incision  varies  with  the  work  to  be  done  and  the  size  of  the 
operator's  hand.  It  must  be  large  enough  to  give  free  access  to  the  kidney.  A 
cut  four  inches  in  length  is  generally  sufficient  for  exploratory  purposes  and  may 
readily  be  enlarged.  The  lower  border  of  the  latissimus  dorsi  presents  and  must 
be  divided.  Layer  by  layer  cut  through  the  external  oblique,  the  internal 
oblique,  the  transversalis  muscle.  Under  the  last-named  muscle  lies  the  trans- 
versalis fascia.  Make  a  small  opening  in  the  fascia  and,  guided  by  the  finger 
passed  through  the  opening,  divide  it  for  the  whole  length  of  the  wound.  The 
quadratus  lumborum  lies  at  the  upper  and  inner  part  of  the  wound  and  is  either 
retracted  towards  the  spine  or  divided,  as  may  be  convenient.     After  division 


Fig.  772. — {Esmarch  and  Kowalzig.) 
I.  External  oblique.     2.   Internal  oblique.     3. 

Transversalis.     4.   Transversalis   fascia,     s,    6,    7. 

Lumbo-dorsal      fascia.        8.      Sacrospinalis.        9. 

Quadratus    lumborum.     10.     Psoas,     ii.     Colon. 

12.  Pancreas.      13.  Kidney.      14.   Spleen. 


LUMBAR    INCISIONS 


631 


of  the  transversalis  fascia  the  perirenal  fat  presents  and  is  torn  through  until 
the  kidney  is  reached.  During  the  deeper  dissection  care  must  be  taken  not 
to  injure  the  pleura  should  it  descend  below  the  last  rib. 

(C)  Triangular  incision  (Konig). — From  the  outer  edge  of  the  erector  spinae, 
at  the  level  of  the  twelfth  rib,  cut  downwards  parallel  and  close  to  the  erector 
muscle  until  the  iliac  crest  is  reached.  From  the  lower  end  of  the  wound  make  a 
curved  incision  directed  towards  the  navel  and  reaching  to  the  outer  margin 
of  the  rectus  abdominalis.  The  division  of  the  deeper  structures  is  carried  out 
in  the  manner  already  described.  Any  parietal  peritoneum  which  may  be 
exposed  is  pushed  aside.  Very  free  access  to  the  kidney  or  to  tumors  of  that 
organ  is  attained. 

(D)  Zuckerkandl's  Incision. — From  the 
outer  edge  of  the  erector  spinas,  at  the  level 
of  the  twelfth  rib,  cut  downwards  to  the 
middle  of  the  iliac  crest;  from  the  latter  point 
cut  forwards  to  near  the  anterior  superior 
spine  of  the  ilium.  The  deep  dissection  is 
done  as  already  described. 

(E)  Trap-door  Incision  (Bardenheuer).— 
From  the  upper  and  lower  extremities  of  the 
vertical  incision  (A)  make  horizontal  cuts 
parallel  to  the  lower  edge  of  the  thorax  and 
to  the  iliac  crest  respectively.  If  these  cuts 
run  forwards,  a  trap-door  is  formed  which 
can  be  reflected  or  retracted  anteriorly;  if 
they  run  backwards  (i.e.,  towards  the  spine), 
wards  is  the  result.  In  some  cases  it  may  be  desirable  to  form  both  an  ante- 
rior and  a  posterior  trap-door  flap. 

Should  the  peritoneum  be  opened  during  the  operation,  it  ought  to  be  closed 
at  once  by  suitable  sutures. 

(F)  C.  T.  Parkes'  Incision. — Make  a  curved  incision  from  a  point  two  inches 
above  the  anterior  superior  spine  to  the  tip  of  the  last  rib.  Expose  the  fascia 
transversalis.  With  the  finger  dissect  well  behind  the  tumor  of  the  kidney. 
Having  separated  all  parts,  make  a  straight  incision  backwards  from  the  first 
cut  and  half-way  between  the  crest  of  the  ilium  and  the  last  rib.  An  excellent 
exposure  is  obtained  of  the  kidney,  vessels,  and  ureter. 

(G)  Mayo's  Incision. — ("Annals  Surg.,"  Jan.,  191 2.) 

Step  I. — From  a  point  2  to  2^^  inches  external  to  the  dorsal  spines  near  the 
outer  margin  of  the  erector  spinae  over  the  twelfth  rib,  or  even  higher,  make  an 
incision  downwards  and  forwards  along  the  anterior  margin  of  the  quadratus 
lumborum  to  a  point  about  i  inch  above  the  crest  of  the  ilium  (Fig.  773).  From 
this  low  point  continue  the  incision  forward  parallel  to  the  iliac  crest  as  far  as 
necessary.  Divide  the  skin,  superficial  and  posterior  layer  of  the  lumbo- 
dorsal  fascia  which  covers  the  erector  spinae  muscle. 

Step  2. — Expose  the  posterior  superior  lumbar  triangle  just  beneath  the 
twelfth  rib  by  cutting  an  opening  through  the  external  and  internal  oblique, 


•     Fig.  773. — {Mayo.) 

one  which  can  be  turned  back- 


632 


OPERATIONS    UPON    THE    KIDNEY 


transversalis  and  latissimus  dorsi  muscles.  Open  the  transversalis  fascia  freely 
and  so  expose  the  perirenal  fat.  Clear  the  twelfth  rib  in  its  posterior  aspect, 
upwards  and  backwards  nearly  to  its  articulation.  Push  the  pleura  upwards. 
Retract  the  rib  upwards  and  the  erector  spina  backwards  (Fig.  774).  This 
gives  remarkably  good  exposure  and  very  much  simplifies  all  operations  on  the 
kidney  possible  through  the  lumbar  route.  If  necessary  the  twelfth  rib  may  be 
dislocated  or  fractured  to  permit  even  greater  exposure. 


I- 10.  774. — (Mayo.) 


II,  Anterior  or  Abdominal  Route.- — If  the  kidney  to  be  exposed  is  very  large, 
an  incision  may  be  made  over  the  tumor  at  any  place  which  may  seem  suitable 
or  advisable.  Such  an  incision  will  be  either  vertical  or  oblique  (running  from 
above  downwards  and  inwards).  Langenbuch's  incision  will  generally  be  found 
to  be  the  best,  as  it  gives  free  access  to  the  renal  vessels  and  avoids  unnecessary 
exposure  of  the  intestines.  Klister  makes  it  a  rule  to  operate  by  the  transperi- 
toneal route  in  cases  of  neoplasm  when  difficulties  and  adhesions  are  present;  if 
the  tumor  is  very  mobile  he  chooses  the  lumbar  route. 

Langenbuch's  Method. — From  a  point  immediately  below  the  ribs  and  about 
three  inches  from  the  middle  line  cut  downwards  for  a  distance  of  four  inches. 
Find  the  outer  edge  of  the  rectus  muscle  (linea  semilunaris).     Cut  down  to 


NEPHROPEXY  633 

the  peritoneum,  following  the  semilunar  line.  Open  the  peritoneum  carefully 
in  the  same  manner  as  a  sac  is  opened  during  a  herniotomy.  Introduce  the 
hand  and  examine  the  opposite  kidney  and  ureter.  This  is  a  most  important 
precaution,  and  must  always  be  observed.  The  opportunity  afforded  to  ex- 
amine the  opposite  kidney  constitute  one  of  the  advantages  of  the  abdominal 
route  over  the  lumbar.  Von  Eiselsberg  convinced  himself  by  touch  (of  the 
hand  in  the  abdomen)  that  the  second  kidney  was  present,  yet  after  nephrectomy 
the  patient  died  from  uremia.  Autopsy  showed  absence  of  the  other  kidney, 
the  surgeon  having  taken  an  induration  of  the  pancreas  to  be  a  kidney.  The 
opposite  kidney  and  ureter  being  found  healthy,  the  intestines  are  covered 
with  a  large  flat  gauze  pad  and  kept  out  of  the  way.  The  outer  surface  of  the 
mesocolon  is  exposed  and  a  small  hole  made  in  its  outer  layer.  This  hole  is 
enlarged  by  tearing.  The  vessels  which  pass  through  the  mesocolon  lie  close 
to  its  inner  layer,  and  thus  injury  to  them  is  avoided.  Through  the  opening  in 
the  mesocolon  the  kidney  is  easily  and  completely  exposed. 

Rutherford  Morison's  Incision. — Open  the  abdomen  through  the  rectus 
muscle.  Make  a  transverse  incision  from  this  back  to  the  centre  of  the  ilio- 
costal space.  Morison  writes:  "This  allows  pus  to  escape  behind  and  away 
from  the  peritoneum,  perfect  drainage  after,  and  good  access  to  vessels  and 
ureter  during  operation."  It  also  permits  exploration  of  the  opposite  kidney  at 
the  beginning  of  the  operation. 

Nephropexy  or  Nephrorrhaphy. — Method  I. — Expose  the  kidney  by  incision 
A  or  B.  Excise  most  of  the  fatty  capsule  lying  posterior  to  the  kidney.  An 
assistant  with  his  fist  pressing  on  the  belly  pushes  the  kidney  up  into  the 
loin.  Pass  a  curved  needle,  armed  with  a  thick  suture,  through  the  muscles 
and  fascia  of  the  back  which  form  the  outer  edge  of  the  wound,  through  the 
remnants  of  the  fatty  capsule  and  into  the  kidney  parenchyma  near  the  outer 
convex  border  of  the  kidney.  The  needle  penetrates  the  kidney  to  a  depth 
of  about  one-half  inch  and  emerges  at  a  point  about  three-quarters  of  an 
inch  internal  to  its  point  of  entrance.  After  emerging  from  the  kidney  the 
needle  passes  through  the  remnants  of  the  fatty  capsule  and  the  muscles  and 
fascia  of  the  back  which  form  the  inner  edge  of  the  wound.  Three  such  sutures 
are  put  in  place,  one  at  the  upper  end  of  the  kidney,  one  at  the  lower,  and  one  in 
the  middle;  but  none  of  them  are  tied.  The  deep  parts  of  the  wound  in  the  back 
are  now  approximated  by  buried  sutures.  When  this  is  done,  the  three  sutures 
which  pass  through  the  kidney  are  carefully  tied.  No  pulling  upon  these  im- 
portant sutures  is  allowable,  otherwise  they  would  cut  their  way  out  of  the 
friable  kidney.  This  is  the  reason  for  closing  the  deep  parts  of  the  lumbar 
wound  {i.e.,  the  parts  through  which  the  kidney  sutures  pass)  before  the 
kidney  sutures  themselves  are  tied.  The  superficial  wound  is  closed.  Some 
surgeons,  notably  Newman,  pass  a  drainage-tube  through  the  wound  to  the 
kidney  so  as  to  produce  a  local  irritation  and  thus  aid  in  the  formation  of 
adhesions.  Suture  materials:  Mildly  chromicized  catgut,  kangaroo  tendon, 
silk  or  silkworm-gut. 

Method  II. — Is  the  same  as  Method  I,  except  in  one  particular:  after 
the  kidney  is  exposed  a  longitudinal  incision  is  made  through  the  fibrous  cap- 
sule, which  when  turned  outwards  and  inwards  like  the  lapels  of  a  coat,  forms 


634 


OPERATIONS  UPON  THE  KIDNEY 


an  outer  and  an  inner  flap.  The  parenchyma  of  the  kidney  is  thus  left  exposed 
for  a  width  of  about  three-quarters  of  an  inch  throughout  almost  the  whole 
length  of  the  posterior  surface  of  the  organ.  The  sutures  are  introduced  as 
before,  except  that  when  entering  and  leaving  the  kidney  they  pass  through  the 
folded  flaps  of  fibrous  capsule. 

The  advantages  claimed  for  this  method  are  (a)  that  better  union  takes 
place  between  the  kidney  and  the  muscles  and  fascia  at  the  back;  (b)  that  the 
threads  passing  through  the  folded  back  flaps  of  fibrous  capsule  are  less  liable  to 
cut  their  way  out.  The  objections  urged  against  the  method  (especially  by 
Albarran)  are  (a)  that  decortication  is  unnecessary;  (b)  that  sclerotic  changes  are 
more  liable  to  occur  and  injure  the  kidney. 

Method  III. — The  kidney  is  exposed  by  incision  B.  At  a  point  opposite  the 
lower  extremity  of  the  kidney  (when  it  is  pushed  up  into  its  normal  position)  a 
pocket  is  formed  by  separating  the  transversalis  fascia  from  the  more  superficial 
structures.     Into  this  pocket  the  lower  end  of  the  kidney  is  snugly  tucked.     One 

or  two  sutures  unite  the  kidney  to  the  sur- 
rounding muscles  and  fascia  and  the  wound  is 
closed.  Pean  is  a  supporter  of  the  above 
operation. 

Method  IV  (Israel's). — Expose  kidney  by 
incision  A.  Recognize  the  last  rib.  Split  the 
fibrous  capsule  of  the  kidney  so  as  to  lay  bare  a 
narrow  strip  of  cortex  reaching  nearly  the  whole 
length  of  the  organ.  Through  the  upper  part 
of  the  posterior  surface  of  the  kidney  pass  a 
double  suture  of  thick  catgut  (Fig.  775,  A  A^,  a 
a^).  Cut  the  loop  of  the  suture  so  as  to  leave 
four  ends  of  suture  on  which  needles  are  to  be 
threaded.  Make  a  knot  on  the  double  thread 
of  catgut  where  it  enters  and  where  it  leaves  the 
kidney  (z-z).  One  of  the  threads  emerging  from 
the  outermost  part  of  the  kidney,  having  been 
armed  with  a  needle,  is  passed,  first,  through  the  fatty  capsule  of  the  kidney,  and 
then  between  the  periosteum  and  the  posterior  surface  of  the  twelfth  rib  (Fig. 
775,  A  A^).  The  other  end  of  thread  emerging  from  the  kidney  at  the  same 
point  is  passed  subperiosteally  in  front  of  the  twelfth  rib  in  such  a  manner 
that  the  two  ends  surround  the  rib  under  its  periosteum.  The  two  threads  are 
knotted  together.  The  two  ends  of  the  catgut  threads  which  emerge  from  the 
inner  part  of  the  posterior  surface  of  the  kidney  (a  a^  are  separately  passed 
through  the  fatty  capsule,  and  the  muscles  and  fascia  on  the  inner  side  of  the 
lumbar  wound.  These  two  ends  of  suture  are  now  tied  together,  care  being  taken 
not  to  tie  so  tightly  as  to  make  the  thread  cut  through  the  renal  tissue.  The  re- 
sult of  the  above  manoeuvre  is  to  sling  the  kidney  by  a  double  thread  the  outer 
end  of  which  surrounds  (subperiosteally)  the  twelfth  rib;  the  inner  end  is 
fastened  to  the  muscles  and  fascia  forming  the  inner  wall  of  the  lumbar 
wound.  Two  more  double  catgut  sutures  are  passed  through  the  kidney  in 
the  same  manner  and  their  loops  cut  so  that  each  double  suture  becomes  two 


Fig.   775. — Israel's  nephropexy. 


NEPHROPEXY 


635 


If//,  ///// 


distinct  sutures  passing  through  the  kidney  together.  The  ends  of  suture 
emerging  from  the  inner  part  of  the  kidney  are  each  separately  passed  through 
the  muscles  and  fascia  on  the  inner  side  of  the  wound  (B  B\  C  Q})  and  there 
tied  together;  those  emerging  from  the  outer  part  of  the  kidney  are  similarly 
passed  through  the  muscles  and  fascia  on  the  outer  side  of  the  wound  (c  c\  b  b^ 
and  there  tied.  The  threads  emerging  on  the  inner  side  are  tied  together; 
none  are  tied  across  the  wound.  The  lumbar  wound  is  closed  by  deep  and 
superficial  sutures. 

Method  V  (Jonnesco's  Operation). — Step  A. — Beginning  at  the  outer  edge 
of  the  erector  spinae  muscles,  make  an  incision  from  four  to  five  inches  along  the 
inferior  border  of  the  twelfth  rib.  If  the 
twelfth  rib  is  short,  the  incision  is  continued 
along  the  eleventh  rib.  Expose  the  whole 
of  the  twelfth  and  if  necessary  part  of  the 
eleventh  rib.  Cut  through  the  transversalis 
fascia  and  expose  the  kidney,  which  an  as- 
sistant presses  up  into  the  wound.  Excise 
most  of  the  fatty  capsule.  Split  the  fibrous 
capsule  of  the  kidney  longitudinally  and  turn 
outwards  and  inwards  an  outer  and  an  inner 
capsular  flap  (as  in  Method  II). 

Step  B. — Pass  a  curved  needle  (Emmet's 
needle)  through  the  following  structures  in 
the  order  named — the  skin  (one  inch  distant 
from  the  lower  edge  of  the  wound),  muscles 

of  sacro-lumbar  mass,  deep  aponeurosis,  folded  inner  flap  of  renal  capsule 
(formed  in  Step  A),  the  kidney  parenchyma,  the  folded  outer  flap  of  renal 
capsule,  the  periosteum  of  the  external  surface  of  the  twelfth  or  eleventh  rib, 
and  the  muscles  and  skin  of  the  superior  edge  of  the  wound  (Fig.  776). 
Thread  into  the  needle  the  end  of  a  silver  wire  suture;  withdraw  the  needle. 
Reintroduce  the  needle  in  the  same  manner  at  a  point  }/'2  inch  distant  and  pull 
through  the  other  end  of  the  silver  wire  suture.  The  result  is  that  a  U  suture 
is  in  place.  Two  such  suffice.  Through  the  loop  of  each  U  is  placed  a  small 
rod  or  pad  of  gauze  to  prevent  the  skin  being  cut.  The  other  ends  of  each 
U  suture  are  twisted  together  over  a  pad  of  gauze.  No  tension  is  put  on  the 
sutures  lest  they  cut  the  kidney  tissue;  their  function  is  to  suspend  the  kidney. 

Step  C. — Close  the  wound  with  catgut  or  silkworm-gut  sutures. 

The  dressings  are  left  untouched  for  ten  days,  after  which  time  all  the 
non-absorbable  sutures  are  removed. 

Method  VI  (Edebohls'  Operation). — Step  i. — Expose  the  kidney  by  Method 
A,  patient  being  in  prone  position 

Step  2.— Deliver  the  kidney  through  the  wound  and  excise  the  fatty  capsule. 

Step  3. — Decapsulate  the  kidney  and  introduce  suspension  sutures  of  forty- 
day  chromic  gut,  as  shown  in  Fig.  777. 

Step  4. — Reduce  the  kidney  and  pass  the  sutures  from  within  outwards 
through  the  whole  thickness  of  the  parietes  except  the  skin  and  tie  them  as  in 
Fig.  778. 


Fig.  776. — Jonnesco's  nephropexy. 


636 


OPERATIONS    UPON    THE    KIDNEY 


Step  5. — Close  the  lumbar  wound. 

In  performing  this  operation  do  not  endeavor  to  anchor  the  kidney  at  as 
high  a  level  as  its  normal  site,  and  be  careful  not  to  cause  any  kinking  of  the 


Fig.  777. — Edebohls' nephropexy.     {Edebohls,  Annals  of  Surg.) 

ureter.  The  main  principle  of  the  operation  is  to  bring  a  large  area  of  decorti- 
cated kidney  into  contact  with  a  corresponding  area  of  the  quadratus  muscle 
denuded  of  its  fascial  coverings. 


Fig.  778. — Edebohls' nephropexy.     {Edebohls,  Annals  of  Surg^) 


Method  VII. — Albarran  ("La  Presse  Medicale,"  21,  Aug.,  1906)  considers 
that  a  good  operation  must  fulfill  the  following  conditiohs:  (i)  Permit  explora- 
tion of  the  kidney  and  ureter.  (2)  Place  the  kidney  in  good  position.  (3)  Fix 
the  kidney  thoroughly.     (4)  Injure  the  parenchyma  as  little  as  possible. 

The  Operation. — Step  i. — Expose  the  kidney  by  Method  B.  In  tearing 
through  the  perirenal  fat  it  is  not  necessary  to  remove  any  of  it,  but  when 


NEPHROPEXY 


6.37 


retracting  the  fat  from  the  lower  pole  of  the  kidney  an  incision  through  it  at 
right  angles  to  the  original  wound  is  of  great  service. 

Step  2.— Deliver  the  kidney  on  to  the  back.     Explore  it  by  sight  and  palpa- 
tion.    Gross  changes  are  easily  made  out.     When  there  is  slight  hydronephro- 


FiG.  779. — Albarran's  nephropexy.     {La  Pr.  Med. 


Fig.  780.— Albarran's  nephropexy.     {La  Pr.  Med.) 


ItJ 


sis  the  kidney  is  not  so  firm  as  usual,  and  it  is  easy  to  bend  it  a  little  on  itself, 
which  is  impossible  in  the  normal  organ.  Examine  the  upper  end  of  the  ureter 
lest  kinks  or  bends  are  present  or  lest  fibrous  bands  cause  obstruction.  Correct 
abnormalities. 


638 


OPERATIONS    UPON    THE    KIDNEY 


Step  3. — Decorticate  the  kidney  completely,  making  the  reflected  true 
capsule  form  two  flaps  (anterior  and  posterior). 

Step  4. — Divide  the  anterior  flap  into  two  parts  (upper  and  lower)  (Fig.  779). 
Ligate  each  of  these  parts  with  strong  chromicized  catgut  (Fig.  780),  leaving 
both  ends  of  the  catgut  long.  Treat  the  posterior  capsular  flap  in  the  same 
manner. 

Step  5. — Retract  the  lumbar  muscles  inwards  and  expose  the  twelfth  rib. 
With  a  needle  draw  one  end  of  each  of  the  ligatures  attached  to  the  upper  por- 
tions of  the  capsule  round  the  rib  and  tie  it  to  the  same  end  of  the  other  ligature 
(Fig.  780).  This  suspends  the  upper  pole  of  the  kidney  to  the  rib.  One- 
third  of  the  long  diameter  of  the  kidney  ought  to  be  now  hidden  by  the  ribs.  If 
it  is  impossible  to  pass  the  sutures  round  the  twelfth  rib,  fix  them  to  the  ex- 
ternal periosteum  of  the  eleventh  rib  and  to  the  costo-vertebral  ligament. 
Before  tying  the  sutures  see  that  the  kidney  is  so  placed  that  the  ureter  is  free 
from  kinks  and  will  drain  the  lowest  point  of  the  pelvis. 


Fig.  781. — Albarran's  nephropexy.     [,La  Pr.  Med.) 


Step  6. — Fix  the  ligatures  attached  to  the  lower  portions  of  the  capsule 
to  the  muscles  on  each  side  of  the  wound.     Fig.  781  explains  this  step. 

Step  7. — Provide  for  drainage — close  the  wound  with  sutures. 

In  all  the  preceding  methods  of  nephropexy  the  aim  of  the  surgeon  has 
been  to  suture  or  sling  the  kidney  to  the  posterior  parietes.  Harris  has  shown 
that  in  cases  of  mobile  kidney  there  is  a  separation  of  the  posterior  peritonum 
from  the  parietes,  and  that  the  attachments  of  the  ascending  mesocolon  are 
loosened.  The  result  is  an  absence  of  normal  support  to  the  kidney  and  the 
presence  of  ptosis  of  the  ascending  colon. 

Harris'  Operation. — Place  the  patient  in  the  prone  position;  expose  the 
kidney  and  bring  it  out  through  the  wound.  Retract  the  edges  of  the  wound 
and  observe  the  post-peritoneal  cavity  into  which  the  kidney  has  been  in 


NEPHROPEXY  639 

the  habit  of  gliding  and  note  the  position  of  the  ascending  colon.  By  a  few 
carefully  placed  catgut  sutures  obliterate  the  above-named  space,  and  the 
essential  element  of  the  Harris  operation  is  completed.  Prepare  the  kidney 
for  suture,  reduce  it,  and  fix  it  to  the  parietes  by  one  of  the  methods  already 
described. 

The  Harris  operation  was  the  first  in  which  any  attention  is  paid  to  the 
fact  that  nephroptosis  is  often  merely  one  part  of  a  condition  of  general  visceral 
ptosis,  and  in  which  an  endeavor  is  made  to  correct  part  of  the  visceral  ptosis 
by  fixation  of  the  colon  (colopexy)  while  the  post-peritoneal  space  is  being 
obliterated.  Willard  Bartlett  obtains  the  objects  of  nephropexy  in  an  indirect 
manner.  His  argument  is  that  if  one  can  fill  up  the  hole  into  which  the  mobile 
kidney  slides  ptosis  becomes  impossible. 

Step  I. — Expose  the  perirenal  fat  through  any  appropriate  posterior  incision. 

Step  2. — Without  at  this  time  exposing  the  kidney,  separate  the  perirenal 
fat  from  the  anterior  surface  of  the  muscles  of  the  back.  Continue  this  separa- 
tion forwards  until  the  peritoneum  is  reached.  Separate  the  fat  from  the  peri- 
toneum up  to  the  pelvis  of  the  kidney. 

Step  3.— Carefully  penetrate  the  perirenal  fat  near  the  convex  edge  of  the 
kidney.  Insert  a  catgut  suture,  as  a  purse-string,  into  the  perirenal  fat  around 
this  hole  which  has  been  made  in  it. 

Step  4. — Deliver  the  kidney  on  to  the  back  through  the  tear  in  the  perirenal 
fat.  Push  the  capsule  of  perirenal  fat  towards  the  pelvis  of  the  kidney  until  it 
lies  like  a  ruff  around  the  renal  pedicle.  Tighten  and  tie  the  purse-string  suture 
taking  great  care  not  to  compress  the  renal  pedicle.  Leave  the  end  of  the  suture 
long. 

Step  5. — Push  the  mass  of  fat  into  the  depth  of  the  wound  and  reduce  the 
kidney.  Fix  the  end  of  the  purse-string  suture  to  the  anterior-inferior  end  of 
the  wound  in  the  parietes.  Close  the  wound.  The  mass  of  fat  compels  the 
kidney  to  retain  its  normal  position  and  is  much  aided  in  this  by  the  adhesions 
which  form  between  the  kidney  and  the  muscles  of  the  back. 

Mobile  kidney  is  exceedingly  common,  and  in  the  majority  of  cases  presents 
no  symptoms.  When  symptoms  are  present,  they  may  be  really  those  of 
neurasthenia,  in  which  case  fixation  of  the  kidney  can  scarcely  be  expected 
to  do  more  than  give  mental  relief.  Of  course,  cases  do  occur  in  which  the 
mobility  of  the  kidney  is  the  causative  factor,  where  tension  exerted  on  the 
structures  at  the  hilus  gives  rise  to  trouble  and  where  kinking  or  displace- 
ments of  the  ureter  occasion  distressing  symptoms  and  conditions.  It  is  in 
this  comparatively  small  class  of  cases  that  nephrorrhaphy  gives  gratifying 
results. 

G.  Percival  Mills  (Proc.  Royal  Soc.  of  Med.,  Feb.,  1914,  Surg.  Sect.)  reviewed 
all  the  cases  of  nephropexy  performed  in  the  General  Hospital,  Birmingham, 
during  1909-1912,  and  came  to  the  following  conclusions  which  support  the 
opinions  expressed  by  the  author  in  the  preceding  paragraph; 

1.  "The  general  results  of  the  operation  of  nephropexy  are  bad. 

2.  Nephropexy  has  very  frequently  been  performed  to  relieve  symptoms  that 
are  not  due  to  the  movable  kidney;  this  is  proved  by  the  persistence  of  the 
symptoms  after  a  successful  operation. 


640  OPERATIONS    UPON    THE    KIDNEY 

3.  The  symptoms  due  to  a  movable  kidney  are  chronic  lumbar  pain  of  the 
renal  type  described,  which  is  absolutely  relieved  only  by  horizontal  rest. 
These  symptoms,  if  present  alone,  are  nearly  always  cured  by  nephropexy. 

4.  When  lumbar  pain  is  associated  with  neurotic  symptoms,  nephropexy 
rarely  gives  relief. 

5.  Nephropexy  fails  to  cure  cases  of  dyspepsia  which  are  supposed  to  be 
due  to  the  obstruction  of  the  duodenum  by  a  movable  kidney. 

6.  The  indications  for  nephropexy  in  a  case  of  movable  kidney  are  as 
follows : 

a.  Intermittent  hydronephrosis;  (b)  pain  of  the  character  described  above; 
(c)  possibly  in  a  few  cases  of  Glenard's  disease." 

Alglave  ("  Rev.  de  Chir.,"  Dec,  1904)  describes  a  number  of  cases  in  which 
ptosis  of  the  kidney  led  to  a  descent  of  the  upper  part  of  the  ascending  colon, 
the  caecum  remaining  fixed.  The  result  of  this  is  an  abnormal  flexing  of  the 
gut,  with  dilatation  and  most  obstinate  constipation.  Cohtis  and  pericoUtis 
are  commonly  present,  with  many  adhesions.  According  to  Alglave,  these 
accidents  are  secondary  to  the  nephroptosis,  but  are  often  so  thoroughly 
established  that  nephropexy  is  insufficient  to  correct  them.  The  author  has 
met  this  condition  in  a  number  of  cases  and  has  seen  fair  results  follow  libera- 
tion of  the  gut  from  its  adhesions.  In  bad  cases  exclusion  of  the  ascending  colon 
by  uniting  the  ileum  to  the  descending  colon  (see  "Intestinal  Exclusion") 
will  be  found  serviceable. 

Many  surgeons,  when  operating  on  the  right  side,  before  proceeding  to 
treat  the  kidney  itself  in  the  operation  of  nephrorrhaphy,  open  the  peritoneum 
freely,  find  the  ascending  colon,  draw  it  out  of  the  wound,  and  follow  one 
of  its  longitudinal  bands  to  the  appendix.  Excise  the  appendix  whether 
diseased  or  not.  In  the  hands  of  an  expert  this  additional  step  consumes 
only  a  very  few  minutes,  and  as  one  eminent  surgeon  remarked  to  the  writer, 
"If  any  operator  ever  gets  close  to  my  appendix,  I  would  never  forgive  him 
should  he  not  remove  it."  The  same  surgeons  who  advocate  appendicectomy 
as  a  step  in  the  operation  also  advocate  exploration  of  the  biliary  passages  as 
a  routine  measure.  The  inexperienced  operator  is  advised  not  to  add  the 
above-mentioned  steps  to  the  operation  of  nephropexy,  as  in  his  hands  the  extra 
risk  incurred  will  probably  more  than  balance  the  benefits  which  may  accrue. 

To  understand  the  advantages  and  disadvantages  of  the  various  methods 
of  exploring  the  kidney  and  of  removing  calculi  from  it,  a  thorough  knowledge 
of  its  surgical  anatomy  is  essential.  The  descriptions  given  in  many  of  the 
textbooks  of  anatomy  are  entirely  insufficient  for  practical  use  at  the  operating 
table.  Of  course  when  a  kidney  is  the  site  of  a  large  collection  of  fluid,  whether 
purulent  or  not,  it  can  be  incised  and  drained  or  excised  without  necessitating 
any  exact  anatomical  knowledge  on  the  part  of  the  surgeon.  The  same  is  true 
when  very  large  calculi  are  present.  In  such  cases  after  exposure  of  the  kidney 
no  real  exploration  is  required;  the  indications  for  treatment  are  fairly  evident. 
When  it  is  necessary  really  to  explore  the  kidney  and  its  pelvis,  precise  anatom- 
ical knowledge  is  essential. 

The  kidney  may  be  taken  to  be  composed  of  a  number  of  conical  masses  of 
parenchyma,  the  secreting  tubules  of  which  open  on  the  nipple-like  apices  of  the 


ANATOMY    KIDNEY 


641 


cones.     These  cones  of  parenchyma  are  fused  together  into  one  mass  in  such 
fashion  that  the  apices  of  the  cones  present  into  a  cavity  (sinus  of  the  kidney) 


#P)^ 


8 


Fig.  782. — {Broedel.) 
p     o      S      t  ^  e 


Fig.  783. — {Broedel.) 

completely  surrounded  by  parenchyma  except  at  the  inner  or  concave  border  of 
the  organ  where  the  sinus  or  cavity  is  open  (hilum).  (Figs.  782  and  783.) 
The  ureter  is  a  tube  which  runs  from  the  bladder  up  to  the  kidney.     When  the 

41 


642 


OPERATIONS    UPON    THE    KIDNEY 


ureter  comes  near  the  hilum  of  the  kidney  it  expands  to  form  a  cavit}-  of  var}'ing 
size,  the  pelvis  of  the  kidney.  The  pelvis  of  the  kidney  extends  into  the  sinus 
of  the  kidney  may  be  of  several  t^-pes. 

(A)  A  number  of  short  tubes  may  be  given  off  from  the  pelvis,  and  into  the 
open  expanded  end  of  each  of  these  tubes  (calyx)  the  apex  of  a  renal  cone  is 
inserted  like  an  acorn  in  its  cup,  so  that  the  urine  escaping  from  the  renal 
tubules  flows  into  the  pelvis  and  so  into  the  ureter.  This  is  the  so-called  classical 
or  ampullar y  type  (Fig.  784)  and  occurs  in  about  30  per  cent,  of  cases  observed 
by  Delbet  and  Mocquot.  ("Rev.  de  Gyn.  et  de  Chir.  Abdominale,"  xi,  No.  4, 
1907.)  The  tubes  leading  from  the  calices  to  the  pelvis  are  very  short,  some- 
times so  short  that  the  apex  of  the  cone  may  protrude  into  the  pelvis  itself. 


Fig.  784. — .\mpunary  type  pelvis.     {Delbet  and  Mocquot.) 


(B)  Ramifying  Type  of  Pelvis. — Just  inside  the  opening  of  the  sinus  of  the 
kidney  the  pelvis  may  divide  into  tubes  (primary  tubes) ;  these  in  turn  may  give 
ofif  secondary  tubes  the  open  ends  of  which  form  the  cahces.  The  division  of  the 
pelvis  may  be  (a)  Bifid — one  primary  tube  going  to  the  upper  pole  of  the  kidney, 
the  other  to  the  lower  pole,  (b)  Trifid— where  the  third  tube  goes  horizontally 
to  collect  urine  from  the  middle  portion  of  the  kidney. 

A  glance  at  Figs.  784,  785,  788  will  explain  the  foregoing  remarks.  The 
pelvis  of  the  kidney  and  its  tributary  tubes  are  attached  to  the  inside  of  the  sinus 
of  the  kidney  merely  by  loose  connective  tissue  and  fat.  There  are  no  openings 
in  the  pelvis  or  its  tributaries  except  the  calices  and  these  are  plugged  by  the 
nipple-like  apices  of  the  renal  cones.  Thus  the  collecting  apparatus  (pelvis, 
tubes,  calices)  is  entirely  distinct  from  the  secreting  apparatus  (the  kidney) 
although  it  is  usually  almost  entirely  hidden  within  the  kidney  sinus.  The 
notion  is  important  as  it  shows  that  no  exploration  of  the  pelvis  is  possible  by 


ANATOMY    KIDNEY 


643 


by  nephrotomy  without  incision  of  the  pelvis,  i.e.,  without  pyelotomy.  The 
renal  artery  reaches  the  hilum  of  the  kidney  at  a  higher  level  than  the  pelvis 
and  here  divides  into  three  or  four  branches  (Fig.  787),  one  of  which  passes  over 
the  upper  border  of  the  pelvis  and  passes  downwards  on  the  posterior  surface  of 
the  origin  of  the  primary  tubes  (Fig.  788).  This  branch  usually  lies  well  inside 
the  sinus,  but  it  may  be  situated  along  the  opening  of  the  sinus  (the  hilum). 
The  renal  artery  or  its  branches  as  soon  as  they  enter  the  hilum  lie  in  contact 
with  the  kidney  parenchyma  to  which  they  give  ofif  branches.     They  are  sepa- 


FiG.  785. — Trifid  pelvis.     {Delbet  and  Mocqiiot.) 


Fig.  786.— Bifid  pelvis.     {Delbet 
and  Mocqtict.) 


rated  from  the  pelvis  and  its  collecting  tubes  by  loose  fatty  connective  tissue 
and  m  the  living  body,  where  the  tissues  are  much  more  supple  than  in  the  ca- 
daver, they,  phis  the  renal  cortex  bordering  the  sinus,  can  be  readily  retracted 
from  the  pelvis  and  from  part  of  the  tubes  (Delbet  and  Mocquot). 

The  arteries  in  their  distribution  do  not  loop  themselves  round  the  calices. 
One  must  remember  that  one  or  more  branches  of  the  renal  artery  may  enter 
the  kidney  through  its  cortical  substance,  away  from  the  hilum  and  require 
separate  attention  during  nephrectomy. 

The  renal  vein  and  its  branches  lie  between  the  artery  and  the  collecting 
apparatus  (pelvis,  tubes,  calices).  They  are  as  loosely  connected  with  the 
latter  structures  as  are  the  arteries,  except  that  venous  anastomoses  occur 


644 


OPERATIONS    UPON   THE    KIDNEY 


Fig.  787. — {Poirier  and  Charpey.) 


Fig.  788. 


EXPLORATION    KIDNEY 


645 


around  the  calices  (Figs.  789  and  790).  In  the  fatty  tissue  of  the  renal  sinus  lie 
the  lymphatics  and  nerves  of  the  kidney. 

From  the  preceding  paragraphs  it  might  seem  that  the  sinus  of  the  kidney 
was  always  the  same  shape  and  bore  the  same  relationship  to  the  pelvis.  This 
would  be  far  from  the  truth. 

Fig.  791  shows  a  kidney  in  which  there  is  little  notching  of  the  inner  border 
of  the  kidney  and  in  which  most  of  the  renal  pelvis  lies  in  an  accessible  position, 


Fig.  789. — (Broedel.) 


i.e.,  not  inside  the  sinus.  Fig.  792  shows  a  very  different  arrangement  in  which 
the  sinus  opens  at  the  bottom  of  a  deep,  acute-angled  notch.  The  pelvis  is  small 
and  is  almost  completely  contained  within  the  notch  and  the  sinus.  Between 
these  two  varieties  there  are  all  sorts  of  gradations. 

Exploration  of  the  Kidney. — Expose  the  kidney,  preferably  by  Methods  A  or 
G,  with  the  patient  in  the  prone  position.  By  pulling  upon  the  fatty  cap- 
sule and  by  pressing  on  the  abdomen  with  the  hand,  bring  the  kidney  into  the 
wound  and  deliver  it  on  to  the  back,  where  it  may  be  palpated  and  inspected 
thoroughly.  Should  it  be  impossible  to  safely  deliver  the  organ  (because  of 
adhesions,  etc.)  separate  it  by  blunt  dissection  from  its  surroundings,  except, 


646 


OPERATIONS    UPON    THE    KIDNEY 


of  course,  at  the  hilus,  when  its  whole  surface  and  pelvis  may  be  palpated. 
Should  the  presence  of  calculi  be  suspected,  but  not  be  determined  by  palpation, 
it  is  often  advised  to  perforate  the  organ  in  all  directions  with  a  fine  round  needle 


Fig.  790. — (Broedel.) 


Fig.  79 1. — {Delbet  and  Mocquot.) 


(lady's  hat-pin) .  Whenever  the  needle  touches  a  calculus,  a  sensation  of  grating 
is  communicated  to  the  hand.  Should  a  cyst  of  the  kidney  be  discovered,  its 
contents  may  be  obtained  for  examination  by  means  of  the  exploring  needle 
and  syringe. 


EXIM.ORATIOX    KIDNEY  647 

The  above  exploration  of  Ihe  kidney  often  fails  to  give  the  information 
desired,  and  further  investigation  is  necessary. 

Exploration  of  the  Renal  Pelvis  without  Pyelotomy.  Delbet's  Method. — 
Expose  the  kidney  through  the  lumbar  route,  deliver  it  on  to  the  back  and  place 
it  so  that  its  posterior  surface  is  exposed  to  view  and  touch.  Beginning  at  its 
ureteral  end,  free  the  posterior  surface  of  the  renal  pelvis  from  its  covering  of 
loose  fatty  areolar  tissue  by  blunt  dissection.  Push  aside  the  areolar  tissue  and 
retract  it,  very  gently,  along  with  the  blood-vessels  and  the  parenchyma  forming 
the  wall  of  the  sinus.  The  same  dissection  may  be  made,  if  necessary,  on  the 
anterior  surface  of  the  pelvis.     By  this  means  most  of  the  pelvis,  often  all  of  it. 


Fig.   792. — {Ddbct  and  Mocqnot.) 

and  sometimes  the  beginning  of  the  primary  tubes  may  be  exposed  to  view.  It 
is  now  possible  to  pass  the  finger  into  the  sinus  behind  the  pelvis  without  tearing 
anything  and  thus  directly  palpate  the  pelvis.  The  finger  can  be  introduced  in 
the  middle  transverse  diameter  of  the  kidney  to  the  bottom  of  the  sinus  and  can 
palpate  the  middle  calices;  towards  the  upper  and  lower  poles  it  cannot  be 
introduced  so  far,  but  it  can  always  explore  a  considerable  portion  of  the  upper 
and  lower  primary  tubes. 

Delbet's  method  permits  useful  accurate  palpation  without  danger;  the 
ordinary  methods  of  palpation  unaccompanied  by  the  dissection  described  are 
clumsy  and  only  calculated  to  reveal  gross  lesions. 

Nephrotomy. — Step  i. — Expose  and  isolate  the  kidney  as  in  the  operation  of 
exploration. 


648 


OPERATIONS    UPON    THE    KmNEY 


KIDNEY 


Step  2. — Deliver  the  kidney  on  to  the  patient's  back.  Surround  the  hilus  or 
pedicle  with  a  rather  fine  rubber  band  or  tube  not  too  tightly  applied,  and  fas- 
tened by  tape  and  forceps,  as  shown  in  Fig.  793.     This  renders  the  next  step 

practically  bloodless,  but  entirely  prevents  explora- 
tion of  the  ureters.  An  intestinal  clamp  with 
rubber  covered  blades  serves  the  same  purpose. 
Instead  of  using  the  rubber  constrictor,  an  assistant 
may  control  the  circulation  with  finger  pressure 
applied  to  the  hilus,  or  no  control  of  the  circulation 
may  be  attempted.  In  some  cases  it  is  impossible 
to  deliver  the  kidney  safely.  Under  these  circum- 
stances hook  the  finger  in  front  of  the  organ  and 
bring  its  convex  margin  as  well  as  possible  into  the 
wound. 

Step  3. — Grasp  the  kidney  between  the  fingers 
and  thumb  of  the  left  hand  and  make  a  longitudinal 
cut  along  its  convex  border  of  such  size  and  depth 
that  the  finger  may  be  passed  into  the  renal  pelvis. 
If  necessary,  the  kidney  may  be  split  open  through- 
out its  whole  length,  as  is  done  at  the  postmortem 
Fig.  793,  table  (Fig.  794).     Introduce  the  finger  through  the 

R.  Rubber  tube  or  band.    T.  wound  and  palpate  the  interior  of  the  kidney  and 

Tape  placed  over  the  crossing-point  -^  -^ 

of  rubber  tube,  and  held  by  forceps,  its  pelvis:  the  fingers  of  the  Other  hand  applied  to 

It  IS  just  as  good  to  fix  the  rubber  ir  >  o  i-r- 

by  the  forceps  without  the  use  of  the  surface  of  the  Organ  aid  this  exploration.     If 

the  elastic  constrictor  has  not  been  employed  or 
after  its  removal,  the  ureters  may  be  examined  by  ureteral  catheters  or  bougies 
passed  through  the  wound.  To  obviate  this  trouble  it  is  proper  to  apply  the 
constrictor  to  the  vessels  alone.     When  the  active  examination  or  operation  is 


Fig.  794. — {Monod  and  Vanverls.) 


Rubber-  ftssut 


Fig.  795. — Suture  of  kidney.     Stitches  tied 
over  rubber  tissue  drain. 


completed,  close  the  renal  wound  with  a  few  catgut  sutures  introduced  by  a 
round  needle,  i.e.,  one  without  cutting  edges.  The  sutures  stop  all  hemor- 
rhage. Close  the  lumbar  wound,  in  layers,  with  buried  sutures  or  with  through- 
and-through  sutures  of  silkworm-gut.     Provide  for  drainage  if  necessary.     This 


NEPHROTOMY 


649 


may  be  accomplished  by  placing  a  few  layers  of  folded  rubber  tissue  over  the 
line  of  suture,  and  tying  the  ends  of  the  catgut  sutures,  left  long  for  this  pur- 
pose, over  the  tissue  (Fig.  7()5). 

The  above  is  the  classical  method  of  performing  nephrotomy,  but  it  takes  no 
cognizance  of  the  arrangements  of  vessels  inside  the  kidney  and  hence  may 
destroy  an  unnecessary  number  of  important  vessels,  thus  cutting  off  nutriment 
from  and  causing  necrosis  of  an  unneces- 
sary amount  of  cortex. 

The  arteries  are  distributed  to  the 
cortex  in  two  groups — an  anterior  and  a 
posterior  group.  The  anterior  vascular 
region  is  wider  than  the  posterior.  Ac- 
cording to  Broedel,  the  line  bb^  (Figs.  796 
and  797)  overlies  the  principal  vessels  of 
the  kidney  parenchyma  and  in  lobulated 
kidneys  is  marked  by  a  distinct  depression 
of  the  surface,  over  which  the  capsule 
seems  thickened,  forming  a  whitish  band 
to  which  the  perirenal  fat  may  be  more 
adherent  than  elsewhere.  An  incision 
(cc^),  just  posterior  to  the  lateral  convex 
border  of  the  kidney  (aa^)  gives  good 
access  to  the  posterior  group  of  calices  and 
injures  the  fewest  possible  vessels 

Cullen  and  Derge  split  the  kidney  by 
passing  a  long,  blunt,  fiat  needle  through 
it  from  pole  to  pole  and  by  means  of  this 
needle  introduce  a  fine  silver  wire  of  low 
tensile  strength.  A  see-saw  motion  given 
to  the  wire  permits  it  to  cut  its  way  out 
of  the  kidney  without  causing  bleeding. 
The  method  is  identical  with  that  used  by 
potters  to  cut  clay.  In  kidneys  where 
disease  has  caused  the  formation  of  areas 
of  fibrous  tissue  so  much  pressure  must  be  put  on  the  wire  that  the  resulting 
trauma  occasions  more  bleeding  than  would  be  caused  by  the  use  of  the  knife 
(E.  H.  Richardson). 

Marwedel's  Nephrotomy. — Expose  the  kidney  by  the  lumbar  route.  De- 
liver it  on  to  the  back.  At  the  middle  of  the  convex  border  of  the  kidney  make 
a  transverse  incision  through  the  parenchyma  into  the  pelvis.  Introduce  the 
finger  to  explore.  If  more  room  is  required  enlarge  the  incision  both  anteriorly 
and  posteriorly  until  the  kidney  is  divided  into  an  upper  and  lower  half.  It  is 
now  easy  to  so  open  the  wound  that  the  pelvis  becomes  very  accessible.  Mar- 
wedel  claims  his  operation  {a)  unusually  free  access  to  the  renal  pelvis;  {b)  less 
destruction  of  parenchyma;  (c)  less  injury  to  important  blood-vessels  and  con- 
sequently less  necrosis  of  parenchyma.     Zondek  shows  that  injury  to  blood- 


FiG.   796. — Broedel's  line  for  incising 
kidney.     {Broedel.) 


650  OPERATIONS    UPON    THE    KIDNEY 

vessels  is  quite  as  great  as  in  the  longitudinal  incision.  When  the  renal  pelvis 
is  of  the  ampullary  type  (30  per  cent.)  undoubtedly  Marwedel's  method  will  give 
perfect  access  to  it,  but  when  the  pelvis  is  of  the  ramifying  variety  the  state  of 
affairs  is  very  different  and  the  exposure  may  be  practically  nil. 

When  nephrotomy  is  performed  as  a  therapeutic  measure,  complete  closure 
of  the  renal  and  lumbar  wounds  is  almost  always  improper.  Drainage  must  be 
provided.     Drainage  may  be  accomplished  as  follows: 

(a)  Introduce  a  wick  of  mildly  iodoformized  gauze,  surrounded  by  rubber 
tissue  (cigarette  drain),  into  the  portion  of  kidney  to  be  drained  and  fix  it  there 


Fig.  797. — Broedel's  incision  of  kidney.     (Brocdcl.) 

by  a  stitch  of  plain  catgut  or  tie  the  ends  of  one  of  the  renal  sutures  around  the 
drain  (Fig.  798).  This  simple  precaution  is  perfectly  harmless  and  prevents 
displacement  of  the  drain.  A  drain  of  folded  rubber  tissue  or  oil-silk  without 
any  gauze  is  probably  better  than  the  cigarette  as  gauze  adheres  to  the  tissues 
and  may  favor  the  formation  of  fistula.  It  is  wise  to  leave  the  drain  in  situ  for 
a  week  or  longer. 

(b)  Use  in  the  same  manner  a  rubber  tube  split  longitudinally  and  containing 
a  wick  of  gauze.  The  split  runs  the  whole  length  of  the  tube,  diminishing  its 
rigidity  and  thus  avoiding  some  possibilities  of  injury  to  tissues  from  pressure. 
Do  not  insert  the  tube  too  deeply,  as  it  may  then  cause  much  pain,  and  even 
reflex  anuria. 

(c)  In  the  same  manner  use  and  fix  in  place  a  dressed  rubber  tulje 
(Fig.  799). 

F.  Voelcker  (Zent.  f.  Chir.,  13,  June,  1914)  in  a  case  of  secondary  hemorrhage 
a  few  days  after  nephrotomy,  delivered  the  kidney  on  to  the  back,  applied  com- 
pressive dressings  and  in  four  days  later  returned  the  kidney  to  its  bed.  This 
procedure  was  successful  and  ought  to  take  the  place  of  nephrectomy  under 
similar  circumstances. 

If  the  kidney  is  the  seat  of  multiple  abscess  and  nephrectomy  is  not  indicated, 
open  all  the  abscesses  freely,  either  through  the  original  renal  incision  or  through 
individual  incisions,  as  may  be  convenient.  If  it  is  believed  that  relief  of  tension 
may  be  of  value  in  a  case  where  nephrotomy  has  revealed  no  pathological  condi- 


NEPHRO-LITHOTOMY 


651 


*    Gauxe 
h'ubber  Ti&su* 


Drainage  of  kidney. 


tion  sufficient  to  account  for  the  symptoms,  then  it  is  wise  to  leave  the  renal 
wound  at  least  partly  open.  A.  H.  Ferguson,  Edebohls,  and  others  practise 
decortication  of  the  kidney  when  they  desire  to  relieve  tension  in  cases  of  nephri- 
tis. Their  operation  for  nephritis  consists  in  exposure,  delivery,  and  decortica- 
tion of  the  kidney.  Excellent  reports  have 
been  published  as  to  the  success  of  decortica- 
tion in  nephritis,  but  the  whole  question  is  still 
subjudice.  Wounds  of  the  kidney  lical  rapidly 
when  sutured. 

F.  S.  Watson  ("Annals  of  Surg.,"  Dec, 
1905;  March,  1906;  Sept.,  1907)  recommends 
double  nephrostomy  to  take  the  place  of 
ureteral  implantations:  (i)  as  a  palliative 
measure  in  cases  of  inoperable  vesical  tumor 
or  of  vesical  tuberculosis  causing  suflfering 
where  the  infection  is  descending  and  both 
kidneys  are  involved;  (2)  as  a  preliminary  to  total  extirpation  of  the  bladder. 
After  the  kidney  is  exposed  and  incised,  the  ureter  is  ligated  as  near  the  renal 
pelvis  as  possible.  When  the  urinary  fistula  is  established,  place  over  Cnot 
into)  it  a  cup-shaped  shield  or  funnel  connected  with  a  metallic  receptacle. 
The  receptacle  can  be  conveniently  emptied  even  in  a  public  urinal  by  means 
of  a  rubber  tube  (Fig.  800). 

Rovsing  instead  of  nephrotomy  practises  lum- 
bar ureterostomy  as  a  part  of  complete  cystectomy 
(see  cystectomy).  Wilms  (of  Basel)  exposes  the 
ureter  at  the  brim  of  the  pelvis,  preferably  extra- 
peritoneally,*  and  brings  it  out  of  the  wound  about 
2  inches  above  the  anterior  superior  spine  of  the 
ilium.  If  the  ureteral  stump  is  long  enough  it  is 
well  to  pass  it  through  a  subcutaneous  tunnel  for  a 
distance  of  i}-^  to  2  inches.  After  the  wound  has 
healed  it  is  easy  to  cut  the  skin,  under  which  the 
ureter  runs,  in  the  form  of  a  flap  and  so  to  envelop 
the  ureter  in  the  flap  of  skin  as  to  form  a  convenient 
spout  (Fig.  801). 

Nephrolithotomy. — Expose  and  if  possible  de- 
liver the  kidney  as  in  nephrotomy.  Control  the 
renal  circulation  by  finger  pressure  at  the  hilus  or  ^^^-^^^^_j^^^.^^^^^^^.^^^^^ 
by  the  elastic  constrictor,  if  this  is  feasible.  In- 
cise the  kidney  as  in  nephrotomy.  If  the  stone  is  small  and  lies  free  in  the 
pelvis,  pass  a  forceps  through  the  renal  wound  and  extract  it.  When  the 
stone  is  large  and  fills  the  renal  calices,  its  extraction  becomes  a  matter  of 
great  difficulty.  Under  such  circumstances  enlarge  the  incision  through  the 
kidney  to  the  necessary  extent.  With  the  finger,  peel  the  stone  out  of  the 
calices  and  remove  it  unbroken.     If  its  removal  entire  is  impossible  fracture  it 


For  exposure  of  ureter  see  Ureterotomy. 


652 


OPERATIONS    UPON   THE    KIDNEY 


with  forceps,  but  let  the  fragments  be  as  few  in  number  as  possible.  If  there 
are  many  and  small  fra{];ments,  some  of  them  are  liable  to  escape  extraction 
and  cause  trouble  in  the  future.  Remove  all  debris,  with  finger,  spoon,  forceps, 
gauze  strips,  or  douche.  When  several  calculi  are  present,  they  may  often  be 
extracted  through  the  same  renal  wound,  but  if  more  convenient,  they  may 


Fig.  800. — Watson's  nephrostomy.     {Watson,  Atmals  Surg.) 


be  removed  through  separate  incisions.  It  is  far  less  damaging  to  the  kidney 
to  make  several  clean  incisions  through  its  parenchyma  and  thus  extract  the 
calculi  with  the  minimum  of  laceration  and  contusion  than  to  endeavor  to  take 
them  all  out  through  one  cut.  The  latter  plan  too  often  results  in  the  kidney's 
being  converted  into  ragged  mass  lying  inside  a  nearly  perfect  capsule. 

The  calculi  having  been  removed,  introduce  and  fix  drains  in  the  renal 
wounds,  as  has  been  described  under  the  heading  Nephrotomy.  Close  the 
nephrotomy  wounds  as  far  as  necessary  with  catgut.  Close  the  lumbar  wound 
except  where  the  drains  emerge.  A  stone  weighing  four  and  one-half  ounces 
has  been  removed  in  the  above  manner. 


PYELOTOMY  653 

Pyelotomy  and  Pyelolithotomy. — The  kidney  is  exposed  and  if  possible 
delivered  after  the  methods  already  described.  The  pelvis  of  the  kidney  is 
incised.  The  incision  should  not  be  located  too  near  the  renal  parenchyma,  for 
the  following  reasons  (Israel):  (i)  In  this  location  sutures  are  inserted  with 
difficulty  and  are  liable  not  to  hold.  (2)  When  a  stone  is  being  extracted  through 
such  a  cut,  the  renal  parenchyma  may  be  injured, 
resulting  in  hemorrhage  and  subsequently  renal 
colic  from  the  blood-clots  formed  in  the  pelvis 
and  ureter.  After  the  stone  is  extracted,  the 
pelvic  wound  is  to  be  closed  by  a  few  catgut 
sutures  unless  drainage  of  the  pelvis  is  demanded. 
Wounds  of  the  pelvis  of  the  kidney  heal  readily 
when  infection  is  absent.  The  Mayos  find  that 
closure  without  leakage  may  be  secured  even  if 
the  suture  of  the  pelvis  is  very  imperfect  provided     \  |1  / 

the  pelvic  wound  is  covered  by  a  flap  of  fatty      \  / 

fascia.  In  nephrolithiasis  there  is  of  ten  a  distinct  pi^.  801.— Wilm's  ureterostomy, 
increase  in  the  amount  of  fatty  tissue  attached 

to  the  pelvis.  If  it  is  possible  to  make  the  pelvic  incision  through  this  fat  do  so, 
and  after  suturing  the  pelvic  wound,  close  the  fatty  wound  separately  with  fine 
catgut.  If  the  pelvic  wound  is  too  large  or  irregular,  or  if  the  fat  does  not  natur- 
ally cover  it,  it  is  easy  to  make  a  flap  of  fatty  tissue  from  the  neighborhood,  lay 
this  flap  over  the  wound  and  keep  it  in  position  by  a  few  fine  catgut  stitches. 
The  lumbar  wound  should  be  drained  by  means  of  folded  rubber  tissue  or  oil-silk. 

Delbet's  Pyelotomy. — "This  may  be  necessary  to  permit  complete  explora- 
tion of  the  superior  and  inferior  calices,  to  extract  a  calculus  or  to  remove 
false  membranes  which  are  sometimes  present  in  cases  of  pseudo-membranous 
pyelitis."  Make  an  incision  through  the  middle  of  the  posterior  surface  of  the 
pelvis  in  the  long  axis  of  the  pelvic  funnel.  Do  not  let  the  incision  involve  the 
ureter,  as  this  might  cause  stricture.  In  almost  every  case  it  is  possible  to  make 
a  cut  large  enough  to  admit  the  little  finger  and  with  it  to  explore  all  the  tubes 
and  calices.  A  fine  scoop  may  be  used  to  reach  parts  inaccessible  to  the  finger. 
If  a  pelvis  is  too  small  to  permit  of  this  incision  and  exploration,  it  is  fairly  safe 
to  assume  that  it  is  healthy  and  contains  no  foreign  body.  After  completing  the 
exploration,  close  the  wound  with  fine  catgut  sutures;  if  silk  is  used  the  suturing 
must  be  of  the  Lembert  type.  Delbet  uses  two  layers  of  suture;  the  first,  of 
fine  catgut,  penetrates  the  whole  thickness  of  the  pelvic  wall,  the  second,  of  silk, 
is  introduced  in  the  Lembert  fashion  and  does  not  penetrate  into  the  pelvic 
cavity.  Simple  suture  with  catgut  is  all  that  is  really  necessary,  the  supple- 
mented sutures  of  silk  do  more  harm  than  good.  Payr  after  suturing  the  pelvis 
reflects  a  flap  of  the  fibrous  capsule  of  the  kidney  having  its  pedicle  near  the 
hilus,  and  sutures  this  flap  over  the  pelvic  wound. 

Comparative  Advantages  or  Disadvantages  of  Pyelolithotomy  and  Nephro- 
lithotomy (Rovsing). — Pyelolithotomy. — Advantages:  Little  hemorrhage  and  no 
injury  to  renal  parenchyma.  Disadvantages:  Stones  in  the  calices  cannot  be 
removed.     Fistulae  are  liable  to  result  and  persist. 

Nephrolithotomy:  By  means  of  this  procedure  all  stones  can  be  removed. 


654  OPERATIONS   UPON   THE    KIDNEY 

When  no  suppuration  exists  the  renal  wound  may  be  closed  and  heal  per  primatn. 
If  pus  is  present,  the  wound  may  be  partially  closed  and  drainage  provided. 
Fistulae  when  they  occur  are  more  readily  closed  than  after  pyelotomy.  In 
many  cases  the  hemorrhage  which  may  occur  is  not  of  importance.  Hemorrhage 
would  be  dangerous  in  patients  weakened  by  prolonged  disease  or  in  cases 
where  it  is  necessary  to  split  the  kidney  throughout  its  whole  length  in  order 
to  remove  a  very  large  stone,  were  it  not  that  the  renal  vessels  may  be  readily 
controlled  by  the  finger  pressure  or  the  elastic  constrictor.  The  injury  to  the 
parenchyma  inevitably  incurred  is  of  comparatively  little  importance. 

The  above  are  Rovsing's  views,  and  his  opinions  always  command  respect. 
The  experiments  of  Delbet  and  Mocquot  show  that  it  is  much  easier  to  reach 
every  calyx  in  the  search  after  small  calculi  b;*^  means  of  pyelotomy  than  by 
nephrotomy. 

John  Clay  ("Brit.  Med.  Journ.,  May  i,  1909)  recommends  the  following 
procedure  in  cases  of  double  nephro-lithiasis  where  there  is  much  destruction 
of  renal  tissue. 

Operation. — Expose  the  kidney  through  the  loin.  Open  the  peritoneum  and 
palpate  the  opposite  kidney  to  make  sure  of  its  condition.  Close  the  peritoneal 
wound.  Deliver  the  kidney  on  to  the  back.  Loosely  pack  with  gauze  the  cav- 
ity from  which  it  was  removed.  Extract  the  stones  from  the  pelvis  and  calices. 
Attend  to  hemostasis.  Wrap  the  kidney  in  gauze  and  let  it  lie  on  the  patient's 
back  draining  into  the  dressings  instead  of  into  the  loose  retro-peritoneal  tissues. 

Operation  2. — As  soon  as  the  kidney  is  covered  -mth  healthy  granulation 
tissue,  replace  it  in  its  normal  bed  and  close  the  wound  after  providing  for 
drainage. 

After  a  proper  lapse  of  time  the  second  kidney  may  be  treated  in  a  similar 
manner. 

Partial  Nephrectomy. — Experiment  and  experience  show  that  wounds  of 
the  kidney  heal  readily,  and  that  large  parts  of  the  normal  kidney  may  be 
removed  without  noticeable  ill  effect.  Tuffier's  experiments  seem  to  show  that 
one-third  or  one-fourth  of  the  kidney  is  suflEicient  for  the  performance  of  function. 

The  kidney  is  exposed  and  delivered  through  any  of  the  incisions  already 
described.  The  diseased  portion  of  the  organ  is  removed,  if  possible,  by  a 
V-shaped  incision,  so  that  the  resulting  wound  may  be  easily  closed  by  catgut 
sutures.  This  typical  removal  is  often  improper,  as  by  it  too  much  healthy 
parenchyma  might  have  to  be  sacrificed.  For  disease  involving  the  upper  or 
lower  ends  of  the  kidney  a  transverse  incision  may  suffice  and  sacrifice  the  least 
possible  amount  of  healthy  parenchyma.  In  the  case  of  irregular  multiple,  but 
localized  abscesses,  where  neither  the  V  nor  the  transverse  incision  may  be 
applicable,  the  surgeon  contents  himself  with  scraping  and  cutting  away  all 
the  diseased  tissue.  Hemorrhage  is  prevented  after  the  last  two  operations 
partly  by  judiciously  applied  sutures  and  partly  by  gauze  packing.  For  the 
packing  to  be  effectual  it  may  be  necessary  to  stitch  the  kidney  to  the  lumbar 
wound.  The  lumbar  wound  is  closed  completely  or  in  part,  as  already 
described. 

Cases  Suitable  for  Partial  Nephrectomy. — Benign  neoplasms,  e.g.,  echinococcic 
cysts,  pyonephritic  disease,  etc.     Note,  however,  that  hypernephromata  often 


NEPHRECTOMY  655 

appear  distinctly  encapsulated  and  easily  removed  by  partial  nephrectomy,  and 
yet  they  are  very  malignant  in  character. 

Nephrectomy. — (A)  Lumbar  Route. — The  kidney  is  exposed  by  one  of  the 
incisions  described. 

I.  Nephrectomy  for  malignant  disease:  A  good  rule  to  adopt  when  operating 
for  malignant  disease  is  to  remove  too  much  rather  than  too  little.  The  same 
principles  which  obtain  in  excision  of  the  breast  obtain  in  nephrectomy  for 
malignant  disease. 

Step  I. — Expose  k.id.nty  freely. 

Step  2. — With  finger  dissection  separate  the  kidney  from  its  surroundings 
until  it  is  left  attached  by  its  pedicle  alone.  If  the  organ  has  become  firmly 
adherent  to  its  surroundings,  it  may  be  easier  to  separate  the  kidney  from  its 
fibrous  capsule  (capsula  propria)  than  from  the  fatty  capsule.  In  such  a  case  the 
fibrous  capsule  may  be  left  to  be  treated  at  a  later  stage  of  the  operation. 

Step  3. — The  pedicle  is  examined.  The  vessels  and  the  ureter  are  recog- 
nized. A  ligature  carrier  is  passed  between  the  ureter  and  the  vessels  and  a 
double  ligature  of  silk  or  reliable  catgut  pulled  through.  One  of  the  ligatures  is 
placed  around  the  vessels  and  tied  tightly  at  as  great  a  distance  from  the  kidney 
as  possible.  This  is  to  permit  division  of  the  pedicle  far  enough  away  from  the 
ligature  to  leave  a  stump  of  length  sufficient  to  prevent  all  danger  of  the  ligature 
slipping.  The  other  ligature  is  tied  around  the  ureter.  A  hemostatic  forceps 
is  applied  to  the  pedicle  between  the  ligatures  and  the  kidney.  The  pedicle 
is  divided  close  to  the  kidney,  leaving  the  hemostat  attached  to  the  stump.  The 
hemostat  gives  one  control  of  the  stump  and  is  left  in  position  until  the  con- 
dition of  the  stump  has  been  reviewed  and  it  is  evident  that  the  ligature  controls 
the  vessels  and  is  in  no  danger  of  slipping.     After  this  the  forceps  is  removed. 

Step  4. — Make  a  careful  and  complete  excision  of  the  fatty  capsule  of  the 
kidney.  This  is  as  important  as  excision  of  the  axillary  glands  in  removal  of 
mammary  cancer.  The  excision  is  made  partly  by  blunt  dissection,  partly  by 
cutting  with  scissors.  All  firm  strands  of  tissue  in  which  vessels  may  be  hidden 
should  be  divided  between  ligatures  or  forceps.  There  must  be  no  rough  tearing. 
The  location  of  the  inferior  vena  cava  should  be  borne  in  mind. 

Gregoire  thinks  that  the  suprarenal  body  ought  to  be  removed  with  the 
kidney  in  the  presence  of  renal  cancer. 

Step  5. — With  retractors  expose  to  sight  the  whole  retroperitoneal  cavity. 
All  hemorrhage  is  attended  to  and  any  tears  which  may  have  been  made  through 
the  peritoneum  are  closed  by  suture. 

Step  6. — Dry  the  cavity.  Provide  drainage  either  by  means  of  gauze  pack- 
ing or  by  tube.  Close  the  lumbar  wound.  Unless  the  wound  is  infected,  the 
drainage  may  be  dispensed  with  after  two  days. 

If  the  tumor  to  be  removed  is  very  large,  it  is  often  wise  to  seize  the  pedicle 
and  any  adhesions  with  forceps  and  attend  to  the  ligations  after  the  tumor  is 
out  of  the  way. 

Occasionally  thrombi,  malignant  in  character,  are  present  in  the  renal  vein 
and  even  in  the  inferior  vena  cava.  Such  thrombi  should  be  removed  even  if 
it  is  necessary  temporarily  to  clamp  the  vena  cava  itself.  Israel  is  authority 
for  this  advice. 


656  OPERATIONS   UPON    THE    KIDNEY 

2.  Nephrectomy  for  non- malignant  disease:  If  the  kidney  is  not  too  adherent 
(as  a  result  of  old  inflammation)  to  its  surroundings,  the  whole  organ  can  be 
shelled  out  of  its  bed  by  finger  dissection.  A  pedicle  needle  is  passed  between 
the  vessels  and  the  ureter  as  they  enter  or  leave  the  hilus;  a  double  ligature  is 
pulled  through  as  the  needle  is  withdrawn.  One  ligature  is  tied  tightly  around 
the  vessels  as  already  described.  The  ligature  intended  for  the  ureter  is  not  yet 
tied.  The  ureter  is  grasped  by  forceps.  The  pedicle  is  divided,  leaving  a  suf- 
ficiently large  stump,  and  the  kidney  is  removed.  The  ureter  is  now  examined. 
If  it  is  clean  and  safe,  the  ligature  provided  for  it  may  be  tied  and  the  ureter 
allowed  to  drop  into  the  wound.  If  the  ureter  is  infected  and  its  cavity  dilated 
and  full  of  pus,  it  must  be  thoroughly  cleansed  both  by  washing  and  by  scraping 
with  a  sharp  spoon.  After  being  cleaned,  the  ureter  may  be  ligated  and  allowed 
to  retract  into  the  wound,  or  it  may  be  left  open  and  fixed  to  the  lumbar  wound 
by  a  few  sutures.  If  the  disease  for  which  operation  is  performed  is  tuberculous 
and  the  ureter  is  involved,  it  may  be  followed,  through  the  lumbar  wound,  down 
to  the  brim  of  the  pelvis  and  excised  to  that  extent.  In  any  event  an  effort 
should  be  made  to  deprive  the  distal  ureter  of  its  mucous  lining  and  to  close  the 
upper  opening  of  the  distal  segment  by  inverting  it.  Mayo  treats  the  ureter  by 
injecting  into  it  about  a  drachm  of  liquid  carbolic  acid.  He  finds  this  effective 
and  harmless. 

If  in  non-malignant  disease  the  kidney  is  so  firmly  adherent  to  its  surround- 
ings as  to  make  removal  by  the  usual  method  a  matter  of  great  difficulty,  then 
its  fibrous  capsule  may  be  opened  and  the  kidney  proper  separated  from  its  cap- 
sule and  removed,  leaving  the  fibrous  capsule  in  situ.  The  vessels  when  isolated 
are  caught  in  a  clamp  which  is  left  in  situ.  If  the  organ  peels  out  without  the 
vessels  being  isolated  and  clamped,  pack  the  cavity  lightly  with  gauze;  as  the 
surrounding  scar  tissue  gives  ample  support  to  the  packing  this  is  thoroughly 
effective  for  purposes  of  hemostasis.  Any  diseased  material  adhering  to  the 
capsule  is  to  be  scraped  away. 

The  excision  of  a  very  large  hydronephrotic  kidney  calls  for  manoevures  not 
yet  considered.  Israel  says  that  observance  of  two  rules  makes  the  operation 
tolerably  easy  and  safe.  First,  as  in  the  case  of  all  benign  tumors,  be  sure  to 
get  down  to  the  capsula  propria.  This  is  accomplished  by  cutting  the  tissues 
layer  by  layer,  each  layer  being  raised  by  two  forceps  before  being  cut  and  the 
cut  being  made  between  the  forceps.  It  is  surprising  how  many  layers  of  more 
or  less  firm  fibrous  tissue  are  formed  from  the  fatty  capsule  and  must  be  passed 
before  the  capsula  propria  is  reached.  Having  reached  the  capsule,  clear  as 
large  an  area  of  its  surface  as  is  possible  without  evacuating  its  contents.  Second, 
a  trocar  and  cannula  are  inserted  into  the  tumor  to  empty  it.  The  cannula  is 
provided  with  a  long  rubber  tube  to  drain  away  the  fluid  without  soiling  the 
wound.  When  the  tumor  has  collapsed,  withdraw  the  cannula,  at  the  same 
moment  closing  its  puncture  wound  by  catching  up  a  fold  of  the  tumor-wall  (at 
the  point  of  puncture)  between  the  finger  and  thumb.  Forceps  may  be  used  in- 
stead of  the  digital  grasp.  Pull  the  now  flaccid  tumor-wall  out  of  the  lumbar 
wound,  separating  adhesions  with  the  flat  of  the  fingers  of  the  other  hand  as  the 
tumor  is  being  delivered.  Tough  adhesions  must  be  divided  between  ligatures 
or  forceps.     These  will  be  most  common  near  the  top  of  the  tumor.     Do  not 


I 


NEPHRECTOMY  657 

bore  in  or  mine  with  the  fingers  around  the  tumor,  and  never  endeavor  to  hook 
out  the  growth  with  the  fingers.  Such  endeavors  may  tear  the  pedicle  or  even 
lacerate  the  vena  cava.  Everything  must  be  done  under  control  of  the  eye. 
When  the  sac  is  so  far  extracted  that  the  region  of  the  hilus  is  reached,  even  more 
care  must  be  exercised  in  the  separation  of  adhesions,  as  in  hydronephrosis  the 
veins  are  not  always  gathered  together  in  a  convenient  pedicle,  but  are  spread 
out  and  have  many  diverging  branches.  Operating  in  the  above  manner,  every 
vessel  may  be  seen  and  ligated. 

(B)  Nephrectomy  by  the  Abdominal  Route. — The  kidney  is  exposed  by 
Langenbuch's  incision  (page  632).  The  finger  passed  through  the  wound  in  the 
mesocolon  separates  the  kidney  from  its  surroundings  until  the  hilus  is  reached. 
With  an  aneurysm  needle  a  double  ligature  is  passed  between  the  ureter  and  the 
vessels,  and  the  vessels  are  tied  in  two  places  and  divided  between  the  ligatures. 
This  double  ligation  is  practised  to  prevent  a  flow  of  blood  from  the  kidney 
which  would  obscure  the  wound.  The  ureter  is  divided  between  forceps.  The 
kidney  is  removed.  The  ureter  is  examined,  and  if  found  clean  and  healthy,  it 
is  ligated  and  allowed  to  retract  into  the  wound.  The  whole  retroperitoneal 
cavity  created  by  the  removal  of  the  tumor  is  examined  and  any  bleeding  point 
which  may  have  been  overlooked  receives  attention.  Oozing  of  blood  is  lessened 
by  temporary  pressure  with  gauze  pads  wrung  out  of  hot  water.  Drainage 
may  be  provided  through  the  lumbar  region  in  the  following  manner:  from  the 
cavity  to  be  drained  a  closed  forceps  is  thrust  backwards  through  the  lumbar 
tissues,  just  external  to  the  quadratus  lumborum  muscle,  until  it  raises  the  skin 
on  the  back.  The  skin  is  incised  and  the  point  of  the  forceps  thrust  through 
the  incision.  If  necessary,  the  opening  may  be  enlarged.  Either  gauze  or 
tubular  drains  may  be  employed,  according  to  circumstances.  The  above  opera- 
tion appears  easy  on  paper,  but  when  the  kidney  is  much  enlarged  and  when  it 
is  adherent  to  its  surroundings,  the  procedure  is  one  of  great  diflOiculty.  While 
the  organ  is  being  separated  from  its  surroundings  it  may  be  necessary  to  apply 
many  ligatures  to  control  hemorrhage.  A  large  cystic  kidney  may  require  to 
have  its  fluid  contents  aspirated  before  the  pedicle  can  be  treated  or  the  tumor 
delivered.  Of  course,  under  such  circumstances  the  puncture  wound  made  by 
the  aspirator  or  cannula  must  be  closed  with  forceps  as  soon  as  the  instrument 
is  withdrawn.  Treatment  of  the  pedicle  often  presents  difficulties.  It  may  be 
easier  to  apply  clamps  to  the  vascular  pedicle  than  ligatures.  If  this  is  done, 
much  care  must  be  exercised.  Thornton  once  included  a  small  piece  of  the 
vena  cava  in  the  forceps  and  lost  his  patient  from  hemorrhage.  Hartmann, 
while  enucleating  a  large  pyonephrotic  kidney,  tore  a  hole  of  3  cm.  (i^  inches) 
in  the  vena  cava,  below  the  renal  vein.  He  immediately  ligated  the  vena  cava 
above  and  below;  the  patient  recovered.  Had  the  tear  involved  the  region  of  the 
renal  veins,  he  would  have  sutured  the  wound  in  the  vena  cava.  Damar  Harri- 
son has  done  this  successfully.  When  clamps  are  used,  ligatures  must  be  sub- 
stituted for  them  as  soon  as  the  tumor  is  removed.  Some  surgeons,  when  possi- 
ble, ligate  the  renal  vessels  before  enucleating  the  kidney.  W^hen  the  ureter 
is  septic,  it  must  be  doubly  tied  near  the  kidney  and  divided  between  the  hga- 
tures.  The  ligation  prevents  its  septic  contents  escaping  into  the  wound.  The 
ureter  (after  the  kidney  is  removed)  is  pulled  outwards  and  fixed  in  the  lumbar 

42 


658  OPERATIONS    UPON    THE    KIDNEY 

drainage  wound.  Lumbar  drainage  having  been  provided,  the  abdominal 
wound  can  be  completely  closed.  Many  surgeons  advocate  careful  suture  of 
the  wound  made  through  the  outer  layer  of  the  mesocolon  so  as  to  close  the 
peritoneal  cavity.     This  is  generally  considered  unessential. 

Remarks. — Exploration  is  indicated  in  cases  where  it  is  believed  that  the 
kidney  has  been  ruptured  and  that  extravasation  of  urine  or  blood  is  taking 
place.  Any  lacerations  found  must  be  closed  by  suture.  If  mere  suturing  is 
insufficient  to  stop  the  hemorrhage,  or  if  the  trauma  has  destroyed  much  renal 
parenchyma,  the  wound  in  the  kidney  should  be  packed  with  gauze  held  in  place 
by  plain  catgut  sutures  (Fig.  798).  The  gauze  should  be  surrounded  by  rubber 
tissue  so  as  to  avoid  adhesion  between  it  and  the  kidney  tissues. 

The  happy  results  of  non-intervention  in  cases  of  uncomplicated  subcutane- 
ous rupture  of  the  kidney,  reported  by  Alfred  Frank  from  Korte's  clinic  ("Archiv 
fur  klin.  Chir.,"  Ixxxiii,  554),  are  such  as  to  dampen  operative  enthusiasm. 
Korte  never  operates  on  uncomplicated  cases  of  rupture  of  the  kidney,  no  matter 
the  extent  of  hemorrhage  and  hematoma.  If  infection  is  present  operation 
must  not  be  delayed. 

Ransohoff  promulgates  the  following  theses  regarding  renal  tuberculosis 
where  operation  is  indicated:  "(i)  When  the  operation  reveals  a  strictly  local- 
ized lesion,  a  partial  excision  or  curettage  should  be  done.*  (2)  Nephrotomy  is 
indicated  when  uncertainty  exists  as  to  the  condition  of  the  opposite  kidney  or 
for  the  temporary  relief  of  an  acute  sepsis,  and  when  the  condition  of  the  patient 
will  not  permit  the  major  operation.  It  is  then  to  be  followed  as  speedily  as 
possible  by  nephrectomy.  (3)  Unless  unusual  conditions  call  for  nephrotomy, 
it  is  not  to  be  advocated  for  renal  tuberculosis.  It  may  even  do  harm  by  auto- 
infection.  (4)  Primary  nephrectomy  should  be  considered  the  normal  proced- 
ure for  renal  tuberculosis  when  an  operation  is  at  all  indicated." 

Liechtenstern  ("German  Urological  Society,"  1907)  examined  at  intervals 
the  urine  of  seventeen  patients  submitted  to  nephrectomy  for  tuberculosis. 
The  examination  was  by  inoculation  of  guinea-pigs.  In  seven  the  results  were 
negative.  In  three  the  results  were  at  first  positive,  later  negative.  In  seven 
every  examination  showed  bacilli.  Voelker  reviewed  the  late  results  of  seventeen 
cases  of  operation  for  renal  tuberculosis  in  the  Heidelberg  clinic  (1902  to  1906). 
His  conclusions  were  (a)  the  disease  is  less  grave  in  the  female;  (b)  in  the  patients 
who  survive  the  operation  the  symptoms  are  late  in  disappearing  (up  to  two 
years) ;  (c)  the  mortality  during  the  first  six  months  after  operation  is  25  per  cent. 

The  presence  of  a  renal  calculus  always  calls  for  operation.  The  danger  of 
the  condition  and  especially  of  the  operation  is  not  so  much  due  directly  to  the 
stone  as  to  infection.  This  seems  a  truism,  but  in  renal  and  biliary  surgery 
physicians  and  patients  are  far  too  prone  to  delay  interference  until  such  becomes 
distinctly,  if  not  very,  dangerous.  The  same  reasons  which  make  early  operation 
safe  in  cases  of  appendicitis  call  for  early  operation  in  renal  calculus,  although  in 
the  latter  a  moderate  amount  of  delay  does  not  lead  to  such  disastrous  results. 

Pyonephrosis  or  surgical  kidney  demands  operation.     If  the  disease  is  so 

*  The  author  has  mistaken  an  apparently  well-encapsulated  hypernephroma  for  a  localized 
tuberculous  lesion,  performed  partial  excision,  and  obtained  a  disastrous  result.  This  error  is 
easily  made,  and  should  be  remembered. 


REMARKS   ON   DECORTICATION  659 

severe  that  drainage  will  put  too  great  strain  on  the  patient's  recuperative 
powers;  if  the  other  kidney  is  in  such  health  that  it  can  be  depended  upon  for 
elimination,  and  if  the  immediate  condition  of  the  patient  permits  nephrectomy, 
then  nephrectomy  is  the  operation  of  choice.  When  doubt  exists  as  to  the  func- 
tional ability  of  the  other  kidney,  or  when  the  general  condition  of  the  patient 
contraindicates  the  more  severe  operation,  drainage  is  the  operation  of  choice. 
The  same  is  true  in  calculus  disease  when  infection  is  present.  If  in  the  above 
disease  the  inflammatory  process  is  moderate  and  a  useful  amount  of  renal  par- 
enchyma remains  intact,  drainage  gives  excellent  results,  or  partial  nephrectomy 
plus  drainage  may  be  the  better  procedure  to  adopt. 

Anuria,  especially  calculus  anuria,  calls  for  nephrotomy,  and,  as  Morris 
points  out,  the  operation  ought  to  be  on  the  kidney  which  appears  to  have  be- 
come last  affected,  i.e.,  on  the  organ  which  presumably  is  in  the  better  condition. 
Anuria  following  nephrectomy  calls  for  immediate  nephrotomy  on  the  remaining 
kidney.     (Willy  Meyer.) 

Harrison  demonstrated  long  ago  that  operations  undertaken  for  calculi 
proved  in  many  instances  curative,  even  when  no  calculi  were  found,  and  he 
concluded  that  nephrotomy  might  be  a  reliable  therapeutic  agent  in  certain 
cases  of  acute  nephritis  by  relieving  renal  tension.  A.  H.  Ferguson,  Edebohls, 
and  others  believe  that  by  decortication  of  the  kidney  a  cure  (symptomatic  at 
least)  may  be  obtained  in  chronic  interstitial  nephritis.  At  present  this  sub- 
ject is  distinctly  sub  judice,  but  very  remarkable  results  have  been  claimed  by 
thoroughly  reliable  men. 

E.  Martini  ("Archiv  fiir  klin.  Chir.,"  Ixxviii,  p.  619)  experimented  on  dogs. 
At  various  periods  after  kidney  decortication  (even  after  many  months)  he 
killed  the  animals  by  bleeding;  ligated  the  renal  artery  and  vein  and  then 
injected  colored  gelatin  through  the  aorta  and  ascending  vena  cava.  By 
these  means  Martini  was  able  to  study  the  collateral  circulation  of  the  kidney. 
An  abstract  of  his  conclusions  follows : 

1 .  The  new  renal  capsule  is  principally  the  result  of  growth  of  the  interstitial 
connective  tissue  and  of  the  endothelium  of  the  vessels  of  the  cortical  zone  of  the 
cortex. 

2.  New  capsule  is  firmly  adherent  to  the  kidney,  is  not  of  uniform  thickness, 
but  is  thicker  than  the  normal  capsule.  Its  thickness  is  greater  if  the  fatty 
capsule  has  been  removed  and  nephropexy  performed  as  well  as  decortication. 

3.  The  new  capsule  shows  no  tendency  to  shrink  or  to  sclerosis;  it  retains  its 
normal  structure  and  rich  vascularity. 

4.  Decapsulation  causes  only  temporary  phenomena  of  hyperemia  in  the 
periphery  of  the  kidney  and  no  epithelial  degeneration. 

5.  There  is  a  temporary  decrease  in  the  secretion  of  urine  from  simple  causes. 

6.  Ligation  of  the  renal  artery  or  vein  causes  more  degeneration  and  necrosis 
in  normal  than  in  previously  decapsulated  kidneys. 

7.  The  collateral  circulation  through  the  new  capsule  can  fully  compensate 
for  the  stoppage  of  outflow  through  the  renal  vein  when  it  is  ligated;  it  only 
partially  takes  the  place  of  the  renal  artery  when  that  is  ligated. 

8.  Decapsulation  and  simultaneous  ligation  of  the  corresponding  renal  vein 
is  fatal. 


66o  OPERATIONS    UPON    THE    KIDNEY 

9.  If  both  kidneys  have  been  decapsulated  and  are  provided  with  a  new 
formed  capsule,  one  renal  vein  may  be  ligated  and  a  month  later  the  other 
ligated  also  without  death  of  the  animal. 

10.  A  dog  can  survive  simultaneous  ligation  of  the  artery  and  vein  of  one 
kidney  only  when  the  fibrous  capsule  of  that  kidney  has  been  previously 
extirpated. 

11.  The  collateral  circulation  of  a  previously  decapsulated  kidney  is  sufficient 
to  preserve  the  life  of  a  dog  when  the  other  kidney  is  removed  and  the  vein  of 
the  decapsulated  kidney  is  ligated. 

Congenital  Cystic  Kidney. — This  disease  is  usually  bilateral  and  is  thought 
to  kill  because  of  the  pressure  exerted  by  the  innumerable  cysts  upon  the 
secreting  tissues.  If  the  growth  and  multiplication  of  the  cysts  could  be 
stopped,  then  a  practical  cure  might  be  attained. 

Fred  Lund  (Journ.  A.  M.  A.,  Sept.  26, 1914)  has  followed  Rovsing  in  expos- 
ing the  kidney  in  the  loin,  puncturing  all  the  exposed  cysts.  A  large  part  of  the 
posterior  surface  of  the  kidney  may  be  seen  and  the  cysts  punctured  by  proper 
retraction  of  the  wound.  As  the  cystic  contents  flow  out,  the  kidney  de- 
creases in  size  and  can  be  delivered  and  held  in  the  hand.  It  is  now  easy  to 
palpate  large  cysts  and  collections  of  cysts  and  to  empty  them  with  a  hollow 
needle.  In  this  manner  a  kidney  which  was  from  six  to  ten  times  the  normal 
size  may  be  reduced  to  twice  the  normal,  returned  to  its  bed  and  the  wound 
closed  without  drainage.  Both  Rovsing  and  Lund  have  had  a  few  gratifying 
results  from  this  operation. 

Bevan  and  McRae  have  each  seen  cases  of  unilateral  polycystic  kidneys. 

Horse-shoe  Kidney. — A.  Martinow  ("Zentralblatt  fiir  Chir.,"  1910,  No.  9) 
describes  a  case  of  horse-shoe  kidney  in  which  he  operated  with  good  effect. 
The  report  is  so  suggestive  that  it  requires  sonsideration  and  may  aid  the 
surgeon  in  locating  a  very  limited  class  of  obscure  abdominal  trouble.  A 
nurse,  aged  forty-nine  complained  from  child-hood  of  a  disagreeable  pulsating 
sensation  in  the  whole  abdomen;  for  many  years  there  was  severe  pain  above 
the  umbilicus  and  marked  obstipation.  The  pains  increased  and  did  not 
disappear  at  night.  The  patient  became  hysterical,  and  underwent  treat- 
ment for  hysteria  during  many  years.  Appetite  poor;  occasional  vomiting; 
bowels  moved  every  two  or  three  days;  marked  peristalsis  and  abdominal 
pains.  A  tumor  was  palpable  above  the  umbilicus.  Aorta,  tumor,  and 
caecum  tender  on  pressure.  Tumor  occasionally  increases  in  size  when  the 
pulsation  of  the  aorta  and  other  abdominal  arteries  becomes  stronger  and 
more  annoying.     No  pain  in  the  kidney  regions.     All  other  organs  normal. 

Diagnosis. — Tumor  of  pancreas  or  horse-shoe  kidney.  Laparotomy  was  per- 
formed. A  tumor  was  found  lying  directly  on  the  aorta;  it  was  about  4  cm. 
wide  and  2  cm.  thick  and  formed  an  isthmus  uniting  the  two  kidneys  lying 
one  on  each  side  of  the  vertebral  column.  The  diagnosis  of  horse-shoe  kidney 
was  clear.     Each  half  of  the  abnormal  kidney  was  provided  with  a  ureter. 

After  incision  of  the  peritoneum  overlying  the  tumor  the  isthmus  was 
grasped  with  two  intestinal  clamps  and  divided.  Immediately  the  two  halves 
of  the  kidney  retracted  one  from  the  other  and  the  aorta  was  freed  from  pressure. 
After  removal  of  the  clamps  from  the  kidney  hemorrhage  was  easily  controlled 


ANATOMY    OF    I'KETER  66l 

by  a  few  catgut  sutures.  The  peritoneal  wound  was  sutured  and  the  abdo- 
men closed  without  drainage.  Martinow  writes,  "I  would  not  assert  that  the 
isthmus  should  be  divided  in  cases  where  horse-shoe  kidney  is  discovered 
accidentally  during  an  operation,  but  I  do  intimate  that  in  cases  with  symptoms 
due  to  pressure  on  the  sympathetic  plexus  this  simple  operation  is  possible 
and  ought  to  be  tried." 


CHAPTER  XLVIII 
OPERATIONS   ON   THE  URETER^ 

Anatomy. — The  ureters  conduct  the  urine  from  the  kidneys  to  the  base 
of  the  bladder,  the  walls  of  which  they  pierce  obliquely,  thus  providing  them- 
selves with  valvular  outlets.  The  average  length  of  the  ureter  is  12  inches; 
its  narrowest  point  is  about  2^-^  inches  below  the  hilum  of  the  kidney  (diameter 
here  about  3^^  inch),  and  the  next  narrowest  point  is  at  the  brim  of  the  pelvis. 
Calculi  are  liable  to  become  caught  at  these  two  places  and  at  the  point  where 
the  bladder  is  entered.  The  ureters  are  lined  by  a  thin  mucosa  which  is  thrown 
into  folds.  A  thick  muscular  and  a  thin  but  elastic  external  fibrous  tunic 
complete  the  ureteral  wall. 

The  ureter  lies  loosely  in  the  post-peritoneal  connective  tissue.  "In  the 
abdominal  portion  of  its  extent  it  lies  upon  the  front  of  the  psoas  muscle,  and 
about  half-way  between  its  commencement  and  the  brim  of  the  pelvis,  or  some- 
where below  that  point,  it  crosses  in  front  of  the  genito-crural  nerve.  The 
upper  half  of  this  portion  of  the  duct,  except  at  its  commencement  on  the  right 
side,  where  it  is  covered  by  a  third  part  of  the  duodenum,  is  in  direct  contact 
with  the  peritoneum,  to  which  it  is  intimately  connected;  and  the  lower  half 
is  separated  from  the  peritoneum  by  the  spermatic  or  ovarian  vessels,  which 
are,  however,  closely  united  both  to  the  ureter  and  to  the  serous  membrane.  .  . 
At  the  brim  of  the  pelvis  the  relation  of  the  ureter  to  the  large  vessels  is  not 
always  quite  the  same,  as  it  may  rest  either  upon  the  lower  end  of  the  common 
iliac  artery  or  upon  the  external  iliac;  it  is  covered  in  front  by  the  peritoneum 
and  it  is  crossed  on  the  right  side  by  the  termination  of  the  ileum,  and  on  the 
left  by  the  commencement  of  the  rectum."  (Morris,  "Surgery  of  the  Kidney 
and  Ureter.") 

Tourneur's  point  corresponds  approximately  to  the  upper  end  of  the  ureter 
and  the  level  of  origin  of  the  spermatic  or  ovarian  artery.  Draw  a  transverse 
line  from  the  tip  of  one  twelfth  rib  to  that  of  the  other.  Draw  a  vertical  line 
upwards  from  the  junction  of  the  middle  and  inner  thirds  of  Poupart's  liga- 
ment.    Where  these  two  lines  cross  is  Tourneur's  point. 

To  find  where  the  ureter  crosses  the  iliac  artery,  Morris  gives  the  following 
advice:  For  practical  purposes,  a  point  lying  at  the  junction  of  the  upper  and 
middle  thirds  of  the  line  indicating  the  course  of  the  common  and  external 
iliac  arteries  will  sufficiently  indicate  its  position.     The  line  marking  the  course 

*  In  this  chapter  very  free  use  has  been  made  of  Morris'  work  on  "Surgical  Diseases  of  the 
Ureter  and  Kidney." 


662 


OPERATIONS    ON    THE    URETER 


of  the  iliac  vessels  is  drawn  from  the  bifurcation  of  the  aorta,  half  an  inch  below 
and  to  the  left  of  the  umbilicus,  to  midway  between  the  anterior  superior  spine 
of  the  ilium  and  the  symphysis  pubis. 

Hydronephrosis  is  commonly  the  result  of  ureteral  obstruction,  whether 
due  to  calculus,  stricture,  external  pressure,  or  torsion  of  the  tube  from  renal 
ptosis.     Of  course,  the  cause  must  be  sought  and,  if  possible,  removed. 


Fig.  802. — (Eckehorn.) 


Fig.  803. — {Eckehorn.) 


Very  frequently  a  branch  from  the  renal  artery,  or  even  direct  from  the  aorta 
enters  the  kidney  at  a  point  remote  from  the  pelvis.  The  ureter  may  become 
kinked  over  this  branch.  The  above  is  a  common  cause  of  hydronephrosis 
and  ligation,  and  division  of  the  aberrant  vessel  is  usually  the  proper  treatment. 

A  glance  at  Figs.  802,  803  and  804  shows  diagrammatically  the  relations 
of  the  ureter  to  aberrant  vessels,  while  Figs.  805,  806  and  810  show  how  the 
vessels  may  produce  hydronephrosis. 


Fig.  804. — (Eckehorn.) 


Fig.  805.— (5azv.) 


Bland  Sutton  believes  that  the  kinking  of  the  ureter  over  the  abdominal 
vessel  is  the  result,  not  the  cause  of  the  hydronephrosis.  A  number  of  reli- 
able surgeons,  however,  find  that  the  hydronephrosis  is  cured  after  division  of 
the  vessel  apparently  causing  the  kinking. 


HYDRONEPHROSIS 


663 


It  is  important  to  note  the  relationship  between  the  uretec  and  the  pelvis 
of  the  kidney.  Normally  the  ureter  opens  into  the  lowest  point  in  the  pelvis, 
but  in  hydronephrosis  the  opening  may  be  high  up  on  the  pelvic  wall,  and 
hence  escape  of  fluid  from  the  kidney  becomes  impossible  even  if  the  original 
obstruction  of  the  ureter  is  remedied.  Various  operations  have  been  devised 
for  the  correction  of  the  faulty  relation  between  ureter  and  renal  pelvis. 

Mynter's  Method. — Expose  and  explore  the  kidney  and  its  pelvis.  Make 
an  incision  into  and  explore  the  interior  of  the  greatly  dilated  pelvis  or  the 
hydronephrotic  sac.  If  possible,  pass  a  catheter  through  the  ureter  down 
to  the  bladder  and  find  if  ureteral  stenosis  exists.  If  the  opening  of  the  ureter 
is  high  up  on  the  side  of  the  sac  (Fig.  807),  make  the  incision  A,  B,  through 
the  wall  of  the  sac,  parallel  and  opposite  to  the  ureter.     Make  the  similar 


Fig.  806. — {Bazy.) 


Fig.  807. 


incision  A,  C,  in  the  ureter.  Unite  the  anterior  edge  of  the  ureteral  wound 
to  the  anterior  edge  of  the  sac  wound  (x-x\  Fig.  808).  Unite  the  posterior 
edge  of  the  ureteral  wound  to  the  corresponding  edge  of  the  sac  wound  (y-y^). 
The  sutures,  of  fine  silk  or  hemp,  must  not  include  the  mucosa  in  their  bite. 
(This  lest  calculi  form  on  them.)  The  result  is  a  lowering  of  the  ureteral  orifice 
to  the  lowest  point  in  the  sac  (Fig.  809.)  The  operation  is  identical  in  prin- 
ciple with  Mikulicz's  pyloroplasty.  If  a  ureteral  stricture  exists  between  the 
points  A  and  C,  the  operation  of  course  cures  that  also.  When  obstruction  is 
due  to  kinking  of  the  ureter  over  one  of  the  renal  vessels,  either  make  an  ana- 
stomosis between  the  sac  and  the  ureter  below  the  obstruction  CFig.  810,  x-y) 
or  divide  the  ureter  and  unite  the  open  end  of  the  lower  segment  to  the  lowest 
point  in  the  hydronephrotic  sac. 

Mayo's  method  of  using  a  flap  of  fat  to  support  the  line  of  suture  in  the 
kidney  pelvis  is  most  valuable  (see  p.  653). 

Kuster  ("Archiv  f.  klin.  Chir.,"  xliv,  850)  describes  a  case  where  the  above 
operations  were  impracticable,  as  an  impermeable  stricture  of  the  ureter  existed 
a  short  distance  below  the  sac.  He  divided  the  ureter  immediately  below  the 
stricture,  separated  it  sufficiently  from  its  surroundings  so  that  it  could  be 
brought  up  to  the  sac  without  tension,  split  the  upper  end  of  the  ureter  (Fig.  811), 
made  an  incision  through  the  posterior  wall  of  the  sac  at  his  lowest  level,  spread 
open  the  split  upper  end  of  the  ureter  and  sutured  it  to  the  vivified  internal 


664 


OPERATIONS    ON    THE    URETER 


surface  of  the  anterior  wall  of  the  sac  (Fig.  812).  The  ureter  was  thus  formed 
into  a  sort  of  funnel  opening  into  the  sac.  The  wound  in  the  sac  was  closed  with 
sutures  (Fig.  813).  The  result  was  good.  Israel  has  lessened  the  size  of  the 
distended  pelvis  by  a  plication  of  its  walls  similar  to  that  practised  for  the  cure 


Renal 
vesseus 


Fig.  808. 

Figs.  808  .4nd 


Fig.  809. 
-Mynter's  operation. 


Fig.  810. — (Modified  from 
Morris.) 


Fig.  811. 


Fig.  8i2.  Fig.  813. 

Figs.  8ii,  812  and  813. — Kuster's  operation. 


Ufetet' 

Fig.  814.  Fig.  815. 

Figs.  814  and  815. — Fenger's  operation. 

of  dilatation  of  the  stomach.  Occasionally  in  hydronephrosis  a  valve  is  present 
at  the  ureteropelvic  junction,  which  prevents  the  complete  evacuation  of  the 
renal  pelvis  or  hydronephrotic  sac.  Fenger's  operation  for  this  condition  is  as 
follows:  Expose  the  kidney.     Open  the  renal  pelvis  and  examine  the  interior, 


EXPOSURE    URETER  665 

especially  the  ureteral  opening.  Pass  a  bougie  into  the  ureter.  Excise  the  valve 
by  a  transverse  incision  (Fig.  814,  A  B).  Close  with  fine  catgut  sutures  the 
wound  left  by  the  incision  of  the  valve.     Close  the  wound  in  the  sac. 

When  hydronephrosis  is  due  to  or  kept  up  by  a  stricture  at  the  junction  of 
the  ureter  and  pelvis,  the  operation  practised  by  Fenger  was  the  following: 
Make  the  incision  A,  a  (Fig.  815),  through  the  stricture  and  continue  for  a  short 
distance  upwards  through  the  sac-wall  and  downwards  through  the  ureteral  wall. 
With  sutures  unite  the  points  A,  a;  B,  b;  C,  c,  etc.  This  practically  amounts 
to  an  anastomosis  between  the  ureter  and  the  renal  pelvis.  To  avoid  tension  it 
may  be  necessary  to  separate  the  ureter  from  its  surroundings  for  a  short  distance. 

Exposure  of  the  Ureter. — (A)  Transperitoneal  Route. — The  ureter  can  be 
reached  through  a  median  or  lateral  abdominal  incision.  This  method  is  valu- 
able as  a  means  of  diagnosis,  permitting,  as  it  does,  palpation  of  the  opposite 
kidney,  and  the  recognition  of  stones  impacted  in  the  ureter  and  of  other  condi- 
tions. When  a  stone  is  situated  low  down  in  the  ureter  it  may  be  palpated 
through  an  incision  through  the  rectus  muscle  or  through  a  "gridiron"  incision 
such  as  used  in  appendectomy,  but  placed  a  little  more  external  than  in  the  latter 


Fig.  816.  Fig.  817. 

Exposure  of  ureter.     (Monod  and  Vanverts.) 

operation.  Guided  by  a  finger  in  the  abdomen,  strip  the  peritoneum  from  the 
parietes  on  the  outer  side  of  the  wound  until  the  ureter  and  stone  are  exposed. 
Protect  the  wound  in  the  peritoneum  either  by  packing  or  by  closing  it.  Incise 
the  ureter  extraperitoneally.  Provide  drainage  through  a  separate  incision. 
Morison  has  frequently  operated  in  this  fashion  and  has  never  infected  the  peri- 
toneum. John  Gibbon  has  had  similar  experience.  In  operations,  such  as 
uretero-ureterostomy  and  uretero-cystostomy,  etc.,  the  transperitoneal  route 
is  of  great  value. 

(B)  Extraperitoneal  Routes. — I.  Lumbo-ilio-inguinal  route  (Morris):  By 
this  route  the  ureter  may  be  explored  throughout  its  whole  length,  (a)  Explora- 
tion of  lumbar  portion  of  ureter.  Place  the  patient  lying  on  his  healthy  side 
with  the  abdomen  turned  somewhat  towards  the  table.  Do  not  place  any  pillow 
under  the  opposite  loin.  Beginning  at  the  outer  edge  of  the  sacro-lumbar  mass 
of  muscles,  a  little  below  the  twelfth  rib,  make  an  incision  obliquely  forwards  and 
downwards  to  a  point  i  inch  internal  to  the  anterior  superior  spine  of  the  ilium. 
Continue  the  incision  parallel  to  and  i  inch  above  Poupart's  ligament,  as  far  as 
its  centre  (Figs.  816  and  817).     Cut  down  to,  hut  not  through,  the  peritoneum. 


666 


OPERATIONS    OX    THE    URETER 


Expose  the  kidney.  Palpate  the  renal  pelvis  between  finger  and  thumb.  By 
exercising  slight  traction  on  the  pelvis  the  ureter  may  be  made  more  prominent. 
With  the  fingers  or  a  pledget  of  gauze  strip  the  peritoneum  from  theparietes 
until  the  ureter  is  seen.  "The  relation  of  the  ureter  to  that  part  of  the  peri- 
toneum which  is  adherent  to  the  spine  is  rather  constant,  the  ureter  being  situ- 
ated just  external  to  the  line  of  adhesion.  Therefore,  when  the  operator  has 
stripped  up  the  peritoneum  and  reached  this  point,  he  will  find  the  ureter  on  the 
stripped-up  peritoneum  external  to  it."  (Kelly.)  Remember  that  the  ureter 
adheres  to  the  peritoneum  even  when  that  membrane  is  raised  from  the  sub- 
jacent structures.  A  little  tension  exercised  on  the  renal  pelvis  helps  to  render 
the  ureter  recognizable. 


UIOINCUINAl    N 


DEE.P      tPIOASlRll.    A 


I'IG.  Si8. — (Hcrrick,  Cleveland  Med.  Jour.) 


(b)  Exploration  of  pelvic  portion  of  ureter.  Roll  the  patient  over  so  that 
while  still  resting  on  his  sound  side  his  back,  instead  of  his  abdomen,  is  turned 
somewhat  towards  the  table.  Enlarge  the  wound,  if  necessary,  forwards, 
"even  as  far  as  the  external  abdominal  ring"  (Morris),  always  carefully  avoiding 
opening  the  peritoneum.  This  huge  wound  may  be  avoided  by  seeking  the 
pelvic  ureter  through  a  low  "gridiron"  incision  which  penetrates  to,  but  not 
through,  the  peritoneum.  Should  the  peritoneum  be  opened  by  accident,  close 
it  at  once  with  sutures.  Sometimes  the  kidney  is  not  available  as  a  guide  to  the 
ureter  and  one  is  forced  to  hunt  for  that  tube  at  the  pelvic  brim.  Here  the  guide 
to  the  ureter  is  the  place  where  it  crosses  the  iliac  artery,  and  when  the  peri- 
toneum is  stripped  off,  it  will  be  found  adhering  to  that  membrane  "like  a 
whitish  or  yellowish- white  tape."     In  the  male  the  ureter  may  be  examined  in 


EXPOSURE    URETER  667 

this  manner  down  to  the  bladder,  but  in  the  female  it  runs  in  the  broad  b'ga- 
ment,  which  makes  it  very  difficult  of  access.  The  uterine  artery  lies  in  front, 
the  veins  behind,  the  ureter, 

Herrick's  Method. — ("Cleveland  Med.  Journ.,"  Dec,  1910.) 

Step  I. — Draw  an  imaginary  line  from  the  inner  lip  of  the  anterior  superior 
spine  to  a  point  above  the  opposite  pubic  spine.  Beginning  at  a  point  ij-^  to 
2  inches  from  the  anterior  superior  spine  make  an  incision  along  the  imaginary 
line  for  3  to  2>}''2  inches  (Fig.  818  ).  This  terminates  at  the  edge  of  the  rectus  "i 
to  i^  inches  above  the  entrance  into  it  of  the  deep  epigastric  artery."  Split 
the  tendinous  external  oblique  along  the  line  of  the  incision.  Split  the  internal 
oblique  and  transversalis  parallel  to  their  fibres  and  to  the  nerve  trunks  which 
lie  between  them.     Do  not  open  the  peritoneum. 

Step  2. — With  the  fingers  dissect  the  peritoneum  up  from  the  side  and  the 
floor  of  the  pelvis.  A  broad  retractor  placed  at  the  lower  end  of  the  incision 
gives  good  access  to  the  deep  pelvis.  Pass  the  finger  to  the  bifurcation  of  the 
common  iliac  artery  and  turn  the  palm  of  the  finger  against  the  under  surface  of 
the  peritoneum  where  it  will  feel  the  ureter  closely  adherent  to  the  peritoneum 
covered  by  some  of  its  reflected  fibres. 

Step  3. — Separate  the  ureter  from  the  peritoneum  for  an  inch  or  two,  pass  a 
tape  around  it  and  apply  slight  traction  when  the  ureter  will  stand  out  like  a 
ridge  extending  to  the  base  of  the  bladder. 

Step  4. — Remove  any  stone  by  incision.  Close  the  cut  -with  plain  catgut 
sutures.     Never  use  gauze  for  drainage.     Close  the  abdominal  wound. 

Kidd's  method  (Lancet,  June  7, 1913)  is  very  like  Herrick's.  Trendelenburg's 
position.  Three-inch  incision  parallel  to  and  i)-^  inches  above  Poupart's  liga- 
ment. Two  inches  of  the  cut  extend  outwards  and  one  inch  extends  inwards 
from  the  outer  edge  of  the  rectus.  Split  the  aponeurosis  of  the  external  oblique 
the  whole  length  of  the  wound.  (N.  B.  The  aponeurosis  of  the  external  and 
internal  oblique  muscles  do  not  fuse  to  form  the  anterior  sheath  of  the  rectus 
until  at  least  one  inch  inside  the  edge  of  that  muscle.)  Retract  the  edges  of 
the  wound  and  split  the  internal  oblique  and  transversalis  in  the  direction  of 
their  fibres  for  a  distance  of  two  inches  external  and  one  internal  to  the  edge 
of  the  rectus.  Retract  the  rectus  inwards  and  observe  the  deep  epigastric 
vessels  as  they  pierce  the  transversalis  fascia  and  dip  in  front  of  the  semilunar 
fold  of  Douglas  to  enter  the  rectus  sheath.  Just  external  to  and  above  the 
point  where  the  deep  epigastric  vessels  enter  the  rectus  sheath  tear  through  the 
transversalis  fascia  into  the  subperitoneal  fat.  Divide  the  transversalis  fascia 
outwards  the  whole  length  of  the  wound.  With  the  finger  separate  the  peri- 
toneum from  the  iliac  fossa  and  side  of  the  true  pelvis.  In  the  pelvic  fossa  note 
and  retract  downwards  and  inwards  the  vas  deferens;  retract  upwards  and  out- 
wards the  spermatic  vessels.  In  the  female  the  ovarian  vessels  and  round 
ligament  are  treated  similarly.  Guided  by  the  external  iliac  artery  find  and 
clear  the  common  and  internal  iliacs.  The  ureter  crosses  the  pelvic  brim  over 
the  external  iliac  artery  and  runs  down  the  pelvic  wall  parallel  to  and  just  in 
front  of  the  internal  iliac.  It  is  attached  to  the  peritoneum.  Strip  the  ureter  from 
its  bed  for  a  distance  of  two  or  three  inches  above  and  below  where  it  crosses 
the  external  iliac.    Long  narrow  retractors  are  required  to  give  good  exposure. 


668  OPERATIONS  ON  THE  URETER 

Introduce  into  the  ureter  two  sutures  of  the  finest  chromic  catgut  by  means 
of  fine  needles  as  shown  in  Fig.  819.  Put  strips  of  gauze  under  the  ureter  to 
soak  up  escaping  urine.  Using  the  sutures  as  retractors  make  a  very  small 
incision  in  the  ureter  with  a  tenotome.  (If  the  urine  is  very  septic  clamp  the 
ureter  above  the  incision  with  suitable  rubber  covered  forceps.)  Introduce  a 
ureteral  bougie  and  locate  the  stone.  Remove  the  stone  with  ureteral  forceps. 
Close  the  ureteral  wound  with  fine  catgut  sutures  and  cover  this  with  sutures 
in  the  periureteral  tissues.  There  is  usually  no  leakage  and  the  wound  heals 
by  first  intention.  If  necessary  the  ureter  may  be  cleared  all  the  way  to  the 
bladder.  In  the  female  this  involves  ligation  of  the  uterine  vessels.  Introduce 
a  slip  of  rubber  tissue  to  the  site  of  the  ureteral  wound  as  a  drain.  Close  the 
wound  in  layers.  One  particular  advantage  claimed  for  the  operation  is  that 
the  ureter  is  generally  opened  remote  from  the  site  of  the  stone  and  hence  in  a 
healthier  place  so  that  there  is  less  fear  of  subsequent  stricture. 

II.  The  sacral  route:  Morris  thus  describes  Delbet's  operation:  "(i)  The 
patient  should  be  placed  upon  his  sound  side,  so  that  the  rectum  may  fall  away 
from  the  wound.  (2)  The  incision  should  be  L-shaped,  with  the  long  arm  ver- 
tical, along  the  border  of  the  coccyx,  and  the  short  falling  upon  the  superior 
extremity  of  the  first,  being  almost  parallel  to  the  fibres  of  the  gluteus  maximus. 
(3)  Cut  the  insertion  of  this  muscle  and  the  sacro-sciatic  ligaments  and  some 
fibres  of  the  pyriformis.  (4)  Lay  bare  the  lateral  face  of  the  rectum  with  for- 
ceps and  a  director.  The  ureter  is  always  to  be  found  adherent  to  the  detached 
peritoneum,  and  can  be  followed  downwards  to  the  bladder  and  upwards  for 
seven  or  eight  cm.  from  its  termination.  This  description  applies  specially  to 
man;  in  woman  the  operation  is  more  difficult  because  of  the  broad  ligament." 

Various  surgeons  have  used  modifications  of  Kraske's  sacral  operation  to 
gain  access  to  the  ureter,  but  these  have  little  to  recommend  them. 

(C)  Perineal  Route. — An  operation  through  the  perineum,  very  similar  to 
that  used  for  the  exposure  of  the  prostate  by  a  curved  transverse  incision, 
permits  the  exposure  of  the  seminal  vesicles,  and  with  them  the  lower  end  of 
the  ureter. 

(D,  E)  Vaginal  and  Rectal  Routes. — Ureteral  calculi  palpated  through  the 
vagina  or  rectum  have  been  successfully  removed  by  direct  incision  through 
the  walls  of  these  cavities.     The  wounds  were  sutured  immediately. 

(F)  Transvesical  Route. — Calculi  impacted  at  the  vesical  orifice  of  the  ureter 
may  be  reached  and  removed  by  suprapubic  or  perineal  cystotomy.  Young 
and  Bransford  Lewis  have  successfully  removed  calculi  in  this  position  by  means 
of  the  cystoscopy 

Ureterotomy  and  Uretero-lithotomy.— Expose  the  ureter  by  one  of  the  extra- 
peritoneal methods.  Introduce  into  it,  if  possible,  two  catgut  sutures  (x-x\ 
Y-Y^,  Fig,  819),  each  of  which  is  in  the  long  axis  of  the  ureter.  Using  the  sutures 
to  fix  the  tubes,  make  a  longitudinal  incision  into  the  ureter,  over  the  calculus, 
if  such  is  present.  It  is  wise,  when  possible,  to  push  the  stone  up  the  ureter, 
incising  at  this  new  point  lest  ulceration  at  the  site  of  impaction  interfere  with 
healing.  Remove  the  calculus  or  explore  the  ureter  as  may  be  indicated.  Ap- 
ply a  long  strip  of  folded  rubber  tissue  or  oil-silk  over  the  ureteral  wound  be- 
tween the  two  sutures.     Tie  the  end  of  the  suture  x  over  the  rubber  tissue  to  Y, 


URETEROTOMY.   URETERECTOMY 


669 


and  the  end  of  the  suture  x^,  similarly  to  y^  (Fig.  820).  Bring  the  free  end  of 
the  rubber  tissue  or  oil-silk  out  of  the  wound  in  the  parietes.  Close  the  parietal 
wound  except  where  the  drain  emerges.  This  closes  the  ureteral  wound  efl5- 
ciently  and  safely. 

Many  surgeons  suture  the  wound  in  the  ureter  with  a  few  fine  silk  or  hemp 
stitches  which  do  not  involve  the  mucosa ;  other  surgeons  omit  all  suture  of  the 
ureteral  wound,  trusting  to  nature  to  close  the  wound,  draining  the  wound  with 
rubber  tissue  or  tube.  Simple  through-and-through  sutures  of  catgut  are  all 
that  is  necessary,  but  a  drain  of  rubber  tissue  or  oil-silk  ought  always  to  be 
attached  to  the  line  of  suture.  The  use  of  gauze  in  connection  with  renal  or 
ureteral  wounds  is  liable  to  lead  to  the  formation  of  fistulae.  When  drainage 
of  the  ureter  is  desired,  one  may  act  as  follows: 

Trim,  in  the  fish-tail  fashion,  the  end  of  an  appropriate  sized  rubber  tube; 
wrap  around  the  tube  a  few  layers  of  gauze;  cover  the  gauze  with  rubber  tissue. 


Fig.  819. 


Fig.  820. 


Fig.    821. — Ureteral    drainage. 


Ureterotomy. 


Leave  about  y^  inch  of  the  ''fish-tail"  end  of  the  tube  free  from  gauze.  Per- 
form the  ureterotomy,  using  catgut  sutures  as  handles  (Fig.  819).  Introduce 
the  bared  end  of  the  dressed  tube  into,  or  over,  the  ureter  (Fig.  821).  Do 
not  permit  the  gauze  on  the  tube  to  be  in  contact  with  the  ureter.  With  a 
needle  stitch  sutures  x-x^  and  y-y^  to  the  tube;  this  holds  the  drain  in  place. 

Ureterotomy  for  the  cure  of  ureteral  stricture  is  performed  as  follows 
(Fenger's  operation) : 

Expose  the  ureter  by  the  extraperitoneal  route.  Make  a  longitudinal 
incision  into  the  ureter  immediately  above  the  stricture;  pass  a  suitable  probe 
or  bougie  through  the  stricture;  continue  the  vertical  incision  through  the 
stricture  and  downwards  until  the  wound  below  the  site  of  stricture  is  equal 
in  length  to  that  above  (Fig.  822).  With  sutures  unite  the  point  a  to  a^,  b 
to  b\  etc.  (Fig.  823).  The  result  is  practically  the  formation  of  an  anasto- 
mosis (Fig.  824)  between  the  upper  and  lower  segments  of  the  tube.  Close 
the  external  wound  after  providing  for  drainage. 

Ureterectomy. — Ureterectomy  may  be  carried  out  as  a  step  in  the  operation 
of    nephrectomy    or  as  a   secondary  operation.     The  ureter  is  exposed  ex- 


670 


OPERATIONS    ON   THE   URETER 


traperitoneally  by  the  lumbo-ilio-inguinal  incision.  It  is  not  always  necessary 
to  make  the  external  incision  continuous  throughout  the  whole  length 
described  on  page  665.  After  the  kidney  is  delivered  or  removed  the  ureter 
may  be  followed,  by  a  burrowing  dissection,  down  towards  the  pelvis,  a 
forceps  or  stout  probe  passed  down  to  the  bottom  of  the  wound  to  act  as  a 
guide,  while  a  second  incision  is  made  through  the  parietes  (Fig.  825).     No 


A' 

Fig.  822.  Fig.  823.  Fig.  824. 

Figs.  822,  823,  and  824. — Fenger's  ureteroplasty. 


special  description  of  technic  is  required.  Note  that  an  apparently  tuberculous 
ulceration  of  the  vesical  mucosa  near  the  mouth  of  the  ureter  is  not  a  contra- 
indication to  nephrectomy  and  ureterectomy.  When  the  diseased  kidney  and 
ureter  are  removed,  the  vesical  lesion  frequently  recovers  spontaneously. 

Ureteral  Anastomosis. — (A)  Monari's  Method:  Lateral  Anastomosis. — This 
operation  is  practically  the  same  as  lateral  anastomosis  of  the  intestine.  Fig. 
826  sufficiently  explains  the  method,  which  is  in  every  way  inferior  to  the  Van 
Hook  operation. 


Fig.  825. — Exposure  of  ureter. 


Fig.  826. — Monari's  ureteral  anastomosis. 


(B)  Van  Hook's  Operation:  Lateral  Implantation. — Split  the  upper  segment 
of  ureter  for  a  short  distance.  This  is  important,  as  it  prevents  stenosis  at  the 
orifice  (Fig.  827).  Ligate  the  upper  end  of  the  lower  segment  of  ureter.  Pass 
the  fine  catgut  suture  x  y  through  the  lower  wall  of  the  upper  segment  opposite 
the  split  described  above  (Fig.  827).  Make  a  vertical  incision  into  the  lower 
segment  immediately  below  the  site  of  ligation.     With  round  needles  (either 


URETERO-CYSTOSTOMY 


671 


Straight  or  curved)  pass  the  suture  x  v  through  the  opening  in  the  ureter  and 
make  its  ends  emerge  at  the  points  o.  n.  (Fig.  828.)  As  catgut  is  not  easily 
threaded  in  fine  needles,  one  may  arm  the  needles  with  a  suture  carrier  of  silk 
or  hemp,  by  which  means  the  introduction  of  the  catgut  becomes  easy  (Fig.  829). 
Insert  the  lower  end  of  the  upper  segment  of  ureter  through  the  wound  in  the 
lower  segment,  pull  the  suture  x  v  sufficiently  tight,  and  tie  it  (Fig.  830). 

Whenever  possible,  the  extraperitoneal  route  should  be  chosen 
in  performing  ureter o-ureter ostomy. 

Uretero-cystostomy. — This  operation  is  called  for  in  certain 
cases  of  persistent  ureteral  fistula,  in  cases  where  part  of  the 
ureter  has  been  destroyed  in  the  course  of  operations,  e.g.,  on 
the  uterus.  It  takes  the  place  of  removal  of  the  corresponding 
kidney,  and  where  feasible  is  the  operation  of  choice. 

(A)  Vaginal  Route. — When  done  to  cure  a  uretero-vaginal 
fistula,  the  operation  consists  essentially  in  freeing  the  lower  end 
of  the  ureter  from  its  surroundings  and  in  suturing  it  into  a 
small  opening  in  the  bladder.  When  freeing  the  ureter,  a 
bougie  or  probe  passed  into  it  is  a  most  valuable  aid.  The  ^P^''^^^^^^- 
method  of  uniting  the  duct  to  the  bladder  will  be  described  in  the  succeeding 
pages. 

(B)  Superior  Extraperitoneal  Route. — Expose  the  ureter  by  the  lumbo-iiio- 
inguinal  incision  or  a  modification  thereof.     This  is  much  less  difficult  to  accom- 


FiG.  827. — 
Van        Hook's 


Fig.  828. — Van  Hook's  ure- 
teral anastomosis. 


'42^" 


Fig.   830. — Van    Hook's 'ure- 
teral anastomosis. 


plish  in  the  male  than  in  the  female,  so  far  as  the  pelvic  segment  of  the  ureter  is 
concerned;  the  broad  ligament  interferes  considerably  in  the  female. 

(C)  Transperitoneal  Route  with  Extraperitoneal  Ureterocystostomy  (Witzel's 
operation). — Open  the  abdomen  by  a  median  incision  in  the  hypogastrium. 
Incise  the  peritoneum  over  the  iliac  vessels,  separate  the  peritoneum  from 
the  subjacent  structures  by  blunt  dissection.  The  ureter  will  be  found  united 
to  the  peritoneum  and  elevated  with  it.     Make  slight  upward  traction  on 


672  OPERATIONS  ON  THE  URETER 

the  ureter  to  make  it  prominent  and  recognizable  low  down,  in  the  broad 
ligament.  By  a  second  incision  in  the  broad  ligament  expose  the  ureter; 
divide  it;  ligate  and  cauterize  the  opening  in  the  lower  segment.  Pull  the 
upper  segment  up  to  and  out  of  the  original  incision  over  the  iliac  vessels. 
With  a  long  forceps  guided  behind  the  peritoneum  to  the  side  of  the  vesical 
region  "above  the  linea  innominata,"  through  this  tunnel  under  the  peritoneum, 
draw  the  ureter  down,  and  anastomose  it  to  the  bladder  extraperitoneally. 
Close  the  two  small  wounds  in  the  peritoneum.  To  make  the  anastomosis 
without  tension  on  the  line  of  suture  Witzel  pulled  the  bladder  towards  the 
ureter  and  fixed  it  there,  to  the  posterior  parietes  at  the  line  of  the  peritoneal 
incision. 

(D)  Intraperitoneal  Rotite. — This  method  has  been  used  successfully  in 
a  number  of  cases  and  seems  to  be  the  method  of  choice  when  uretero- 
cystostomy  is  undertaken  in  the  course  of  an  abdominal  operation  in  which 
the  ureter  has  been  divided.  The  end  of  the  upper  segment  of  the  ureter 
must  be  found,  if  necessary,  in  the  manner  described  in  Witzel's  operation, 
and  sufficient  of  it  separated  from  its  surroundings  to  permit  its  approxima- 
tion to  the  bladder,  without  tension.  To  aid  in  this  approximation  Witzel's 
plan  of  suturing  the  bladder  to  the  side  of  the  pelvis  may  be  useful,  but 
Kelly's  procedure  is  better.  Kelly  detaches  the  bladder  from  the  horizontal 
rami  of  the  pubes  and  thus  can  bring  the  bladder  to  the  ureter.  The  dissec- 
tion of  the  ureter  ought  not  to  be  too  "clean"  lest  nutrition  be  threatened 
and  necrosis  result. 

Methods  of  Uniting  the  Ureter  to  the  Bladder. — (A)  Pass  a  forceps  through 
the  urethra  into  the  bladder  and  push  its  point  against  the  bladder-wall  at 
the  place  where  it  is  desired  to  make  the  anastomosis.  At  this  point  incise 
the  bladder.  The  ureter  has  already  been  prepared  and  has  a  long  suture 
penetrating  its  wall.  Catch  the  ends  of  this  suture  in  the  forceps  and  pull 
them  into  the  bladder  and  out  through  the  urethra  (in  the  male  the  urethra 
may  be  opened  in  the  perineum  for  the  passage  of  the  forceps;  in  the  female, 
the  urethra  serves).  Traction  on  the  suture  pulls  the  open  end  of  the  ureter 
into  the  bladder  and  keeps  it  there  temporarily.  To  prevent  contraction  of 
the  open  end  of  the  urethra  either  cut  it  obliquely  or  split  it  as  in  the  Van 
Hook  operation  for  anastomosis.  Carefully  suture,  with  several  tiers  of  suture, 
the  outer  coats  of  the  bladder  to  the  outer  coats  of  the  ureter  in  the  Lembert 
fashion. 

(B)  This  method  is  similar  to  the  above,  but  a  ureteral  catheter  is  used 
in  place  of  the  forceps.  Pass  a  ureteral  catheter  through  the  urethra  into 
the  bladder  and  bring  its  end  out  through  an  incision  in  the  bladder  at  the 
site  of  anastomosis.  Introduce  the  end  of  the  catheter  into  the  end  of  the 
ureter  and  tie  it  there  with  a  fine  plain  catgut  ligature  (Fig.  831).  Aided  by 
traction  on  the  catheter  pull  the  end  of  the  ureter  into  the  bladder  and  fix  it  there 
by  several  layers  of  sutures  introduced  after  the  Lembert  fashion.  The  ure- 
teral catheter  serves  to  drain  the  ureter  and  hold  it  in  position  until  union  takes 
place. 

(C)  Van  Hook  Method. — The  end  of  the  ureter  is  split  to  prevent  subsequent 
stenosis.     The  operation  is  practically  the  same  as  in  the  case  of  uretero-ure- 


ECTOPIA   VESICAE 


673 


terostomy,  except  that  a  line  of  Lembert  sutures,  burying  the  site  of  anasto- 
mosis and  the  one  stitch  which  penetrates  all  the  coats  of  the  bladder,  adds 
much  security  (Figs.  832,  833). 

Implantation  of  the  ureter  into  the  intestine,  preferably  into  the  sigmoid,  is 
carried  out  in  the  same  fashion  as  into  the  bladder,  but  the  results  have  uni- 
formly proved  disastrous,  as  infection  invariably  passes  up  the  duct  to  the  kid- 


Ureio'' 


Fig.  831.  Fig    832. 

Figs.  831,  832  and  833. — Uretero-c\-stostomy. 


Fig.  833. 


ney.  This  disaster  may  be  avoided  by  using  Harold  Stiles  valvular  implanta- 
tion (p.  725)  von  Maydl's  implantation  of  the  ureters,  plus  a  portion  of  adjacent 
bladder-wall,  into  the  sigmoid  does  not  belong  to  the  same  category  and  gives 
good  results.     It  will  be  described  in  another  chapter. 

Union  of  the  ureter  to  the  skin  is  occasionally  necessary,  but  the  results  are 
bad.  Infection  gains  access  to  the  tube  and  so  to  the  kidney.  The  operation 
has  its  field  of  usefulness,  however.  When  operating,  e.g.,  on  a  cancerous 
uterus,  the  ureter  may  be  accidentally  or  intentionally  divided;  the  condition  of 
the  patient  may  not  admit  of  uretero-ureterostomy  or  uretero-cystostomy. 
Under  such  circumstances  it  may  be  the  best  policy  to  fix  the  ureter  to  the  skin 
and  subsequently  perform  uretero-cystostomy. 

It  has  been  suggested  that  in  all  cases  of  ureteral  anastomosis  success  is 
promoted  if  the  corresponding  kidney  is  exposed  posteriorly,  fixed  to  the  lumbar 
region,  and  drained  through  a  nephrotomy  wound. 


CHAPTER  XLIX 

OPERATIONS  ON  THE  BLADDER 

ECTOPIA  VESICA   (EXSTROPHY  OF  BLADDER) 

Exstrophy  of  the  bladder  maybe  complete  or  incomplete.  When  incomplete, 
the  case  is  usually  one  of  non-obliterated  urachus,  and  urine  escapes  from  the 
umbilicus.  This  may  be  due  to  some  mechanical  obstacle  to  normal  urination, 
and  treatment  must  be  directed  primarily  to  removal  of  such  obstacle  {e.g., 
phimosis).  If  spontaneous  closure  of  the  fistula  at  the  umbilicus  does  not  occur, 
the  passage  may  be  obliterated  by  appHcation  of  the  cautery  or  by  excision. 

Complete  exstrophy  of  the  bladder  is  a  condition  in  which  the  anterior 
vesical  wall  and  a  corresponding  portion  of  the  parietes  are  absent.  The 
anterior  surface  of  the  posterior  vesical  wall  pouts  forwards  and  the  urine 
escapes  at  once  as  it  leaves  the  ureters.     As  a  part  of  the  maldevelopment,  one 


674 


OPERATIONS    ON    THE   BLADDER 


finds  the  pubic  bones  ununited  and  the  penis  in  a  condition  of  epispadias. 
Operations  for  the  reUef  of  ectopia  vesicae  may  be  divided  into  five  classes: 

I.  The  formation  of  an  anterior  wall  to  the  bladder  by  means  of  cutaneous 
flaps,  the  epidermal  side  being  turned  inwards  to  provide  an  epithelial  lining  for 
the  viscus. 

II.  Union  of  the  edges  of  the  defect,  thus  providing  a  small  cavity,  but  one 
lined  by  the  bladder  mucosa. 

III.  Formation  of  an  anterior  wall  to  the  bladder  from  a  segregated  loop  of 
intestine,  thus  providing  a  mucous  instead  of  an  epidermal  lining. 

IV.  Excision  of  all  the  exposed  bladder  and  transplantation  of  tlie  ureters 
into  the  penile  gutter. 

V.  Transplantation  of  the  ureters  into  the  intestine  and  excision  of  the 
bladder. 


1 


riap 


Raw  Sar/fice 
le/r  after 

r/tilisnt/oti   of 
flaps  aA-C. 


Ftap   I     c.       "^ 


^ 


Fig.  834.  Fig.  835. 

Figs.  834  and  835. — Wood's  operation. 

I.  Wood's  Operation  for  Ectopia  Vesicae. — Object  of  operation  is  to  provide 
an  anterior  wall  to  the  bladder  and  that  such  wall  be  lined  with  epithelium. 

The  Operation. — Flap  A  (Fig.  834)  is  made  from  the  skin  of  the  abdomen 
above  the  ectopic  bladder  and  has  its  base  near  the  bladder.  In  dissecting  the 
flap  from  the  subjacent  tissues  care  must  be  taken  to  stop  the  dissection  at  least 
yi  inch  away  from  the  edge  of  the  bladder — i.e.,  the  hinge  of  flap  A  should  be  at 
least  yi  inch  distant  from  the  defect  to  be  covered.  The  size  of  flap  A  should  be 
greater  than  the  defect  to  be  covered.  This  is  to  allow  for  the  shrinkage  which 
always  takes  place  in  the  flap.  If  it  is  desired  to  cover  the  dorsum  of  the  penile 
groove  with  the  same  flap,  then  flap  A  may  be  extended  upwards  (the  portion  D  of 
flap  A  D  being  used  for  this  purpose) .  (Greig  Smith.)  Flaps  B  and  C  are  obtained 
from  the  skin  of  the  abdominal  wall  to  the  side  of  the  bladder  and  of  flap  A. 

The  margins  of  the  bladder  are  freshened  by  dissection  except  along  the  edge 
opposite  the  hinge  of  flap  A,  and  where  the  penile  groove  or  gutter  enters  the 


ECTOPIA   VESICA  675 

bladder.  Flap  A  is  turned  downwards,  the  line  being  the  hinge  or  line  of  turn- 
ing, so  that  the  epithelial  surface  faces  the  bladder  and  the  raw  surface  is  exter- 
nal. The  edge  of  the  flap  is  stitched  to  the  freshened  edge  of  the  bladder.  Spe- 
cial care  must  be  taken  in  suturing  the  lateral  margins  near  the  base  of  the  flap, 
otherwise  union  does  not  take  place.  Flap  C  is  dissected  from  the  subjacent 
tissues  and  slid  over  the  raw  surface  of  flap  A  on  one  side  (Fig.  835).  The  same 
is  done  with  flap  B.  Both  are  sutured  in  position.  The  extensive  raw  surface 
left  on  the  abdominal  wall  by  the  removal  of  flaps  A,  B,  and  C  is  diminished  by 
sliding  inwards  the  surrounding  skin,  and  the  remainder  is  covered  by  Thiersch's 
skin-grafts.  If  the  extension  D  of  flap  A  has  been  provided,  then  its  edges  are 
stitched  to  a  line  of  freshening  on  each  side  of  the  penile  gutter. 

II.  Trendelenburg's  Operation. — Note,  in  cases  of  exstrophy,  the  pubic  bones 
are  not  united  at  the  symphysis.  This  want  of  union  prevents  immediate 
closure  of  the  defect  in  the  bladder  and  urethra.  Trendelenburg  overcomes 
the  above  difl&culty  as  follows: 

Make  an  incision  about  three  inches  in  length  over  each  sacro-iliac  synchon- 
drosis. Open  these  joints  and  divide  their  ligaments  and  the  interarticular 
cartilages.  Press  the  anterior  superior  iliac  spines  together,  so  that  the  pubic 
defect  is  obliterated  or  lessened.  Suture  and  dress  the  sacro-iliac  wounds. 
Keep  the  pubic  bones  in  apposition  by  means  of  suitable  binders  applied  to  the 
anterior  borders  of  the  pelvis.  After  the  wounds  have  thoroughly  healed,  the 
exposed  surface  of  the  bladder  may  be  seen  lying  at  the  bottom  of  a  more  or  less 
vertical  groove,  and  may  now  have  its  edges  freshened,  mobilized,  and  united  by 
sutures  in  the  middle  line. 

This  operation  has  given  some  excellent  results. 

J.  W.  Perkins,  finding  division  of  the  sacro-iliac  synchondrosis  too  difficult 
and  dangerous,  divided  the  ilium  close  to  the  synchondrosis  with  the  chisel  and 
obtained  the  same  result. 

Trendelenburg  informs  the  author  that  he  has  used  this  method  of  oste- 
otomy but  considers  it  more  hazardous  than  his  original  procedure.  (For  much 
information  as  to  the  treatment  of  exstrophy,  see  Trendelenburg's  paper  in 
"Annals  of  Surgery,"  August,  1906.) 

Schlange's  Operation. — Schlange  makes  an  incision  along  the  outer  edge 
of  the  lower  part  of  each  rectus  muscle  and  loosens  the  muscle  from  its  surround- 
ings. He  then,  with  chisel  and  mallet,  divides  the  bony  insertion  of  the  muscle 
from  the  rest  of  the  pubis  and  slides  the  mobilized  insertion  towards  the  middle 
line,  where  he  fixes  it.  The  mobilization  of  the  recti  muscles  permits  of  the 
approximation  of  the  edges  of  the  bladder  and  their  union  after  freshening. 

Konig  ("Lehrbuch,"  ii,  634)  has  twice  endeavored  to  close  the  pubic  and 
vesical  defects  by  one  operation.  He  says:  "I  divided  the  horizontal  and 
descending  rami  of  the  pubis  through  a  small  wound  over  the  obturator  fora- 
men. This  permitted  closure  of  the  defect  in  the  symphysis  when  pressure  was 
exerted  on  the  pubis.  The  margins  of  the  bladder  and  of  the  urethral  groove 
were  now  freshened  and  sutured  by  two  lines  of  stitches.  Unfortunately,  both 
patients  succumbed. ' '  The  principle  of  Konig's  procedure  seems  admirable  and  its 
danger  does  not  appear  to  the  author  to  be  intrinsically  greater  than  that  of 
some  of  the  other  methods  the  ultimate  results  of  which  are  by  no  means  brilliant. 


676 


OPERATIONS    ON    THE   BLADDER 


Segond's  Operation.— 5/f/>  i.—  Make  the  incisions  AB,  DC,  BC,  around 
the  ectopic  bladder.  The  points  A  and  D  must  not  be  at  a  lower  level  than 
the  mouths  of  the  ureters.  Freshen  the  edges  of  the  penile  groove,  E  and  F 
(Fig.  8^6). 


Fig.  836. — Exstrophy  of  bladder. 


Step  2. — Dissect  the  ectopic  bladder  downwards  as  a  flap.  The  dissection 
must  not  be  carried  below  the  level  of  the  ureteral  mouths. 

Step  3. — Turn  the  bladder  flap  downwards  and  suture  its  edges  to  the  corre- 
sponding sides  of  the  penile  groove  (Fig.  837). 
Step  4. — Make  a  transverse  incision 
through  the  base  of  the  malformed  foreskin 
(Fig.  837,  X).  By  making  the  glans  penis  pass 
through  the  hole  in  the  foreskin  the  latter  is 
brought  on  to  the  dorsum  of  the  penis  and  its 
tissue  can  be  used  to  cover  the  raw  surface  on 
the  back  of  the  new-formed  dorsum  of  the 
penis. 

III.  Rutkowski's  Operation. — Rutkowski's 
operation  and  the  similar  one  of  Mikulicz  have 
been  used  with  more  or  less  success  in  the  treat- 
ment of  exstrophy.  They  will  be  found  suf- 
ficiently described  in  the  pages  devoted  to 
repair  of  defects  in  the  bladder-wall. 

IV.  Sonnenburg,  in  a  case  ifi  which  the  ex- 
posed vesical  mucosa  protruded  greatly,  and 
in  which  no  urinal  could  be  used,  operated  in 
the  following  manner:  Make  an  incision  all 
around  the  exposed  mucous  membrane,  and 
through  this  cut  dissect  the  mucosa  from  the 
abdominal  parietes,  but  do  not  injure  the 
peritoneum.     Remove  the  mucosa  completely. 

Dissect   the    lower    ends    of    the    ureters    from    the    surrounding  structures 
sufficiently  to  permit  their  implantation  into  the   upper  end  of   the  gutter. 


Fig. 


837. — Segond's  operation. 
{FarabeuJ.) 


ECTOPIA   VESICA 


677 


which  represents  the  urethra,  and  fix  them   there   with   sutures.     Close    the 
defect  left  in  the  abdominal  wall  by  flaps  slid  over  from  its  sides. 

V.  Maydl's  Operation. — Excise  all  the  exposed  vesical  mucosa  except 
that  portion  immediately  around  the  orifices  of  the  ureters  (Fig.  838) .  Carefully 
cleanse  the  wound  and  field  of  operation  after  the  excision  of  the  filthy 
mucous  membrane.  Open  the  abdomen.  Find  the  sigmoid  and  bring  a  loop 
of  it  out  of  the  wound.  By  stripping,  empty  the  gut  of  its  contents.  Apply  an 
intestinal  clamp  or  tape  above  and  below  the  part  selected  for  anastomosis. 
Incise  the  gut  longitudinally.  With  through-and-through  sutures  unite  the 
edges  of  the  portion  of  bladder-wall  attached  to  the  ureters  to  the  edges  of  the 
wound  in  the  sigmoid  (Figs.  839  and  840).  Cover  this  line  of  suture  by  a  line 
of  continuous  Lembert  sutures.     The  result  is  that  the  remnant  or  ellipse  of 


Fig.  838. 


Fig.  839. 
Figs.  838,  839  and  840. — Maydl's  operation. 


Fig.  840. 


bladder-wall  is  inserted  like  a  patch  into  the  incision  in  the  sigmoid.  Note  that 
no  great  separation  of  the  lower  ends  of  the  ureters  from  their  surroundings  is 
required;  the  loop  of  sigmoid  is  brought  down  to  the  ureteral  portion  of  blad- 
der, which  is,  of  course,  mobilized.  The  implantation  of  the  segment  of  blad- 
der-wall containing  the  ureters,  instead  of  the  implantation  of  the  ureters 
themselves,  is  the  important  principle  in  the  operation;  by  it  the  normal 
ureteral  valves  or  sphincters  are  retained  and  infection  is  prevented  from  as- 
cending the  ureters.  Several  modifications  of  Maydl's  operation  have  been 
suggested,  but  most  of  them  merely  complicate  the  technic. 

VI.  Makkas'  Operation.— ("Zentralblatt  fur  Chir.,"  1910,  No.  S3-)  To 
avoid  the  dangers  of  ascending  infection  inseparable  from  any  method  by  which 
the  ureters  are  made  to  discharge  into  a  cavity  containing  faeces,  Makkas  ex- 
cludes the  caecum  from  the  rest  of  the  intestinal  tract,  unites  its  cavity 
to  the  skin  by  means  of  appendicostomy  and  at  a  later  date  implants  the 
ureters  into  the  segregated  caecum  using  the  appendix  as  a  vent  for  the  escape 
of  the  urine. 

The  Operation. — Stage  I.- — Step  i.- — Open  the  abdomen  by  an  incision 
through  the  right  rectus  muscle. 

Step  2. — Examine  the  caecum.  If  the  caecum  cannot  be  pulled  to  the 
middle  line,  mobilize  it  by  incising  the  parietal  peritoneum  parallel  and  close 
to  its  outer  side. 


678 


OPERATIONS    ON   THE   BLADDER 


X 


Fig.  S41. — Makkas'  operation 

{Makkas.) 


Separate  the  caecum  by  blunt  dissection  from  its  posterior  connections 
exactly  as  in  ca^cectomy  but  carefully  preserve  intact  its  blood  supply. 

Step  3. — Divide  the  ileum  close  to  the  caecum  and  close  both  the  distal  and 
proximal  segments  of  the  gut,  Fig.  841. 

Step  4. — Divide  the  ascending  colon  above  the  cacum  and  close  both  the 
proximal  and  distal  segments  of  the  colon. 

Step  5. — Make  a  lateralanastomosis  between  the  proximal  segment  of  ileum 
and  the  distal  segment  of  the  colon  (or  the 
sigmoid). 

Step  6. — Perform  appendicostomy  bringing  the 
appendix  out  through  a  special  opening.  (Bringing 
the  appendix  out  through  an  opening  made  by 
splitting  the  muscles  of  the  abdominal  wall  as 
in  the  McArthur-McBurney  operation  would,  it 
appears  to  the  author,  provide  an  excellent 
sphincter  to  the  appendix.) 

If  appendicostomy  seems  inadvisable  or  im- 
possible because  of  adhesions,  small  size  of  the 
appendix,  etc.,  perform  caecostomy. 
Step  7. — Close  the  abdomen. 
After-treaiment. — After  the  lapse  of  ten  days 
pass  a  Nelaton  catheter  through  the  appendix  daily  and  irrigate  the  caecum. 
Stage  II. — This  stage  is  practically  identical  with  the  Maydl  operation  except 
that  the  mobilized  portion  of  the  bladder-wall  attached  to  the  ureters  is  im- 
planted into  the  lower  part  of  the  segregated  caecum  instead  of  into  the  sigmoid. 
When  the  operation  is  completed  the  new  bladder  must  be  kept  empty  by  a 
catheter  introduced  through  the  appendix. 

In  Makkas'  case  the  catheter  was  clamped  after  eight  days  and  the  new 
bladder  emptied  every  two  or  three  hours.  At  first  the  capacity  of  the  bladder 
was  only  too  c.c.  After  four  weeks  the  capacity  increased  to  300-325  c.c.  and 
the  bladder  required  to  be  evacuated  every  three  or  four  hours  through  the 
day  but  not  at  all  during  the  night. 

If  the  catheter  was  removed  while  the  bladder  was  full  there  was  no 
escape  of  urine,  but  this  continence  was  not  absolute  as  drops  of  urine  escaped 
when  the  patient  moved  about.  The  urine  was  not  albuminous  but  contained 
mucus.  The  necessity  of  leaving  the  catheter  in  situ  permanently  is  a  dis- 
advantage, the  lessening  of  the  dangers  of  ascending  infection  is  a  great 
advantage  over  the  Maydl  method. 

Geo.  A.  Peters'  Operation  (Brit.  Med.  Jour.,  June  22,  igoi).—Step  i. — Cut 
the  point  off  a  No.  5  soft  rubber  catheter  so  that  urine  can  enter  its  end.  Pass  it 
about  2  inches  up  the  ureter.  Fix  the  catheter  by  a  few  fine  sutures  caught 
through  the  extreme  end  of  the  ureteral  papilla.  Treat  the  other  ureter  similarly. 
Step  2. — Make  a  cut  through  the  bladder  wall  (mucosa  and  musculosa) 
around  each  ureteral  orifice  at  a  sufi&cient  distance  to  leave  intact  the  peculiar 
obHque  arrangement  of  the  vesical  end  of  the  ureter.  As  soon  as  the  entire 
thickness  of  the  bladder  wall  has  been  penetrated,  mobiUze  the  lower  end  of 
the  ureters  by  blunt  dissection. 


ECTOPIA   VESICA  679 

Step  3. — Excise  all  the  bladder  down  to  the  prostate  where  the  vesiculae 
seminales  debouche.  If  there  is  danger  of  injuring  the  peritoneum  at  any  place 
then  at  that  point  some  of  the  bladder  muscle  may  be  left  but  all  the  mucosa 
must  be  removed. 

Step  4. — Working  through  the  wound  expose  the  lateral  aspects  of  the 
rectum. 

Step  5. — With  finger  in  rectum  choose  the  exact  point  for  ureteral  implanta- 
tion, which  must  be  above  the  internal  sphincter,  on  the  lateral  (not  the  ante- 
rior) wall  so  as  to  avoid  kinking,  and  high  enough  to  permit  the  ureter  to  project 
M  to  32  i^ch  into  the  bowel,  so  as  to  form  a  valvular  papilla.  At  the  chosen 
point  press  the  point  of  a  forceps  from  the  rectum  towards  the  wound,  and  incise 
the  gut  wall  upon  the  projecting  forceps.  The  hole  made  in  the  rectal  wall 
must  be  of  such  size  as  to  hold  snugly,  but  not  too  snugly,  the  ureter  with  its 
contained  catheter.  Pull  the  catheter  and  ureter  into  the  rectum.  The  ureter 
must  project  without  tension,  not  less  than  )^  inch  into  the  lumen  of  the  bowel. 
The  operation  is  the  same  on  both  sides. 

Leave  the  catheters  in  situ  at  least  two  or  three  days  or  until  they  come  away 
of  themselves.  Do  not  try  to  close  the  wound  left  by  the  ablation  of  the  bladder. 
If  the  wound  is  fairly  firmly  packed  with  gauze,  support  is  given  to  the  ureters 
in  their  new  position. 

Remarks. — Peters'  operation  avoids  all  dangers  of  peritonitis  as  the  peri- 
toneum is  never  penetrated.  The  results' have  been  excellent  in  the  cases 
reported  by  Peters  and  by  Holman  (Brit.  Med.  Jour.,  Jan.  31,  1920).  Holman 
agrees  with  Mayo  that  it  might  be  wise  to  allow  an  interval  of  some  weeks  to 
elapse  between  the  transplantation  of  each  ureter. 

Cuneo's  Operation. — ("LaPresseMed.,"  Jan.  10, 191 2.)  Open  the  abdomen. 
Choose  a  suitable  segment  of  ileum  and  segregate  it  by  dividing  the  gut  at  two 
places.  Restore  the  continuity  of  the  ileum  by  enterorrhaphy.  Close  the 
proximal  end  of  the  segregated  segment.  Low  down  on  the  anterior  surface 
of  the  rectum  make  an  incision  through  the  rectal  wall  leaving  the  mucosa 
intact.  From  this  incision  make  a  tunnel  passing  between  the  mucosa  and 
the  anal  sphincter  to  the  skin.  Push  the  open  end  of  the  segregated  segment  of 
ileum  through  the  tunnel  and  suture  it  to  the  skin.  After  healing  has  taken 
place,  implant  the  ureters  with  the  trigone  of  the  bladder  into  the  segregated 
intestine.  Cuneo's  patient  could  retain  urine  for  two  hours  during  the  day 
but  was  incontinent  at  night.     The  urine  was  normal. 

Heitz-Hovelacque  Operation. — This  operation  is  identical  in  principle  with 
Cuneo's  and  gives  almost  identical  results.  Open  the  abdomen.  Divide  the 
rectum  at  the  level  of  the  second  or  third  sacral  vertebra.  Close  the  distal 
segment  of  gut.  This  forms  the  new  bladder.  Bring  the  proximal  segment  of 
gut  downwards  behind  the  new  bladder  separating  the  latter  sufficiently  from 
the  sacrum.  Implant  the  ureters  in  the  new  bladder.  Make  an  incision 
through  the  musculature  of  the  back  of  the  new  bladder  and  form  a  tunnel  to  the 
skin  between  the  mucosa  and  the  anal  sphincter.  Pull  the  mobilized  upper 
segment  of  rectum  (or  pelvic  colon)  through  the  tunnel  and  suture  it  to  the  skin. 
The  result  of  this  operation  was  almost  identical  with  that  of  Cuneo.  It  is 
said  that  there  was  no  escape  of  gas  or  faeces  during  urination. 


68o  OPERATIONS  ON  THE  BLADDER 

Remarks. — The  great  objection  to  all  operations  which  endeavor  to  re- 
construct the  bladder,  whether  by  the  use  of  skin-flaps,  by  the  union  of  the 
edges  of  the  imperfect  viscus,  or  by  the  implantation  of  a  segregated  loop  of 
intestine,  is  that  the  result  is  merely  the  formation  of  a  urinary  receptacle  which 
is  devoid  of  any  sphincter  and  hence  cannot  retain  the  urine.  The  only  ad- 
vantages to  be  obtained  by  such  operations  are  the  protection  of  the  vesical 
mucosa  from  injury  and  the  direction  of  the  urine  towards  the  penile  gutter, 
where  it  is  more  feasible  to  attach  a  portable  urinal.  The  operation  of  excision 
of  the  imperfect  bladder  and  transplantation  of  the  ureters  into  the  penile 
gutter  possesses  both  these  advantages,  and  is  perhaps  a  better  procedure  than 
any  of  those  which  seek  to  reconstruct  the  bladder.  In  performing  plastic 
operations  such  as  those  described  it  is  very  difiicult  to  obtain  complete  union 
of  the  transplanted  flaps  to  their  surroundings — hence  fistulas  occur  which,  un- 
less closed,  nullify  the  operation.  One  very  grave  objection  to  the  plastic 
operations  which  provide  the  new  bladder  with  an  epidermal  lining  is  that 
urinary  salts  are  inevitably  deposited  on  the  bladder-walls  and  cause  much 
distress.  No  matter  how  carefully  the  flaps  have  been  selected,  fine  hair  is 
liable  to  grow  on  them  and  give  rise  to  complications.  Prima  facie,  one  would 
think  that  when  the  new  bladder  is  lined  with  true  mucous  membrane,  as  in 
Rutkowski's  operation,  the  danger  from  calculus  deposits  would  be  obviated, 
but  experience  shows  this  not  to  be  true;  hence  the  same  objection  obtains. 

When  simple  uretero-sigmoidostomy  or  uretero-colostomy  is  performed, 
infection  inevitably  passes  up  the  ureters  and  leads  to  a  fatal  issue.  Stiles 
valvular  implantation  of  the  ureters  (p.  725)  seems  to  avoid  this  danger. 
Maydl's  idea  that  transplantation  of  the  ureters,  plus  their  sphincteric  attach- 
ment to  the  bladder-walls,  avoids  the  danger  of  infection  ascending  from  the  gut 
seems  correct.  Peters'  operation  seems  to  have  the  advantages  without  the 
dangers  and  difficulties  of  Maydl's  and  is  probably  preferable.  The  lower 
gut  is,  or  becomes  very  tolerant  to  the  presence  of  urine,  and  the  anal  sphincter 
is  capable  of  retaining  the  urine  for  a  very  respectable  length  of  time. 

Operative  Treatment  of  Rupture  of  the  Bladder. — The  diagnosis  of  rupture 
of  the  bladder  from  the  symptoms  alone  is  not  always  possible  before  it  is  too 
late  to  be  of  aid  in  treatment.  Other  or  operative  means  of  diagnosis  are  often 
essential. 

Diagnosis  by  Operation. — When  the  patient  has  overcome  initial  shock 
(twelve  to  twenty-four  hours),  or  immediately  if  his  condition  warrants,  diag- 
nosis by  operation  may  be  attempted. 

I.  Injection  of  air  or  water  into  the  viscus.  By  injecting  air  or  water  into 
the  bladder,  should  the  viscus  be  ruptured,  no  globular  tumor  will  form  over 
the  pubis,  and  when  the  water  is  allowed  to  flow  back,  much  less  will  return 
than  was  injected.  Should  there  be  no  rupture,  the  distended  bladder  will  be 
easily  found  in  its  normal  site. 

The  above  operation  has  often  served  a  good  purpose,  but  Schlange  points 
out  that  the  water  or  air  introduced  under  pressure  is  liable  to  cause  separation 
of  peritoneum  from  the  bladder  along  a  ragged  rupture — quite  a  serious  ob- 
jection. The  same  objection  holds  good  against  cystoscopic  examination. 
Another  objection  which  might  be  urged  is  that  in  the  case  of  an  extraperitoneal 


CYSTOTOMY  68 1 

rupture  the  air  or  water  might  easily  distend  the  bladder  to  its  normal  limits 
and  so  lead  to  mistake. 

II.  Several  surgeons  have  recommended  perineal  section  and  examination 
of  the  bladder  through  the  wound.  This  has  but  few  advantages  over  the  next 
method,  and  is  possessed  of  many  disadvantages. 

III.'  Suprapubic  cystotomy.  Without  the  aid  of  rectal  distention  the  sur- 
geon cuts  into  the  bladder  above  the  pubis.  Under  the  special  circumstances 
(empty  bladder,  etc.)  much  care  must  be  taken  to  "hug"  the  pubis.  The 
bladder  having  been  opened,  the  finger  soon  discovers  any  ruptures  of  its  wall. 

If  intraperitoneal  rupture  is  present,  the  skin-wound  is  enlarged  upwards 
and  the  belly  opened.  Any  bloody  urine  in  the  peritoneal  cavity  is  gently 
sponged  away.  It  may  now  he  necessary  to  put  the  patient  in  the  Trendelen- 
burg position.  The  ragged  wound  of  the  bladder  is  examined,  and  if  necessary, 
some  of  its  bruised  edges  trimmed  away,  A  line  of  chromicized  catgut  sutures 
is  put  in  place.  These  sutures  pass  through  all  the  coats  of  the  viscus  except 
the  mucosa.  A  line  of  Lembert  sutures  is  inserted  superficially  to  protect  the 
deep  ones.  The  abdominal  cavity  is  now  cleaned,  either  by  flushing  with 
normal  salt  solution  or  by  gently  sponging  with  gauze  pads.  The  laparotomy 
wound  is  closed  with  or  without  drainage.  ^ 

In  extraperitoneal  rupture  the  danger  is,  of  course,  from  infiltration  of  urine. 
The  suprapubic  cystotomy  guides  the  surgeon  to  the  threatened  or  affected 
regions  and  he  can  at  once  provide  free  drainage  by  appropriate  incisions  and 
by  packing  such  regions  with  iodoform  gauze.  Bleeding  must  be  stopped  either 
by  ligature,  pressure,  or  packing. 

How  ought  the  suprapubic  wound  of  the  bladder  to  be  treated?  In  such 
cases  it  ought  always  to  be  left  open.  Schlange  unites  the  vesical  mucous 
membrane  to  the  skin  by  a  few  stitches.  The  bladder  itself  is  lightly  fiUed 
with  iodoform  gauze,  so  that  it  is  constantly  emptied  of  urine  by  capillary  drain- 
age. Permanent  catheterization  of  the  ureters  and  packing  of  the  bladder  is 
a  tempting  procedure  which  would  be  liable  to  lead  to  ureteritis  and  pyelitis. 

Suprapubic  Cystotomy. — The  operation  of  suprapubic  cystotomy  may  be 
required  for  the  removal  of  calculi  or  neoplasms  from  the  bladder,  for  the  re- 
moval of  enlarged  lobes  of  the  prostate,  for  purposes  of  exploration  and  the 
treatment  of  various  vesical  lesions,  and  for  the  carrying  out  of  retrograde 
catheterization,  etc.  Preliminary  treatment  varies  according  to  circumstances 
— in  one  case,  e.g.,  prostatectomy,  it  is  wise  to  endeavor  to  cleanse  the  bladder 
by  appropriate  means;  in  another  case,  e.g.,  bleeding  villous  tumors,  such  treat- 
ment is  calculated  to  encourage  serious  hemorrhage;  in  cases  of  cystitis  where 
treatment  per  urethram  is  a  failure,  the  cystotomy  is  undertaken  to  provide 
drainage,  and  the  failure  of  other  treatment  means  failure  to  cleanse  the  bladder. 
In  all  cases  the  large  intestine  should  be  well  emptied  before  operation.  Local 
or  general  anaesthesia  is  requisite. 

Shave  the  pubis  and  cleanse  the  hypogastrium  and  the  penis.  Introduce 
a  catheter  and  irrigate  the  bladder  with  warm  salt,  boracic  acid,  or  Thiersch's 
solution.  When  the  irrigation  is  finished,  distend  the  viscus  with  the  solution 
or  with  air.  Remember  that  in  cases  of  old  cystitis  the  bladder- wall  is  often 
very  weak  and  cannot  safely  be  greatly  distended.     A  good  plan  is  to  test  the 


682  OPERATIONS  ON  THE  BLADDER 

capacity  of  the  bladder  before  any  anaesthetic  is  administered  and  act  according 
to  the  knowledge  gained.  Many  surgeons  prefer  air  distention  to  fluid.  Air  is 
said  to  bring  the  viscus  more  easily  against  the  abdominal  wall,  and  when  the 
bladder  is  opened,  there  is  no  gush  of  infected  fluid  over  the  field  of  operation. 
These  advantages  are  of  no  great  value  and  most  surgeons  prefer  the  warm 
aqueous  solutions,  which  are  more  easily  sterilized  and  managed  than  is  the  air. 
Air  distention  has  led  to  several  catastrophies.  Having  distended  the  bladder 
within  the  limits  of  safety,  withdraw  or  plug  the  proximal  end  of  the  cathe- 
ter and  tie  a  rubber  band  around  the  penis  to  prevent  the  escape  of  the  water  or 
air.     If  the  catheter  is  left  in  silu,  it  acts  as  a  guide  to  the  bladder. 

Some  surgeons  endeavor  to  lift  the  bladder  still  more  against  the  belly-wall 
by  inserting  a  rubber  bag  into  the  rectum  and  distending  iL  with  air  or  water. 
This  procedure  is  unnecessary  and  has  led  to  many  serious  injuries  being  inflicted 
on  the  rectum.  Even  distention  of  the  bladder  itself  is  not  absolutely  necessary, 
but  when  possible,  is  always  of  immense  value,  as  it  pushes  the  vesical  fold  of 
peritoneum  upwards  and  makes  the  extraperitoneal  exposure  of  the  bladder 
easy. 

Place  the  patient  in  the  Trendelenburg  position,  as  this  enlarges  the  extra- 
peritoneal area  through  which  one  must  proceed. 

I.  Vertical  Incision. — Beginning  on  the  pubis  near  its  upper  edge,  make  a 
vertical  median  incision  upwards  for  from  3  to  4  inches.  Expose  and  divide 
the  anterior  layer  of  deep  fascia  and  separate  the  pyriform  and  recti  muscles. 
Carefully  pick  up  and  divide  the  deep  layer  of  fascia,  thus  exposing  the  pre- 
vesical fat.  Hook  the  finger  behind  the  pubis  and  pull  upwards  the  prevesical 
fat,  and  with  it  the  vesical  fold  of  peritoneum.  Recognize  the  peritoneal  fold 
and  retract  it  upwards  out  of  danger.  Rarely  the  peritoneal  fold  may  be  ad- 
herent to  the  pubis  and  must  be  freed  by  blunt  or  sharp  dissection.  During 
the  manoeuvres  described  the  peritoneal  cavity  may  be  accidentally  opened. 
This  accident  is  only  important  if  not  promptly  recognized  and  corrected  by  a 
few  carefully  placed  sutures.  Expose  the  anterior  wall  of  the  bladder  by  bluntly 
dissecting  through  the  fat  in  front  of  it.  Once  the  peritoneal  fold  is  recognized 
and  retracted,  do  not  hug  the  posterior  surface  of  the  pubis  too  closely,  as  to  do 
so  means  exposure  of  the  bladder  at  a  level  difficult  of  access  and  where  it  is 
very  vascular;  it  also  means  the  formation  of  a  ragged  pouch  difficult  to  drain, 
in  very  unresisting  tissues.  The  nearer  its  dome  the  bladder  can  be  exposed 
extraperitoneally,  the  better.  The  bladder  will  be  recognized  by  its  globular 
form,  if  distended,  or  by  the  catheter  in  it  if  it  is  not  distended.  It  has  a  brown 
ish-red  color,  and  one  can  see  the  longitudinal  fibres  of  the  detrusor  muscle  on 
its  surface. 

The  bladder  having  been  freely  exposed,  pick  up  a  portion  of  its  wall  with 
a  sharp  hook  or  volsella,  and  with  a  strongly  curved  needle  pass  two  long 
sutures  through  its  walls  parallel  to  the  direction  in  which  it  is  desired  to  incise 
the  bladder.  These  sutures  serve  as  convenient  tractors.  Jacobson  omits 
their  use,  as  he  thinks  they  do  more  damage  than  forceps  attached  to  the  edges 
of  the  incision.  The  writer  has  never  seen  harm  result  from  the  thread  tractor, 
and  they  are  certainly  much  more  convenient  than  forceps,  which  always  im- 
pede further  operative  work.     Incise  the  bladder,  either  vertically  or  trans- 


CYSTOTOMY  683 

versely,  sufficiently  to  admit  one  or  two  fingers.  The  transverse  incision  is  the 
better;  it  is  more  readily  enlarged  and  more  readily  closed.  If  the  vertical 
incision  is  chosen  and  requires  enlargement,  such  enlargement  must  be  done 
downwards  in  an  awkward  location,  deeply  behind  the  pubis.  If  for  the  pur- 
poses of  the  subsequent  steps  of  the  operation  (removal  of  calculi,  tumors,  etc.) 
the  wound  in  the  parietes  is  found  too  narrow,  more  space  may  be  obtained  by 
making  a  number  of  small  incisions  or  nicks  in  the  edges  of  the  recti  muscles,  or 
those  muscles  may  be  separated  from  their  pubic  insertion.  More  room  has 
also  been  obtained  by  subperiosteal  excision  of  part  of  the  pubic  bones.  Such 
extreme  measures  to  gain  space  are  rarely  necessary. 

The  treatment  of  the  various  lesions  met  with  in  the  bladder  will  be  dis- 
cussed later. 

Treatment  of  the  Wound  in  the  Bladder. — If  the  bladder  is  not  seriously  in- 
fected or  the  wound  has  not  been  greatly  contused,  e.g.,  by  the  removal  of  stones, 
etc.,  the  opening  may  be  closed  in  whole  or  in  part.  If  marked  vesical  infection 
is  present,  or  if  the  walls  are  much  contused,  it  may  be  necessary  or  judicious 
to  leave  the  wound  wide  open. 

Closure  of  the  Vesical  Wound. — If  the  mucosa  is  inclined  to  bleed,  unite  the 
edges  of  the  wound  in  it  by  a  row  of  continuous  fine  catgut  sutures.  With 
fine  catgut  on  a  rounded  needle  (one  without  cutting-edges)  unite  the  edges  of 
the  wound  in  the  muscular  wall  of  the  bladder.  If  it  can  be  accomplished 
without  undue  tension,  bury  the  layer  of  muscle  suture  by  a  row  of  stitches  in- 
serted in  the  Lembert  fashion  and  composed  of  fine  silk  or  linen.  It  is  very 
desirable  to  have  an  inverted  wound  with  wide  surface  in  apposition.  Close 
the  wound  in  the  parietes  after  providing  tubular  or  cigarette  drainage  for 
the  prevesical  space.  If  the  bladder  is  completely  closed  as  above,  urine 
must  be  drawn  off  frequently  by  the  catheter  or  permanent  catheterization  must 
be  kept  up.  It  is  a  very  good  and  eminently  safe  precaution  to  provide  perineal 
drainage  before  closing  the  vesical  wound.  This  may  be  done  as  follows: 
Through  the  suprapubic  opening  pass  a  closed  forceps  through  the  internal 
meatus  into  the  membranous  urethra.  Place  the  patient  in  the  lithotomy  posi- 
tion. With  the  forceps  above  mentioned  make  prominent  the  membranous 
urethra  just  behind  the  bulb.  Cut  down  on  the  point  of  the  forceps  and  with 
them  seize  and  pull  into  the  bladder  the  end  of  a  soft-rubber  catheter  (No.  36 
Fr.  or  larger).  With  a  stitch  fix  the  catheter  to  the  perineal  wound.  Proceed 
with  the  closure  of  the  suprapubic  wound. 

If  it  is  desired  to  establish  suprapubic  drainage,  partially  close  the  wound, 
if  it  is  too  large,  and  introduce  into  the  bladder  a  3<4-inch  rubber  tube  or  even 
two  such  tubes.  The  ends  of  the  tubes  should  not  impinge  "against  the  base  of 
the  bladder  and  they  should  be  cut  so  as  to  be  bevelled  and  be  provided  with 
lateral  openings.  In  such  cases  it  is  wise  to  sew  the  bladder  to  the  parietal 
fascia  around  the  point  of  exit  of  the  tubes.  This  is  to  prevent  leakage  of  urine 
into  the  abdominal  wound.  When  the  vesical  wound  is  not  large  and  drainage 
is  desired,  one  may  proceed  as  follows:  Dress  a  ^-inch  rubber  drain  by  covering 
it  with  two  or  three  layers  of  gauze;  this  in  turn  covered  by  rubber  tissue 
(practically  a  cigarette  drain  with  a  tube  through  its  centre).  Introduce  the 
end  of  the  drain  a  very  short  distance  into  the  bladder.     With  catgut  suture  the 


684 


OPERATIONS    ON   THE   BLADDER 


edges  of  the  bladder  wound  to  the  drain  or  its  dressing.  Push  the  tube  a  little 
further  into  the  bladder;  this  inverts  the  edges  of  the  bladder  wound.  In  the 
Lembert  fashion,  with  catgut,  suture  the  surface  of  the  bladder  all  around  the 
wound  to  the  tube.  We  thus  have  a  double  line  of  sutures  (catgut)  uniting  the 
bladder  to  the  tube  and  forming  a  water-tight  joint.  Fix  the  ends  of  the  last 
row  of  sutures  to  the  parietal  fascia  so  as  to  keep  the  bladder  in  contact  with 
the  abdominal  wall  and  close  the  wound  in  the  latter.  The  water-tight  joint 
around  the  tube  is  intended  to  keep  urine  and  infection  away  from  the  prevesical 
fat  and  the  abdominal  wound  until  healing  has  progressed,  to  some  extent,  at 
least. 

If  from  any  cause  it  is  deemed  proper  to  leave  the  vesical  wound  entirely 
open,  it  is  wise  to  attach  its  edges  to  the  fascia  abdominalis  by  a  few  points  of 
suture,  and  to  pack  its  cavity  loosely  with  iodoform  gauze. 

It  is  easy  to  attach,  with  a  glass  joint,  a  long  piece  of  tubing  to  the  bladder 
drain  and  by  siphonage  conduct  the  urine  to  a  suitable  receptacle  placed  be- 
neath the  bed. 

II.  Transverse  Incision. — Bardenheuer  and  many  other  surgeons 
prefer  a  transverse  to  a  vertical  incision,  as  more  room  is  obtained. 
The  disadvantage  of  this  method  is  the  liability  to  subsequent 
hernia.  In  cases  of  intravesical  tumor  the  transverse  incision  is 
specially  good.  Place  the  patient  in  Trendelenburg's  position. 
Make  a  slightly  curved  horizontal  incision  through  the  skin  from  the 
neighborhood  of  one  external  inguinal  ring  to  the  other,  immediately 
above  and  parallel  to  the  pubic  bones.  Divide  the  fascia  covering 
the  recti  muscles.  Separate  the  recti,  pyramidales,  and  the  linea  alba 
from  the  bone.  The  retraction  of  the  muscles  gives  a  wide  space  for  the 
subsequent  work;  if  more  space  is  required,  separate  the  recti  from  each 


Fig.  842.— 
Lithotomy  scoop. 


Fig.  843. — ^Lithotomy  forceps. 


other  vertically.     The  rest    of  the  operation   is   the  same  as  that  already 
described. 

Suprapubic  Lithotomy. — This  operation  is  practically  that  of  cystotomy 
plus  the  removal  of  the  stone.  If  the  calculus  present  is  believed  to  be  large, 
the  transverse  incision  is  the  better,  as  it  gives  more  room.  It  is  bad  practice 
to  drag  a  stone  out  through  too  small  an  incision,  as  the  resulting  trauma  is  far 
more  noxious  than  the  making  of  a  large  opening  by  a  sharp,  purposeful  cut. 
Calculi  must  be  removed  by  appropriate  forceps  or  scoop  (Figs.  842  and  843). 


CYSTOTOMY  685 

In  the  absence  of  these  special  and  very  convenient  instruments,  common  sense 
informs  us  that  the  same  object  may  be  attained,  though  less  expeditiously,  by 
the  use  of  the  fingers,  ordinar  y  forceps,  or  a  loop  of  wire.  The  suprapubic  route 
insures  a  good  survey  of  the  interior  of  the  bladder,  and  hence  prevents  the  not 
uncommon  fault  of  overlooking  a  second  or  third  stone.  Remember  that  a 
second  calculus  may  lie  encysted  in  the  pouch  behind  the  prostate.  When  there 
is  no  great  infection  present,  it  is  good  practice  to  establish  perineal  drainage  in 
the  manner  already  described  and  close  the  suprapubic  wound.  If  infection  is 
considerable  suprapubic  drainage  ought  to  be  established,  either  alone  or  in 
combination  with  perineal.  The  after-treatment  consists  in  keeping  the  bladder 
clean;  the  cystitis  usually  quickly  subsides  on  removal  of  its  cause. 

Occasionally  the  stone  may  lie  in  a  congenital  or  acquired  diverticulum.  If 
this  is  the  case  Fenwick  advises  fragmentation  of  the  stone  in  situ  by  means  of  a 
chisel  lightly  struck  by  a  mallet.  In  one  case  where  the  stone  was  un- 
intentionally broken  the  author  found  great  difl5culty  in  removing  the 
fragments.  In  another  case  where  a  stone,  3%  x  i^^  x  i}  2  x  2^  inches 
in  diameter,  lay  in  a  diverticulum  the  mouth  of  which  was  only  large 
enough  to  admit  the  forefinger,  forcible  dilatation  of  the  opening  permitted 
removal  of  the  calculus,  hemorrhage  was  trivial,  and  no  evil  seemed  to 
result.     (Excision  of  vesical  diverticula,  see  page  712.) 

Suprapubic  Cystotomy  for  Benign  Neoplasms. — Benign  neoplasms  are 
usually  pedunculated;  they  may  be  single  or  multiple,  sometimes  being 
very  numerous,  filling  up  most  of  the  space  in  the  bladder.  Most  vesical 
papillomata  bleed  easily,  and  on  account  of  this  tendency  it  may  be  convenient 
to  throw  into  the  bladder,  immediately  before  operation,  a  small  quantity  of 
a  solution  of  adrenalin.  The  advantage  gained  by  the  use  of  adrenalin  is 
that  less  bleeding  occurs  during  the  active  operation,  and  hence  the  surgeon 
sees  better  what  he  is  doing;  whether  hemorrhage  is  more  or  less  liable  to  occur 
secondarily,  i.e.,  after  the  effects  of  the  drug  have  worn  off,  is  another  matter, 
and  not  yet  proved. 

The  bladder  is  opened  preferably  by  the  transverse  incision,  because  of  the 
free  access  obtained.  When  the  tumor  is  pedunculated,  seize  its  base  in  a 
curved  clamp  and  cut  away  the  free  portion  of  the  growth.  Never  drag  upon 
the  forceps  so  as  forcibly  to  tear  away  the  growth.  Sometimes  the  tumor  is  so 
delicate  that  mere  pressure  with  the  forceps  separates  it  from  its  base.  When 
possible,  excise  with  scissors  the  portion  of  the  pedicle  grasped  by  the  forceps 
and  close  the  wound  in  the  mucous  membrane  with  one  or  two  points  of  catgut 
suture.  The  finger  of  an  assistant  pushing  up  the  bladder  from  the  rectum  may 
aid  greatly  in  this  work  when  the  site  of  the  trouble  is  on  the  posterior  bladder- 
wall.  If  the  tumor  is  sessile  or  has  a  broad  base,  cut  it  away  with  scissors,  as 
close  to  the  bladder- wall  as  possible,  and  cauterize  the  stump  with  the  thermo- 
cautery. Some  surgeons  operate  on  tumors  and  various  bladder-lesions  through 
a  kind  of  coffer-dam,  so  as  to  avoid  urine  and  blood  from  other  parts  obscuring 
the  field  of  operation.  The  model  on  which  all  such  coffer-dams  are  made  is  the 
old  Ferguson's  tubular  vaginal  speculum,  passed  through  the  abdominal  wound 
and  enclosing  in  its  distal  opening  the  area  to  be  attacked.  The  coffer-dam 
undoubtedly  is  a  great  aid  in  operating,  but  it  has  the  serious  disadvantage  of 


686  OPERATIONS  ON  THE  BLADDER 

requiring,  for  many  purposes,  the  use  of  special  scissors  and  forceps  to  permit  of 
work  being  done  through  its  narrow  lumen.  After  the  removal  of  tumors  drain- 
age is  essential,  and  the  use  of  various  antiseptic  and  more  especially  astringent 
douches  is  advantageous.  Repeated  operations  may  be  necessary  before  all 
the  neoplasms  are  removed.  If  hemorrhage  is  alarming,  the  bleeding  areas 
may  be  packed  with  iodoform  gauze. 

Nitze  and  Sonnenburg  write  as  follows  ("Handbuch  der  practischen  Chir.," 
iii,  838) :  "Passing  one  or  two  fingers  gently  into  the  bladder,  one  informs  him- 
self as  to  the  nature  of  the  tumor  and  the  manner  of  its  origin  on  the  bladder- 
wall.  If,  as  is  very  common,  the  tumor  is  a  large,  solid  villous  growth  with  a 
pedicle,  or  if  a  pedicle  can  be  formed  by  cautious  pulling  on  the  tumor,  catch  it 
gently  but  firmly  between  the  fore-  and  middle  fingers  and  pull  it  upwards 
from  the  mucous  membrane  for  such  a  distance  that  a  curved  forceps  or  clamp 
can  be  applied  to  the  pedicle  between  the  fingers  and  the  mucosa.  By  careful, 
but  strong  traction  on  the  locked  forceps,  endeavor  to  bring  the  base  of  the 
tumor  up  to  the  level  of  the  external  wound.  It  is  astonishing  how  far  up 
continued  traction  can  bring  the  mucous  membrane  of  the  base  of  the  bladder 
without  injury  to  the  patient.  If  the  tumor  is  large,  it  often  prevents  ocular 
inspection  of  the  mucosa  around  its  base  and  the  necessary  recognition  of  the 
ureteral  openings.  Under  these  circumstances  one  tears  away  the  villous  masses 
from  their  pedicle;  no  hemorrhage  results  because  the  forceps  are  in  situ  com- 
pressing the  pedicle.  The  whole  field  of  operation  being  exposed  to  view, 
pass  two  silver  wires  through  the  portion  of  bladder-wall  that  is  pulled  up 
by  the  forceps,  at  a  considerable  distance  from  the  pedicle,  and  then  with  the 
knife  or  cautery  (knife-blade)  excise  the  pedicle,  and  with  it  some  of  the  sur- 
rounding mucosa.  Injury  to  the  ureters  can  usually  be  avoided  during  the 
extirpation  of  benign  neoplasms  even  if  the  latter  are  situated  at  their  orifices, 
but  their  injury  generally  does  no  harm;  even  complete  excision  of  the  ureteral 
orifices  is  well  borne.  After  extirpation  of  the  base  of  the  tumor  the  silver 
wires  already  in  place  prevent  retraction  of  the  field  of  operation  and  thus 
hemorrhage  can  be  more  readily  attended  to,  and  sutures  introduced,  after 
which  the  silver  wires  are  removed." 

Malignant  neoplasms  cannot  be  efficiently  treated  in  the  above  fashion. 
All  nibbling,  hesitating  methods  are  worse  than  useless,  merely  stimulating 
to  increased  rapidity  of  growth.  The  principles  of  operation  are  identical 
with  those  for  operation  on  carcinoma  located  elsewhere,  viz.,  wide  and  complete 
removal,  partial  or  total  cystectomy. 

The  most  serious  form  of  non-malignant  ulcer  of  the  bladder  is  the  tuber- 
culous, and  this  will  be  taken  as  the  type  in  discussing  the  operative  treatment 
of  ulcer.  As  in  other  locations,  so  also  in  the  bladder  rest  is  a  sine  qua  non 
of  treatment.  Drainage  through  the  suprapubic,  the  perineal,  or  through 
both  routes  is  the  best  means  of  obtaining  the  necessary  rest,  and  in  cases  of 
simple  ulceration  may  be  essentially  all  the  treatment  required.  When  the 
ulceration  is  tuberculous,  further  operative  treatment  is  necessary.  Open 
and  explore  the  bladder.  A  cold  electric  lamp  introduced  through  the  wound 
is  a  great  aid,  as  also  is  light  from  a  head-mirror  or  lamp.  If  the  ulcer  is  soli- 
tary, hmited  in  extent,  and  situated  on  the  anterior  part  of  the  bladder  from 


PROSTATECTOMY  •  687 

which  the  peritoneum  can  be  stripped,  it  is  wise  to  excise  the  affected  portion 
of  vesical  wall  and  close  the  wound  completely  after  providing  perineal  drain- 
age. If  the  ulcer  is  situated  at  the  base  of  the  bladder — and  this  is  commonly 
the  case — cauterize  it  with  the  thermocautery  or  with  pure  formalin  and  rub 
iodoform  into  it.  The  subsequent  local  treatment  must  consist  of  drainage 
and  lavage  with  suitable  antiseptic  lotions.  General  treatment  is  of  the  utmost 
importance — good  food,  fresh  air,  tonics,  and  some  form  of  guaiacol  are  our 
main  reliances. 

The  natural  resisting  power  of  the  bladder  against  tuberculosis  is  well 
illustrated  in  cases  of  tuberculous  nephritis  and  ureteritis  in  which  secondary 
lesions  appear  in  the  bladder  around  the  ureteral  orifices.  After  nephrectomy 
and  ureterectomy  the  vesical  lesions  often  disappear  spontaneously.  This 
fact  encourages  us  in  the  treatment  of  vesical  tuberculosis. 

Suprapubic  F*rostatectomy  and  Prostatotomy. — Open  the  bladder  and 
explore  so  as  to  recognize  the  variety  of  prostatic  enlargement  present  and  the 
presence  or  absence  of  vesical  calculi.     If  the  latter  are  present,  remove  them. 

I.  Enlarged  Pedunculated  Middle  Lobe. — This  lobe  may  be  the  sole  obstacle 
to  urination,  forming  a  valve  which  occludes  the  vesical  meatus. 

Method  ^:  Cut  through  the  pedicle  with  scissors  and  remove  the  lobe. 
Hemorrhage  is  easily  controlled  by  temporary  pressure  with  pads  wrung  out 
of  hot  water. 

Method  B:  Incise  or  tear  through  the  mucosa  covering  the  lobe  and  shell 
it  out  with  the  finger.  This  method  is  available  whether  the  hypertrophied 
lobe  is  pedunculated  or  not. 

Never  omit  to  examine  the  prostatic  urethra,  lest  the  lateral  lobes  impinge 
upon  it  and  require  removal. 

II.  Enlarged  Lateral  Lobes  with  or  without  Enlargement  of  the  Middle  Lobe. — 
Introduce  a  gum-elastic  catheter  into  the  bladder  through  the  urethra,  to  act 
as  a  guide  to  the  position  of  the  prostatic  urethra.  Make  an  incision  through 
the  mucous  membrane  over  the  most  prominent  part  of  the  swelling.  With 
the  finger,  aided  if  necessary  by  closed  blunt-pointed  scissors,  peel  the  mucosa 
from  the  surface  of  the  prostate.  Insinuate  the  finger  through  the  mucosal 
wound,  between  the  prostate  and  the  urethra,  and  separate  these  structures. 
In  the  same  way  separate  the  outer  surface  of  the  prostate  from  its  surroundings, 
the  finger  passing  between  the  true  and  false  prostatic  capsules.  The  fingers 
of  an  assistant  should  be  passed  through  the  anus  to  elevate  and  steady  the 
prostate.  Working  as  above,  the  prostate  may  be  removed  in  one  piece  or  in 
two  or  more  sections.  Freyer  is  often  successful  in  leaving  the  prostatic  urethra 
intact,  though  when  it  is  injured  no  harm  seems  to  result.  Moynihan  removes 
the  prostatic  urethra  with  the  gland.  It  is  claimed  that  when  the  two  lateral 
lobes  are  removed  separately  the  ejaculatory  ducts  are  not  destroyed.  The 
author  for  a  number  of  years  has  omitted  the  use  of  any  catheter  or  sound  as  a 
guide.  He  introduces  his  finger  through  the  suprapubic  wound  into  the  internal 
or  vesical  meatus,  with  his  finger  nail  penetrates  the  mucosa  and  shells  out 
the  enlarged  lobes.  In  this  procedure  he  has  the  support  of  L.  L.  McArthur 
C'Surg.,  Gyn.,  Obst.,"  Ap.  10,  p.  412).  Hemorrhage  is  easily  controlled  by 
temporary  pressure  with  pads  wrung  out  of  hot  water.     Freyer  introduces 


688  OPERATION'S    ON    THE    BLADDER 

a  large  drain  into  the  bladder  through  the  abdominal  wound  and  sutures 
the  vesical  wound  around  it.  Through  the  tube  irrigation  with  hot  water 
may  be  practised  and  any  blood-clots  removed.  The  drain  is  kept  in  posi- 
tion for  about  one  week,  when  it  is  removed  and  the  wound  permitted  to  close. 
Fuller,  after  completing  the  enucleation  of  the  prostate,  establishes  perineal 
drainage  and  closes  the  suprapubic  wound.  In  cases  in  which  there  is  much 
infection  it  is  probably  best  to  maintain  both  perineal  and  suprapubic  drainage 
for  a  few  days.  Prostatectomy  via  the  perineal  route  will  be  described  on 
another  page. 

W.  E.  Lower  (Annals  Surg.,  Feb.,  1914)  strongly  recommends  Crile's  anocias- 
sociation  in  prostatectomy  as  it  eliminates  shock.     He  operates  as  follows: 

One  hour  before  operation  give  a  hypodermic  injection  of  morphine  and 
scopolamine. 

Immediately  before  the  operation  irrigate  the  bladder  and  inject  60  to  90 
c.c.  of  a  5  per  cent,  solution  of  alapin  through  a  catheter  which  is  then  clamped 
and  left  in  situ. 

Administer  nitrous  oxide  and  oxygen. 

Perform  suprapubic  cystotomy  after  infiltrating  the  skin  and  all  the 
tissue  planes  as  well  as  the  bladder-wall  with  a  ^  per  cent,  solution  of 
novocaine. 

Gently  retract  the  wound  in  the  bladder  with  four  suitable  retractors 
and  inject  the  prostatic  capsule  with  the  novocaine  solution. 

Enucleate  the  prostate.     N.  B.:  The  catheter  is  still  in  situ. 

Push  the  vesical  mucosa  which  covered  the  prostate  down  into  the  cavity 
left  by  the  enucleation,  so  that  the  vesical  mucosa  meets  the  urethral  mucosa. 
Keep  the  mucosa  in  position  by  narrow  strips  of  gauze  packed  over  it  and 
around  the  point  of  the  catheter.  The  ends  of  the  gauze  come  out  through  the 
vesical  wound. 

Paul  M.  Pilcher  (Surg.,  Gyn.  and  Obst.,  Feb.,  1917)  emphasizes  the  impor- 
tance of  renal  decompression  before  removing  the  prostate.  The  Pilcher 
operation  is  done  in  two  stages. 

Stage  I. — Suprapubic  Cystotomy. — Under  local  anesthesia  open  the  bladder 
as  near  its  fundus  as  possible  after  brushing  the  peritoneal  fold  upwards.  In- 
troduce a  Pezzer  catheter  through  the  wound  and  make  a  water  tight  closure 
of  the  vesical  wound  round  the  catheter  by  means  of  a  purse  string  suture  of 
catgut.  Close  the  abdominal  wound  by  deep  and  superficial  sutures.  The 
result  ought  to  be  primary  union,  no  leak,  and  effective  seahng  of  the  peri-  and 
prevesical  spaces.  When  the  urinary  output  has  regulated  itself  as  regards 
quantity  and  quaUty  proceed  to  Stage  2,  usually  in  from  one  to  two  weeks. 

Stage  2.  Step  i. — Administer  a  general  anesthetic.  If  less  than  two  weeks 
have  elapsed  since  the  primary  operation  it  is  easy  to  enlarge  the  drainage 
opening  with  the  finger.  If  cicatrization  is  more  complete  enlarge  the  opening 
by  a  short  (i  inch)  transverse  incision  on  each  side  of  the  drainage  track.  These 
incisions  as  a  rule,  only  penetrate  to  the  recti-muscles. 

Step  2. — Introduce  the  finger  and  enucleate  the  prostate  in  the  usual  manner. 

Step  3. — Pass  a  metal  catheter  per  urethram  into  the  bladder.  Place  the 
open  end  of  the  urethral  tube  of  Pilcher's  bag  hemostat  (Fig.  844)  over  the  end 


CYSTECTOMY 


689 


of  the  catheter  and  fix  it  by  a  stitch  jKissing  throujj;h  the  eye  of  the  catheter. 
Withdraw  the  silver  catheter  and  thus  pull  the  rubber  tube  through  the  urethra 
and  the  bag  hemostat  into  the  neck  of  the  bladder.  Distend  the  bag  with  air. 
Bring  the  inflating  tube  out  through  the  sui)rapubic  opening.  This  procedure 
controls  hemorrhage  and  secures  drainage  through  the  urethra. 

Pass  a  rubber  tube  about  i  inch  in  diameter  through  the  suprapubic 
wound,  to  project  into  the  bladder  for  about  3-^  inch.  Fix  this  tube  to  the  skin 
by  sutures.  Connect  the  drain  by  tubing  to  an  appropriate  bottle  to  collect 
the  secretions. 


844. — Pitcher's  bag  hemostat 
{Surg.,  Gyn.  and  Ohst.) 


Pilcher's  modified  Pezzer  catheter. 
{Surg.,  Gyn.  and  Obst.) 


After  from  24  to  48  hours  remove  the  bag  hemostat  and  drainage  tube. 
Replace  them  by  Pilcher's  modification  of  Pezzer's  catheter  (Fig.  845),  which 
after  a  few  hours  should  drain  off  all  the  urine  without  leakage.  After  about 
one  week  the  drain  may  be  temporarily  closed  and  urine  may  be  passed  per 
urethram.     Generally  the  drain  may  be  removed  on  the  eleventh  day. 

Cystectomy. — Cystectomy  may  be  partial  or  complete. 

Partial  Cystectomy. — This  operation  is  mostly  commonly  indicated  in  cases 
of  circumscribed  malignant  neoplasm,  and  whenever  feasible  should  be  carried 
out  extraperitoneally.  The  anterior  wall,  most  of  the  fundus,  and  some- 
times even  part  of  the  posterior  wall  of  the  bladder  may  be  exposed  without 
opening  the  peritoneal  cavity.  Expose  the  bladder  as  in  suprapubic  cystotomy. 
Carefully  pull  the  prevesical  fold  of  peritoneum  upwards,  and  by  blunt  dis- 
section separate  its  vesical  layer  from  the  bladder  to  the  desired  extent.  If 
the  peritoneum  is  accidentally  torn,  the  tear  must  be  at  once  closed  with  sutures. 
Having  exposed  the  bladder  at  the  site  of  the  tumor  (anterior  wall  or  fundus), 
open  it  and  remove  the  whole  thickness  of  the  diseased  portion,  making  the 
necessary  cuts  in  healthy  tissue.  Remove  too  much  rather  than  too  little  tissue 
along  with  the  neoplasm.  Close  the  wound  by  sutures  exactly  as  in  suprapubic 
cystotomy,  after  -providing  for  drainage — preferably  through  the  perineum. 
44 


690  OPERATIONS  ON  THE  BLADDER       * 

If  the  neoplasm  has  infiltrated  the  bladder-wall  so  as  to  attack  the  peritoneal 
covering  and  its  location  is  favorable,  the  operation  may  still  be  accomplished 
practically  extraperitoneally.  Expose  the  bladder  and  reflect  the  peritoneum 
from  it  except  where  it  is  adherent  over  the  site  of  the  neoplasm;  with  scissors 
cut  around  the  site  of  adhesions;  with  sutures  close  the  gap  in  the  peritoneum 
and  remove  the  diseased  cystic  wall  as  already  described. 

When  the  disease  affects  the  posterior  bladder-wall,  but  does  not  infiltrate  the 
peritoneal  covering,  it  may  be  removed  as  follows:  Apply  a  solution  of  adrena- 
lin to  the  bladder  so  as  to  control  hemorrhage,  not  from  any  fear  of  loss  of  blood, 
but  to  keep  blood  from  obstructing  the  view.  Incise  the  bladder-wall  all 
around  the  neoplasm,  cutting  in  healthy  tissue.  Cut  down  to  but  not  through 
the  peritoneal  coat.  Remove  the  disease,  along  with  the  whole  thickness  of 
the  wall,  minus  the  peritoneal  covering.  Close  the  wound  by  a  layer  of  sutures 
(catgut)  involving  the  muscular  coats  alone,  and  one  involving  the  mucosa 
alone.  Should  the- peritoneum  be  accidentally  opened,  close  it  at  once  by  a 
few  catgut  or  fine  silk  sutures.  The  operation  as  above  described  involves 
more  precise  suturing  than  most  surgeons  are  capable  of  doing.  It  must  re- 
quire marvelous  skill  to  suture  with  precision  the  various  vesical  coats  when  the 
work  has  to  be  done  at  the  bottom  of  a  deep  cavity.  If  the  peritoneal  covering 
is  uninjured,  probably  the  best  method  to  pursue  is  to  make  the  stitches  involve 
the  muscular  and  mucous  coats.  These  stitches  will  probably  not  secure 
complete  union;  there  will  be  separation  of  the  edges  in  time,  but  they  will 
lessen  the  size  of  the  defect  and  so  hasten  recovery.  If  it  is  possible  to  pull 
the  wound  up  towards  the  surface  of  the  body,  then  of  course  its  closure  is 
easy. 

When  the  tumor  is  situated  at  the  trigone,  the  operation  is  very  much  as 
above  described.  One  cuts  through  the  bladder-wall  layer  by  layer  until  the 
perivesical  fat  is  reached,  and  then  removes  the  disease.  If  the  ureter  is  in- 
volved in  the  disease,  pass  a  catheter  into  it  and  dissect  it  free  from  its  sur- 
roundings for  about  two  inches;  remove  such  part  of  it  as  may  be  diseased; 
secure  its  ends  temporarily  by  a  thread.  After  the  resection  of  the  bladder- 
wall  is  completed  unite  the  ureter  once  more  to  the  bladder.  Occasionally  it 
has  been  necessary  to  anastomose  the  ureter  to  the  rectum  or  skin;  this  is  very 
undesirable. 

Transperitoneal  Partial  Cystectomy. — Francis  Harrington  ("Annals  Surg.," 
1893),  struck  by  the  safety  with  which  wounds  of  the  bladder,  accidentally 
inflicted  during  laparotomy,  may  be  sutured,  boldly  opened  the  bladder  through 
the  peritoneal  route.  C.  H.  Mayo  followed  Harrington  with  a  number  of 
successful  operations  for  vesical  neoplasms. 

The  Operation. — Wash  out  and  empty  the  bladder  completely.  Put  the 
patient  in  Trendelenburg's  position. 

1.  Make  a  median  incision  between  the  pubis  and  umbilicus  about  6  inches 
long.  Open  the  peritoneum.  Thoroughly  pack  with  gauze  to  keep  the  intes- 
tines away  and  to  protect  the  belly  cavity. 

2.  Pick  up  the  bladder  with  two  volsellae  and  incise  it  between  them.  The 
incision  is  median  and  about  2  inches  in  length.  With  gauze  mop  out  any 
fluid  in  the  bladder.     Enlarge  the  incision  in  the  bladder  upwards  and  down- 


CYSTECTOMY 


691 


wards  until  the  cut  equals  one-third  or  more  of  the  vertical  circumference  of 
the  viscus. 

3.  If  the  tumors  are  pedunculated  and  benign,  cut  through  them  flush  with 
the  vesical  mucosa  and  burn  the  wound  with  a  cautery  (Fig.  846). 

If  the  tumors  are  sessile  and  benign,  remove  them  and  burn  their  site. 


Fig.  846. — Partial  cystectomy.     (Mayo.) 


If  the  tumors  are  malignant,  excise  them  with  the  mucosa  by  means  of 
the  cautery  knife.  Do  not  try  to  destroy  the  growth  with  the  cautery,  but 
lift  it  up  with  forceps  and  dissect  it  away,  using  the  cautery  as  a  knife. 

4.  Close  the  wound  in  the  bladder  by  through-and-through  catgut  stitches 
introduced  in  the  Connel  fashion  (Fig.  847).  Put  in  a  second  layer  of  stitches 
(hemp)  in  the  continuous  Lembert  or  Gushing  fashion.  At  the  lower  end  of 
the  cut,  where  the  bladder  is  not  covered  with  peritoneum,  it  is  easy  to  so  loosen 
the  parietal  peritoneum  continuous  with  the  vesical  peritoneum  that  it  can  be 
made  to  lie  on  the  bladder  and  permit  the  continuation  of  the  Lembert  suture 


692 


OPERATIONS    ON    THE   BLADDER 


until  the  bladder  is  completely  closed.  Usually  no  drainage  is  required,  but 
should  cystitis,  etc.,  demand  drainage,  provide  for  it  in  the  following  manner: 
(a)  Bring  about  i  to  i^i  inches  of  the  lowest  part  of  the  parietal  peritoneum 
on  the  left  side  of  the  abdominal  wound  over  to  the  right  side  of  the  vesical 
wound  and  fix  it  there  by  a  few  catgut  sutures. 


Fig.  847. — Partial  cystectomy.     Suture  of  bladder.     (Mayo.) 


(b)  Make  a  stab  wound  in  the  bladder  about  %  inch  to  the  right  of  the 
lower  end  of  the  vesical  wound.  Introduce  a  split  rubber  tube  containing 
a  strand  of  gauze  into  the  bladder  and  bring  it  out  through  the  lower  end  of 
the  abdominal  wound.  With  fine  catgut,  suture  the  parietal  to  the  vesical 
peritoneum  just  external  to  the  stab  wound  in  the  bladder  and  continue  this 


CYSTECTOMY 


693 


Stitching  so  as  to  unite  the  parietal  to  the  vesical  peritoneum  just  above  the  line 
of  the  drainage  tube. 

The  object  of  this  elaborate  method  of  drainage  is  to  avoid  (o)  contamina- 
tion of  the  belly  cavity  with  urine  escaping  along  the  drain;  (b)  contamination 
of  the  line  of  Lembert  sutures. 


Fig.  848. — {Squier  and  Heyd,  Surg.,  Gyn.  and  Obst.) 

Exposure    of    prevesicle    space.     Urachus    and    divergent  obliterated  hypogastric  arteries  held  taut  by 

intestinal  forceps. 

5.  Close  the  abdominal  wound.  If  drainage  is  not  used,  draw  off  the 
urine  with  a  catheter  as  may  be  necessary;  commonly  the  urine  is  voided 
voluntarily.     If  drainage  is  used,  the  dressings  must  be  removed  frequently. 


Fig.  849. — {Squier  and  Heyd,  Surg.,  Gyn.  and  Obst.) 
Exposure  of  left  ureter  by  blunt  dissection  along  the  course  of  left  obliterated  hypogastric  artery 

An  account  of  Young's  method  of  partial  cystectomy  is  given  in  the  section 
on  Excision  of  the  Seminal  Vesicles. 

Squier-Heyd  Operation  (Surg.,  Gyn.  and  Obst.,  July,  1914). — Step  t. — From 
a  point  one  inch  above  and  to  the  left  of  the  umbilicus  make  an  incision  down- 


694 


OPERATIONS    ON    THE   BLADDER 


wards  to  a  point  two  inches  above  the  pubis  in  the  middle  line.  Open  the  peri- 
toneum. Place  the  patient  in  the  extreme  Trendelenburg  position.  Push  the 
intestines  towards  the  diaphragm.  Thoroughly  isolate  the  field  of  operation 
with  gauze  pads. 


Fig.  850. — {Squier  and  Heyd,  Surg.,  Gyn   and  Obst.) 
Exposure  of  left  ureter  by  blunt  dissection  along  the  course  of  the  left  vas  deferens. 

Step  2. — Continue  the  incision  downwards  through  the  skin  and  fascia. 
Divide  the  pyramidales  transversely  at  the  pubis.  Expose  the  prevesical 
space  but  do  not  interfere  with  the  pubo-vesical  attachment  at  any  stage  in 
the  operation. 


Fig.  851. — {Squier  and  Heyd,  Surg.,  Gyn.  and  Obst.) 
Final  separation  peritoneum  from  bladder,  exposing  both  ureters,  vasa  deferentia  and  upper 

pole  of  trigone. 

Step  3. — At  the  lower  angle  of  the  peritoneal  incision  catch  the  urachus  and 
peritoneum  with  a  forceps  protected  by  rubber  tubing  (Fig.  848).  Pull  on  the 
forceps  upwards  and  make  prominent  the  obliterated  hypogastric  vessels 
hj-pogastric  cords). 


CYSTECTOMY 


695 


Step  4. — Pull  the  left  hypogastric  cord  upwards  and  to  the  right.  By  blunt 
dissection  between  the  cord  and  the  lateral  wall  of  the  pelvis,  expose  the  left 
vas  deferens  as  it  runs  along  the  pelvic  wall  to  the  inner  side  of  the  hypogastric 
cord  (Fig.  849). 


Fig.  852. — {Squier  and  Hcyd,  Surg.,  Gyn.  and  Ohst.) 
Bladder  pulled  down  towards  symphysis.     Primary  incision  in  bladder. 

Step  5. — Exert  gentle  traction  on  the  exposed  vas,  and  dissect  bluntly 
downwards  along  it  until  the  pelvic  ureter  is  exposed  as  it  bends  inwards  above 
the  fascia  of  the  pelvic  floor  to  enter  the  bladder.  At  this  point  the  ureter  is 
crossed  on  its  inner  side  by  the  vas  (Fig.  850). 


Fig.  853. — (Squier  and  Heyd,  Surg.,  Gyn.  and  Ohst.) 
Bladder   wound   enlarged   downwards. 

Repeat  Step  4  and  5  on  the  right  side. 

Step  6. — Divide  the  urachus  close  to  the  bladder  (Fig.  851).  Strip  the  peri- 
toneum from  the  bladder  until  the  recto-vesical  space  is  reached.  Push 
Douglas'  cul-de-sac  upwards  and  backwards.     Pull  the  bladder  downwards 


696 


OPERATlnXS    OX    '\'UF.    BLADDER 


Fig.  854. — (Squier  and  Heyd,  Surg.,  Gyn.  and  Obst.) 

Bisection  posterior  wall  bladder. 


Fig.  855. — (Squicr  and  Ilcyd,  Suri^.,  Gyn.  ami  Obsi.) 
Neoplasm  and  afFe.ted  ureter  excised,  en  masse  with  much  healthy  tissue.     Hemostasis  with  angled 
forceps.     Temporary  ligature  around  proximal  urctf  r. 


Fig.  856. — {Squier  and  Heyd,  Surg.,  Gyn.  and  Obst.) 
Partial   closure   of  bladder  wound.     Stab  wound  for  implantation  of  ureter.     Forceps  grasping  ureter. 


CYSTECTOMY 


697 


towards  the  symphysis  until  the  upper  poles  of  the  seminal  vesicles  are  exposed. 
The  whole  fundus  of  the  bladder  and  the  upper  portion  of  the  trigone  are  fully 
exposed.     The  ureters  are  constantly  in  sight.     There  is  little  bleeding.  ^ 

Stgp  7.— Carefully  unite  the  denuded  lamella  of  the  peritoneum  to  the  upper 
end  of  the  abdominal  incision  so  that  all  the  subsequent  procedures  are  extra- 
peritoneal. 


Fig.  Ss7-—(Squier  and  Heyd,  Surg.,  Gyn.  and  Obsl.) 
Implantation  of  divided  ureter  after  partial  closure  of  the  bladder. 

The  rest  of  the  operation  is  sufficiently  described  by  Figs.  852-859  with 
the  legends  under  them. 

Squier  and  Heyd  note  that  fifteen  patients  were  operated  on  by  their  method 
in  two  years  with  no  operative  mortality. 

''In  the  last  three  the  technique  was  carried  out  without  entering  the 
peritoneal  cavity,  thereby  making  the  operation  entirely  extra-peritoneal. 
In  addition,  approximately  the  same  technique  has  been  utilized  for  removing 
calculi  at  the  lower  end  of  the  ureter  and  for  an  extensive  resection  for  diver- 
ticulum of  the  bladder." 


698 


OPERATIONS    ON    THE   BLADDER 


Fig.  858. — {Squier  and  Heyd,  Surg.,  Gyn.  and  Obst.) 
Counter-opening  for  drainage  of  bladder. 


Fig.  859. — {Squier  and  Heyd,  Surg.,  Gyn.  and  Obsi.) 
Accurate  closure  of  the  peritoneal-cavityr'showing  the  two  cigarette  drains  and  separate4Stab-wound  for 

drainage  of  .bladder. 


RUTKOWSKIS    OPERATION 


699 


RuthowskVs  Operation  for  the  Repair  of  Defects  in  the  Bladder-wall. — Scope 
of  operation:  Rutkowski's  operation  may  be  used  to  close  the  bladder  in  cases 
of  ectopia.  It  also  promises  to  be  useful  in  repairing  the  bladder  after  the 
removal  of  tumors.  In  describing  the  operation  it  will  be  assumed  that  the 
case  is  one  of  tumor. 

The  Operation. — i.  Open  the  belly  by  a  4-inch  incision  in  the  middle  line 
near  the  pubis.     E.xpose  the  bladder. 

2.  Excise  the  tumor  and  as  much  of  the  vesical  wall  as  may  be  necessary. 

3.  Pull  a  loop  of  ileum  down  towards  the  bladder  and  divide  it  at  two  places 
(x-x,  Fig.  860).  The  distance  between  the  two  lines  of  section  (x-x)  depends 
on  the  size  of  the  defect  in  the  bladder  which  it  is  desired  to  close. 


Fig.  860. 


Figs.  860,  861  and  862. 


Fig.  861. 
-Rutkowski's  operation. 


Fig.  862. 


4.  The  afferent  and  efferent  loops  of  ileum  (a  and  e,  Figs.  860  and  861) 
are  united  by  end-to-end  anastomosis  and  at  once  returned  to  the  abdominal 
cavity. 

5.  The  isolated  segment  of  ileum  (s,  Figs.  860  and  861)  is  split  along  its 
free  border  {i.e.,  along  the  side  opposite  to  the  mesenteric  attachment).  A 
flap  of  tissue  is  thus  obtained  (s,  Fig.  862)  which  is  rectangular  in  shape,  covered 
on  one  side  by  mucous  membrane,  on  the  other  by  peritoneum,  and  contains 
non-striated  muscular  fibres.  To  the  middle  of  its  serous  surface  is  attached 
the  mesentery  through  which  it  is  nourished. 

6.  The  edges  of  the  flap  are  attached  to  the  edges  of  the  defect  in  the  bladder 
by  a  double  layer  of  sutures.  The  mucous  surface  of  the  flap  faces  the  in- 
terior of  the  bladder.  The  deep  layer  of  sutures  (catgut)  includes  the  whole 
thickness  of  the  bladder  and  of  the  gut  walls  except  the  surface  of  the  mucous 


700  OPERATIONS  ON  THE  « LADDER 

membrane.     The  superficial  layer  (silk)  is  applied  after  the  Lemberi  method. 
Continuous  sutures  are  used. 

7.  A  catheter  is  passed  into  the  bladder  per  urethram  and  is  kept  there. 

8.  The  abdominal  wound  is  closed. 

Mikulicz  has  modified  the  above  operation.  After  isolating  a  segment  of 
ileum  and  uniting  the  afferent  and  efferent  loops  (Step  4),  he  closes,  by  suture, 
one  end  of  the  isolated  segment  and  sutures  the  other,  or  open  end,  to  the 
abdominal  wound  near  the  bladder.  The  abdominal  wound  is  closed.  After 
a  sufficient  period  of  time  has  elapsed  to  demonstrate  that  the  segment  of 
ileum  is  sufficiently  nourished,  he  proceeds  to  remove  the  vesical  tumor  and 
repair  the  bladder  with  the  segment  of  ileum  obtained  at  the  first  operation. 

Complete  Cystectomy. — TuflBer  ("Revue  de  Chir.,"  April,  1898)  reports  a 
successful  case  of  complete  cystectomy  in  a  man  suffering  from  extensive  epithe- 
lioma confined  to  the  bladder.  In  his  case  the  operation  was  complicated 
by  a  previous  suprapubic  cystotomy  having  been  practised.  The  complica- 
tion was  overcome  by  packing  the  bladder  with  gauze  and  by  dissecting  the 
fistulous  tract  free  from  the  parietes.  Ample  room  for  work  was  obtained 
by  a  combination  of  the  transverse  and  vertical  incisions  recommended  in 
cystotomy.  The  steps  of  the  operation  were,  briefly,  as  follows:  Exposure 
of  the  anterior  surface  of  the  bladder.  Separation  of  the  anterior  and 
lateral  surfaces  from  the  peritoneun^^nd  adjacent  structures.  It  is  thus  easy 
to  isolate  the  neck  of  the  bladder  and  the  pedicles  containing  the  inferior 
vesical  vessels  and  the  ureters.  Clamp  the  vessels  and  ureters  together  and 
cut  between  the  clamps  and  the  bladder.  Divide  the  neck  of  the  bladder 
between  clamps  and  cauterize  the  opened  urethra.  It  may  be  well  to  make 
the  division  of  the  vesical  neck  with  the  cautery.  With  forceps  or  clamps 
pull  the  bladder  into  the  abdominal  wound  and  decorticate,  i.e.,  separate 
it  from  its  peritoneal  covering  under  traction.  Tuffier  succeeded  in  doing 
this  without  opening  the  peritoneal  cavity.  If  the  peritoneum  is  torn,  the 
opening  must  be  closed  at  once  with  sutures.  Having  removed  the  bladder, 
turn  to  the  pedicles  containing  the  vesical  vessels  and  ureters.  Isolate  the 
ureters  and  tie  the  vessels.  Pass  a  catheter  into  each  ureter  and  fix  it  to 
the  ureter  with  a  stitch.    Ligate  the  vessels  in  the  urethral  stump. 

In  Tuffier's  case  he  at  once  anastomosed  the  ureters  to  the  rectum,  but  the 
union  evidently  gave  way,  as  the  patient  developed  a  suprapubic  fistula.  If 
the  patient  is  in  poor  condition,  it  is  wise  to  bring  the  ureteral  catheters  out 
through  the  suprapubic  wound  and  leave  any  attempts  at  anastomosis  until 
later.  After  attending  to  hemostasis,  pack  the  cavity  with  gauze  and  partially 
close  the  wound  with  sutures.  Tuffier's  classical  case  lived  in  comfort  for  seven 
months.  In  the  female,  Pawlik  operated  in  two  stages  with  an  interval  of 
about  three  weeks.     His  operation  may  be  performed  as  follows: 

First  Stage. — Ureter o-vaginal  anastomosis.  Catheterize  the  ureters.  Incise 
the  vagina  over  each  ureter.  Divide  and  bring  the  end  of  each  ureter  into  the 
vagina.  Split  the  lower  end  of  each  ureter  for  about  ^^  inch  and  suture  the 
edges  of  the  split  to  the  vaginal  wound.  Fix  with  stitches  a  catheter  in  each 
ureter. 


CYSTECTOMY  70I 

Instead  of  practising  any  method  of  ureteral  implantation,  Frank  Watson 
advises  permanent  nephrostomy. 

Second  Stage. — Excision  of  the  bladder.  Fill  the  bladder  with  an  emulsion 
of  iodoform.  Through  a  suprapubic  incision  separate  the  bladder  from  its 
surroundings  down  to  the  urethra.  Empty  the  bladder.  Pack  the  suprapubic 
wound  with  gauze.  Make  an  incision  through  the  anterior  wall  of  the  vagina 
at  a  point  opposite  the  internal  urinary  meatus,  pull  the  isolated  bladder 
through  this  incision,  and  divide  it  where  it  joins  the  urethra.  Remove  the 
bladder.  Pass  ureteral  catheters  through  the  urethra  into  the  ureters.  Denude 
and  close  by  sutures  the  vaginal  outlet,  thus  forming  a  urinary  reservoir  drained 
by  the  urethra. 

F.  S.  Watson  recommends  nephrostomy  as  a  preliminary  to  complete 
cystectomy. 

Rovsing  (German  Surg.  Assoc,  1907)  advises  the  removal  of  the  bladder  as 
if  it  was  a  cystic  tumor  without  opening  it. 

Step  I. — Fill  the  bladder  with  a  mild  antiseptic  solution.  Put  the  patient 
in  Trendelenburg's  posture.  Expose  the  distended  bladder  through  a  curved 
transverse  incision  (convexity  downwards),  near  the  pubis. 

Step  2. — Separate  the  vertex  and  sides  of  the  bladder  from  their  connections. 
While  doing  this  doubly  ligate  and  divide  all  strong  bands  of  tissue  containing 
vessels.  If  possible  separate  the  posterior  wall  from  its. peritoneal  covering. 
If  the  infiltrated  bladder  wall  is  firmly  adherent  to  the  peritoneum,  open  the 
belly  cavity  and  remove  the  bladder  with  its  peritoneal  covering. 

Step  3. — Expose,  doubly  ligate,  and  divide  the  ureters  about  M  to  ^  inch 
from  the  bladder. 

Step  4. — {a)  In  the  female  it  is  easy  to  free  by  blunt  dissection  the  neck 
of  the  bladder  and  about  ^  inch  of  the  urethra.  Clamp  and  divide  the 
urethra. 

{h)  In  the  male  separate  the  base  of  the  bladder  and  the  prostate  from  the 
rectum.  This  leaves  the  bladder  attached  to  the  body  by  the  membranous 
urethra  alone.  Doubly  clamp  and  divide  the  urethra.  Leave  the  distal  clamp 
in  situ  for  24  hours  to  prevent  bleeding  from  the  cavernous  tissue. 

Step  5. — If  the  peritoneum  has  been  opened,  close  it  with  sutures.  Pack 
the  cavity  with  gauze  which  is  brought  out  through  the  middle  of  the  wound. 
Unite  the  wounded  recti  muscles.  Close  the  excess  of  wound.  Apply 
dressings. 

Step  6. — Expose  both  ureters  through  a  3-  to  4-inch  incision  on  each  side 
running  obliquely  outwards  and  downwards  from  the  edge  of  the  erector  spinae 
muscles.  The  ureters  can  be  palpated  close  to  the  pelvis  of  the  kidney.  Fix 
the  ureters  with  a  finger,  and  with  another  finger  bluntly  dissect  them  loose 
throughout  their  whole  length  and  pull  them  out  of  the  lumbar  wounds.  Close 
the  lumbar  wounds  with  sutures,  leaving  the  ureters  hanging  loosely  out  of 
them.  Pass  a  No,  12  catheter  into  each  ureter  to  prevent  its  compression  by 
the  wound.  Pull  the  exposed  part  of  each  ureter  through  the  perforated  finger 
of  a  rubber  glove  to  protect  the  wound.  Apply  dressings.  By  the  time  the 
lumbar  wounds  have  healed  the  excess  of  ureter  has  become  shrunken  and 


702  OPERATIONS  ON  THE  BLADDER 

necrosed,  and  may  be  removed.  Rovsing  has  performed  the  above  operation 
three  times,  twice  successfully. 

J,  Verhoogen  ("  Journ.  de  Chir.,"  March,  1907;  ref.  "Zent.  fur  Chir.,"  1907, 
No.  32)  recommends  the  following  operation: 

(i)  Open  the  abdomen.     Explore  as  to  extent  of  disease,  adhesions,  etc. 

(2)  Expose  the  ureters  where  they  cross  the  vessels  at  the  pelvic  brim. 

(3)  Anastomose  the  right  ureter  to  the  caecum,  the  left  to  the  sigmoid. 
[Make  the  anastomoses  valvular,  like  Witzel's  gastrostomy. 

(4)  Excise  the  bladder,  forming  an  anterior  and  posterior  peritoneal 
flap. 

(5)  Drain  through  the  vagina,  or,  in  the  male,  through  the  perineum  after 
removing  the  prostate. 

(6)  Close  the  abdominal  wound  entirely. 

Operative  removal  of  benign  neoplasms  gives  good  results;  the  extirpation 
of  malignant  growths  occasionally  does  so. 

Prostatotomy. — The  principle  at  the  base  of  all  operations  for  the  relief 
of  the  troubles  arising  from  enlarged  prostate  is  the  provision  of  drainage  for 
the  most  dependent  portion  of  the  bladder.  Such  drainage  may  be  secured 
by  suprapubic  prostatotomy. 

Expose  and  open  the  bladder  by  the  vertical  incision.  Explore  the  bladder 
and  recognize  the  nature  of  the  prostatic  obstruction.  Introduce  a  tubular 
speculum  (caisson  or  coffer-dam)  and  engage  the  prostate  in  its  open  end. 
The  use  of  this  is  not  essential.  With  gauze  dry  the  surface  of  the  tissues 
enclosed  in  the  end  of  the  speculum.  Pass  a  thermocautery,  heated  to  a  red 
heat,  through  the  speculum  and  burn  a  groove  or  gutter  from  the  prostatic 
urethra  to  the  vesical  pouch  behind  the  prostate.  This  provides  drainage  of 
the  most  dependent  portion  of  the  bladder.  If  the  lateral  lobes  of  the  prostate 
obstruct  the  urethra,  it  is  well  to  burn  deep  grooves  or  gutters  in  them  also. 
Provide  suprapubic  drainage  and  partially  close  the  wound.  This  operation 
is  very  similar  in  principle  to  the  Bottini  operation,  but  it  is  done  under  guid- 
ance of  the  eye. 

Galvano-caustic  Prostatotomy  (Bottini' s  Operation). — The  object  of  the  Bot- 
tini operation  is  to  make  one  or  more  furrows  through  the  obstructing  prostate, 
thus  lowering  the  vesical  orifice  of  the  urethra  and  permitting  efficient  drainage 
of  the  bladder. 

The  favorite  instrument  for  division  of  the  prostate  is  Freudenberg's  modi- 
fication of  Bottini's  galvanocautery  (Fig.  863).  H.  Young  has  devised  an 
instrument  in  which  various  sized  blades  can  be  used  ("Jour.  Am.  Med.  Assoc," 
Jan.  II,  1902). 

Da  Costa  thus  describes  the  operation:  "The  bladder  should  be  emptied, 
irrigated,  and  distended  with  air,  and  the  posterior  urethra  must  be  anesthetized 
by  instillation  of  cocain  or  eucain.  The  current  is  tried  to  see  how  many 
seconds  it  requires  to  heat  the  blade  sufficiently.  The  current  is  broken, 
the  instrument  is  introduced,  the  cooling  current  is  set  in  motion,  and  one 
assistant  watches  this  and  nothing  else.  Turn  on  the  current.  Wait  the  re- 
quired number  of  seconds  for  the  blade  to  become  red  hot  (twelve  to  fifteen 
seconds),  turn  the  screw  at  the  handle,  and  burn  a  groove  in  the  prostate.    A 


ENLARGED  PROSTATE.   REMARKS 


703 


(ff 


groove  should  be  burned  towards  the  rectum,  one  to  the  side,  and,  if  it  is  thought 
desirable,  one  to  the  opposite  side.  No  groove  should  be  burned  towards  the 
pubes.  When  a  groove  has  been  burned,  return  the  blade  into  its  sheath, 
increasing  the  current  while  doing  so  in  order  to  keep  the  blade  from  adhering 
to  the  tissue,  and  then  shut  off  the  current.  After  withdrawing  the  instrument 
it  is  not  necessary  to  introduce  and  retain  a  catheter.  The  patient  is  confined 
to  bed  only  twenty-four  hours,  there  is  rarely  bleeding  or  fever,  and  the  results 
are  good.  The  scars  contract  and  the  gland  atro- 
phies. During  the  period  of  healing  a  steel  sound 
should  be  passed  from  time  to  time  (Bangs)." 

Chetwood  has  devised  a  short  cautery  which 
he  introduces  through  a  perineal  opening  and  so 
escapes  the  grave  danger  of  urethral  injury  men- 
tioned on  page  704. 

For  the  indirect  treatment  of  prostatic  hyper- 
trophy J.  W,  White  has  strongly  recommended 
castration,  and  R.  Harrison  and  Mears  vasec- 
tomy (division»or  resection  of  the  vasa  deferentia). 
These  operations  are  too  simple  to  require  de- 
scription. 

Remarks  on  the  Treatment  of  Prostatic  Hy- 
pertrophy.— The  patients  are  almost  always  aged 
in  years,  and  still  more  aged  in  physical  condi- 
tion. Unfortunately,  until  recently,  operation  has 
been  considered  the  last  resort,  hence  the  patients 
have  been  permitted  to  get  into  a  very  dreadful 
condition.  The  operation  required  for  cure  is 
always  one  of  severity,  hence  if  the  patient  can  be 
kept  in  a  fair  state  of  comfort  and  health  by 
palliative  treatment,  such  treatment  is  the  best. 
Whenever  hygienic  measures  and  the  proper  use 
of  the  catheter  fail  to  give  relief,  it  is  wrong  to 
waste  time;  the  patient  must  be  given  the  option  of  radical  treatment. 

Castration  or  orchidectomy  is  the  least  efficacious  method  of  treatment, 
and  having  a  high  rate  of  mortality  and  of  induced  insanity,  it  has  been  prac- 
tically discarded.  Vasectomy  possesses  any  advantages  which  may  pertain  to 
castration  and  is  much  less  dangerous.  It  has  no  efifect  on  fibrous  and  adeno- 
matous enlargement,  but  favorably  influences  congestive  conditions.  It  seems 
to  be  of  use  in  cases  of  "prostatismus"  where  the  symptoms  of  prostatic  hyper- 
trophy are  present,  but  there  is  no  residual  urine.  Wassiljew  ("Centralblatt 
f.  Chir.,"  1903,  No.  26)  thinks  the  benefits  derived  are  due  to  the  resulting 
lowering  of  the  tone  of  the  vesical  sphincter. 

The  main  objects  aimed  at  by  operations  on  the  prostate  are  (i)  removal 
of  the  cause  of  the  obstruction,  (2)  lowering  of  the  vesical  mouth  of  the  urethra 
so  that  the  bladder  may  empty  itself. 

The  most  surgical  means  of  attaining  the  above  objects  is  by  prostatectomy, 
either  suprapubic  or  perineal.     Both  of  these  methods  are  good  in  suitable 


Fig.  863.— Cautery. 
{De  Costa.) 


704  PERINEAL    SECTION 

cases.  Where  the  perineum  is  deep,  or  where  the  hypertrophy  is  mainly  intra- 
vesical, the  suprapubic  route  is  the  better.  Most  forms  of  hypertrophy  can  be 
removed  by  the  perineal  route,  and  this  route  gives  the  better  drainage. 
Suprapubic  prostatectomy,  is  the  favorite  with  most  surgeons.  Whichever 
method  is  chosen,  the  operation  is  one  of  severity  and  ought  not  to  be  under- 
taken when  renal  disease  is  present.  Prostatotomy,  whether  accomplished 
via  the  suprapubic  route  by  means  of  a  thermocautery  or  through  the  urethra, 
as  in  the  Bottini  operation,  attains  one  of  the  objects  of  radical  operation 
in  that  it  lowers  the  vesical  orifice  of  the  urethra.  The  suprapubic  method 
has  the  advantage  of  being  done  under  the  guidance  of  the  eye,  with  inexpensive 
instruments,  and  of  requiring  no  special  manual  training.  The  disadvantages 
are  the  necessary  suprapubic  cystotomy,  and  the  fact  that  the  resulting  scar 
in  the  prostate  is  thicker  and  clumsier  than  that  left  by  the  galvanocautery. 
The  Bottini  operation  has  been  thoroughly  tested  by  many  surgeons,  notably 
by  Horwitz  and  Willy  Meyer,  the  latter  having  operated  71  times  on  59  patients 
without  any  reference  to  the  character  of  the  lesion  or  the  presence  of  renal  or 
other  disease.  Out  of  the  59  cases  7  died,  but  the  death  was  the  direct  conse- 
quence of  the  operation  in  but  3. 

The  author  has  seen  one  case  in  which,  owing  to  some  unsuspected  flaw 
in  the  instrument  used,  the  urethra  was  severely  burned,  and  in  part  obliterated, 
while  the  prostate  itself  had  escaped  without  being  cauterized.  The  condi- 
tion of  the  prostate  was  demonstrated  during  a  subsequent  suprapubic  opera- 
tion done  by  J.  Block  to  establish  drainage.  The  original  operator  was  a 
surgeon  of  great  experience  in  this  class  of  work. 


CHAPTER  L 

PERINEAL  SECTION 
PERINEAL   CYSTOTOMY 

Perineal  cystotomy,  or  the  boutonniere  operation,  is  perhaps  the  simplest 
and  safest  method  of  opening  and  exploring  the  bladder.  As  a  method  of  ex- 
ploration it  is  defective  in  that  it  is  difficult  to  reach  all  parts  of  the  bladder 
with  the  finger,  especially  when  the  perineum  is  deep.  Ocular  inspection 
is  also  impossible.  As  a  therapeutic  agent  it  is  of  great  value  in  providing 
drainage  and  giving  rest,  not  merely  to  the  bladder,  but  to  the  urethra;  it  also 
permits  the  removal  of  small  calculi  and  neoplasms  from  the  bladder.  Perineal 
cystotomy  is  one  of  the  steps  in  certain  methods  of  perineal  prostatectomy. 

Preparation  of  the  Patient. — Thoroughly  evacuate  the  large  intestine  by 
means  of  irrigation.  Irrigate  the  bladder  and  partially  fill  it  with  warm  water 
or  boracic  acid  solution.  Shave  the  perineum.  Cleanse  the  perineum,  scrotum, 
penis,  and  hypogastric  region.  Place  the  patient  in  the  lithotomy  position 
with  the  buttocks  elevated  and  well  over  the  edge  of  the  table. 

The  Operation. — Step  i. — Pass  a  staff,  provided  with  a  median  groove  on 
its  convex  side,  into  the  bladder.  By  holding  the  handle  of  the  staff  close 
to  the  hypogastrium  force  its  curve   against    the   perineum,    which  is  thus 


CYSTOTOMY 


705 


made  prominent.  Intrust  the  staff  to  an  assistant,  who  holds  it  steadily 
and  accurately  in  place.  The  surgeon  now  sits  down,  facing  the  field  of 
operation. 

Step  2. — Protect  the  hand  with  a  rubber  glove  and,  per  rectum,  palpate 
the  prostate,  etc.  Having  done  this,  remove  the  glove.  With  the  fingers  of 
the  left  hand  steady  the  skin  of  the  perineum  and  make  a 
median  incision  from  a  point  posterior  to  the  scroto-perineal 
junction  to  within  one  inch  of  the  anus.  Keeping  strictly 
in  the  middle  line,  deepen  the  incision  until  the  urethral 
bulb  is  exposed.  Do  not  injure  this  structure.  Pull  the 
bulb  forwards  in  the  middle  line  and  continue  the  dissection 
behind  it  until  the  staff  can  be  felt  in  the  membranous 
urethra.  Open  the  urethra  on  the  staff,  and  freely  incise 
it  from  the  bulb  to  the  apex  of  the  prostate. 

Step  3. — Guided  by  the  groove  in  the  staff  pass  a 
curved  grooved  director  or  a  Teale's  gorget  (Fig.  864)  into 
the  bladder.  Remove  the  staff.  Along  the  director  or 
gorget  push  the  finger  into  the  bladder  with  a  boring 
motion.  This  forcibly  dilates  the  prostatic  urethra.  With 
the  finger  explore  for  calculi,  neoplasm,  enlarged  prostate, 
etc.  If  a  small  calculus  is  present,  remove  it  with  a  litho- 
tomy forceps  or  scoop.  If  a  small,  benign,  pedunculated 
neoplasm  presents,  remove  it  with  the  finger  or  by  crushing 
its  pedicle  with  forceps.  Be  careful  not  to  drag  forcibly 
on  the  tumor.  Sessile  or  large  tumors  are  better  attacked 
through  a  suprapubic  incision. 

Step  4. — Having  finished  the  exploration  or  the  active  operation,  introduce 
a  drainage-tube  approximately  equal  in  size  to  the  exploring  finger.  Watson's 
drainage-tube  is  excellent  (Fig.  865).  R.  Harrison  uses  a  large  rubber  catheter 
with  a  terminal  as  well  as  lateral  eye.  With  one  or  two  points  of  suture 
make  the  perineal  wound  hug  the  tube.  Fix  the  tube  in  place  with  a  safety- 
pin  or  tapes.     Test  the  patency  and  eflBiciency  of  the  drain  by  irrigating  the 

bladder  through  it.  The  end  of  the  tube  should 
reach,  but  not  penetrate  far  into,  the  bladder. 
Return  the  patient  to  bed,  the  upper 
end  of  which  ought  to  be  elevated  slightly. 
The  mattress  ought  to  be  firm  and  not  sag 
under  the  patient's  weight,  otherwise  drainage 
will  be  poor.  The  perineum  is  covered  by 
dressings  kept  in  place  by  a  T-bandage 
through  which  the  drainage-tube  emerges. 
It  is  easy  to  attach  to  the  drain  a  long  rubber  tube  which  conducts  the 
urine  to  any  convenient  receptacle.  After  two  or  three  days  the  drainage- 
tube  must  be  changed.  The  time  during  which  drainage  must  be  kept  up 
varies  according  to  the  operation  performed.  After  a  simple  lithotomy 
the  tube  should  be  removed  in   two  or  three  days  and  the  wound  allowed 


Fig. 


-Teale's 
gorget. 


Fig.  865. — Watson's  drain. 
{Stewart.) 


45 


7o6  PERINEAL    SECTION 

to  heal.  In  cases  of  cystitis  or  posterior  urethritis  drainage  ought  to  be 
kept  up  until  the  tissues  get  into  a  healthy  condition. 

If  in  Step  3  forcible  digital  dilatation  fails  to  give  a  sufficiency  of  room, 
median  prostatotomy  may  be  performed.  Using  the  finger  in  the  prostatic 
urethra  as  a  guide,  introduce  a  probe-pointed  knife  and  with  it  divide  the  pros- 
tate in  the  middle  line  posteriorly.  Bleeding  may  be  stopped  by  pressure 
from  a  snugly  fitting  Watson's  drain  or  by  packing  the  wound  with  gauze 
around  a  stiff  gum-elastic  drainage-tube.  Prostatotomy  performed  as  above 
is  an  integral  part  of  some  of  the  procedures  for  the  removal  of  enlarged  prostatic 
lobes. 

As  the  perineal  operations  for  the  removal  of  vesical  calculi  (lateral  lith- 
otomy, Wood's  operation,  etc.)  are  thoroughly  described  in  every  text-book  on 
general  surgery  ("American  Text-book;"  De  Costa;  Moullin;  Rose  and  Car- 
less;  Parkes,  etc.),  they  will  not  be  treated  of  here.  The  same  is  true  of  the 
operation  of  litholapaxy. 

PERINEAL  PROSTATECTOMY 

A  very  large  number  of  incisions  have  been  described  by  which  the  prostate 
may  be  exposed  in  the  perineum.  When  these  are  analyzed  they  resolve 
themselves  into  two,  each  of  which  may  be  modified  during  the  operation 
according  to  the  dictates  of  common  sense. 

Method  A :  Median  Incision. — The  earlier  steps  of  this  operation  are  iden- 
tical w'ith  those  of  median  perineal  cystotomy.  When  the  membranous  urethra 
is  opened  and  the  prostatic  urethra  dilated,  pass  into  the  bladder  a  suitable 
tractor,  and  with  it  pull  the  prostate  downwards  into  the  wound. 

Several  efficient  tractors  have  been  devised  for  this  purpose;  the  best  known  are  Parker 
Syms',  provided  with  a  dilatable  rubber  bulb;  Young's  (Figs.  866,  867),  having  separable 
metal  blades,  and  A.  H.  Ferguson's.  In  the  absence  of  a  special  instrument  any  good  stout 
metal  sound  answers  the  purpose. 

With  scissors  or  knife  incise  the  fibrous  sheath  of  the  prostate;  insinuate 
the  finger  between  the  sheath  and  the  gland  and  enucleate  the  latter.  Some 
times  the  prostate  comes  aw^ay  in  one  piece,  sometimes  in  two  or  more  frag- 
ments. Most  surgeons  begin  the  enucleation  in  the  left  lobe;  this  is  a  mere 
matter  of  convenience.  "Usually,  but  not  always,  the  floor  of  the  prostatic 
urethra  is  divided  when  the  middle  portion  is  being  taken  out;  but  the  author 
has  had  all  his  specimens  examined  by  the  microscope,  and  it  has  been  shown 
that  no  mucous  membrane  has  been  taken  away"  (except  in  one  case).  (Parker 
Syms,  "Brit.  Med.  Jour.,"  Nov.  8,  1902.)  Drain  the  bladder  by  a  perineal 
tube  (No.  36  Fr.)  fastened  to  the  upper  part  of  the  wound.  Pack  the  wound 
cavity  firmly  with  iodoform  gauze.  Attach  a  rubber  tube  to  the  drain  so  as 
to  conduct  the  urine  to  a  suitable  receptacle.  Wash  out  the  bladder  fre- 
quently through  the  drain.  Change  the  gauze  pack  after  the  lapse  of  twenty- 
four  hours,  lessening  the  amount  of  gauze  used.  Encourage  the  patient  to 
move  about  in  bed  and  to  sit  up  at  the  earliest  possible  moment.  This  is 
important.  Remove  the  drain  in  about  one  week.  After  the  drain  is  removed 
wash  out  the  bladder  at  intervals  by  means  of  a  catheter.     Occasionally  intro- 


PKOSTATECTUMY 


707 


duce  a  sound  to  maintain  the  urethra  patent.  In  operating  in  much  the  same 
manner  as  above  described,  H.  Young  divides  the  prostatic  capsule  external 
to  the  location  of  the  seminal  ducts,  and  believes  he  is  able  to  remove  a  suf- 
ficiency of  the  gland  without  destroying  these  structures.  That  portion  of 
the  prostate  subjacent  to  the  ejaculatory  ducts  is  not  involved  in  the  hyper- 
trophic process  and  hence  can  be  safely  left. 


Fig.  866. 
Figs.  866  and  867.- 


FiG.  867. 
-Young's  prostatic  tractor.     (Young.) 


Another  method  is  as  follows:  Expose  and  open  the  membranous  urethra 
as  above;  guided  by  the  finger  passed  through  the  prostatic  urethra  divide  the 
prostate  posteriorly  in  the  middle  line  with  a  probe-pointed  knife  (median 
prostatotomy).  Seize  the  edge  of  the  divided  capsule  in  forceps,  and  with 
the  finger  separate  the  capsule  from  the  gland  and  shell  out  the  latter  en  masse 
or  in  pieces.  As  the  enucleation  proceeds,  it  is  well  to  make  traction  on  the 
lobes,  which  are  being  removed,  by  means  of  claw-like  sharp  retractors.  George 
Gray,  after  dividing  the  prostate  as  above,  pushes  his  finger  into  the  bladder, 
insinuates  it  between 'the  prostate  and  the  vesical  mucosa  and  then  shells  out 
the  enlarged  lobes  from  above  downwards.  Through  the  urethral  wound  it  is 
easy  to  shell  out  the  middle  lobe  if  it  is  enlarged,  and  to  remove  any  vesical 
calculi;  Vhich  may  be  present.     In  cases  where  enucleation  with  the  finger  is 


708  PERINEAL    SECTION 

difficult  some  surgeons  extripate  by  morcellement,  cutting  the  gland  away 
piecemeal  with  scissors  or  rongeur  forceps;  when  this  is  done,  it  is  advised  to 
begin  the  extirpation  remote  from,  and  work  towards,  the  urethra. 

Method  B :  Transverse  Incision.- — Zuckerkandl  was  probably  the  first  to 
advocate  this  method  of  exposing  the  prostate.  The  whole  operation  has  been 
well  systematized  by  Albarran.  Very  many  operators  have  devised  various 
modifications  in  details,  using  incisions  of  divers  shapes,  H,  Y,  V,  etc.,  to  in- 
crease the  exposure  of  the  prostate.  Practically,  any  one  of  these  cuts  give 
as  good  results  as  any  other. 

Prepare  the  patient  as  already  d^cribed  and  place  him  in  the  lithotomy 
position  with  the  pelvis  well  elevated.  This  posture,  a  combination  of  the 
Trendelenburg  and  lithotomy  positions,  is  of  very  great  service,  being  almost 
essential.  Introduce  a  sound  or  staff  into  the  bladder  and  entrust  its  handle 
to  an  assistant. 

Step  I. — One  fingerbreadth  in  front  of  the  anus  make  a  slightly  curved 
(concavity  posterior)  transverse  incision  through  the  skin  and  subcutaneous 
tissue,  from  one  ischial  tuberosity  to  the  other. 

Siep  2. — Guided  by  the  sound  in  the  urethra  expose  its  membranous  por- 
tion and  bulb.  Catch  the  tissues  on  each  side  of  the  bulb  with  voleella  for- 
ceps and  so  pull  the  bulb  upwards  out  of  the  way  and  at  the  same  time  steady 
the  perineum.  Do  not  open  the  urethra.  Introduce  a  finger  of  the  left  hand 
(protected  by  a  rubber  glove)  into  the  rectum,  and  with  the  right  hand  separate 
the  rectum  from  its  anterior  connections — i.e.,  from  the  prostate.  This  may 
be  done  by  blunt  dissection,  aided  by  an  occasional  cut  with  scissors.  If  the 
surgeon  keeps  close  to  the  prostate,  this  step  is  easy.  The  finger  in  the  rec- 
tum saves  injury  to  that  structure.  Introduce  a  broad,  flat,  long-bladed 
retractor  into  the  wound  and  pull  the  rectum  and  posterior  surface  of  the 
wound  backwards,  exactly  as  the  vagina  is  retracted  in  operations  on  the  cer- 
vix uteri. 

Step  3. — Make  the  assistant  turn  the  beak  of  the  sound  backwards  so  as 
to  lie  behind  the  middle  lobe  of  the  prostate  and  pull  it  down  into  the  wound 
as  much  as  possible.  Instead  of  a  sound  Young's  (Figs.  866  and  867)  or  Fer- 
guson's prostatic  tractor  may  be  used.     The  prostate  now  lies  exposed. 

Step  4. — Split  the  prostatic  capsule  by  a  transverse  or  vertical  incision  as 
may  be  convenient.  If  it  is  desired  to  save  that  portion  of  prostate  correspond- 
ing to  the  urethral  floor,  make  a  longitudinal  cut  on  each  side  through  the  cap- 
sule. Seize  the  edges  of  the  wound  in  the  capsule  with  forceps  and  with  the 
finger  insinuated  beneath  the  capsule  enucleate  the  gland.  As  the  enuclea- 
tion proceeds  pull  on  the  part  being  removed  with  claw-shaped  retractors.  If 
the  urethra  is  accidentally  torn,  the  middle  lobe  when  enlarged  can  be  easily 
reached  and  enucleated  with  the  finger.  The  accident  to  the  urethra  does  not 
seem  to  be  of  much  moment.  If  the  urethra  is  not  opened  and  a  projecting 
middle  lobe  is  present,  it  can  be  reached  and  removed  with  the  finger  through 
the  prostatic  wound. 

Step  5. — Partially  close  the  deep  wound  with  sutures.  Introduce  a  drain 
into  the  bladder  and  firmly  pack  the  wound  with  iodoform  gauze. 

It  will  be  seen  that,  except  in  the  matter  of  exposure,  the  operation  by 


CANCER    PROSTATE  709 

transverse  incision  is  almost  identical  with  that  by  median.  Undoubtedly 
by  the  transverse  method  a  much  better  exposure  of  the  field  of  operation  is 
obtained,  at  the  expense  of  a  little  more  trauma,  but  most  of  the  actual  work 
is  done  by  the  finger  unguided  by  the  eye,  hence  the  improved  exposure  is  not 
of  so  much  value  as  might  appear  at  first  glance. 

All  the  operations  here  described  are  carried  out  inside  the  capsule;  extra- 
capsular operations  have  been  devised  and  described,  but  they  occasion  so 
much  shock  and  hemorrhage  that  they  are  unsuited  to  the  extirpation  of  benign 
neoplasms.  While  none  of  the  methods  described  can  be  truly  named  complete 
prostatectomies,  yet  they  approach  so  nearly  to  completeness  that  they  may  be 
termed  so  for  the  sake  of  convenience  and  to  distinguish  them  from  the  next 
class  of  operations,  which  are  frankly  incomplete.  Rydygier,  Riedel,  and 
others  frequently  expose  the  prostate  by  the  transverse  incision  and  content 
themselves  with  excising  portions  of  the  lateral  lobes,  opening  neither  the  ure- 
thra nor  the  bladder.  The  result  of  taking  away  such  portions  of  the  prostate 
is  that  pressure  is  removed  from  the  prostatic  urethra,  and  as  the  wounds 
heal  and  contract,  the  urethral  lumen  is  widened.  The  method  is  less  severe 
than  the  more  complete  operations  and  has  given  good  results  even  in  cases 
in  which  the  middle  lobe  has  been  enlarged.  Of  course,  the  operation  is  meant 
primarily  for  cases  of  hypertrophy  of  the  lateral  lobes  and  it  has  a  distinct 
field  of  usefulness. 

Radical  Prostatectomy  for  Cancer. — Young  has  described  a  method  of  re- 
moving the  prostate  for  cancer  (''Johns  Hopkins  Bulletin,"  Oct.,  1905;  "Annals 
Surg.,"  Dec,  1909)  which  he  carried  out  in  six  cases.  One  of  the  patients  was 
alive  and  well  four  and  a  half  years  and  another  six  months  after  the  opera- 
tion. The  operation  is  only  suited  to  cases  in  which  the  disease  is  well  limited 
to  the  prostate  or  at  least  does  not  extend  more  than  a  short  distance  beneath 
the  trigone. 

The  Operation. — Steps  i,  2  and  3. — Place  the  patient  in  the  exaggerated 
lithotomy  position.  Expose  the  membranous  urethra  and  prostate  by  an 
inverted  V-incision.  Proceed  as  in  prostatectomy  by  the  transverse  incision 
(Method  B,  Steps  i,  2,  3,  p.  708)  until  the  prostatic  tractor  is  put  in  place 
and  the  posterior  surface  of  the  prostate  has  been  exposed,  largely  by  blunt 
dissection.  If  there  is  any  doubt  as  to  diagnosis,  incise  the  capsule  and  remove 
a  segment  of  gland  for  immediate  microscopic  examination. 

Step  4. — Free  the  lateral  adhesions  of  the  prostate  and  also  the  seminal 
vesicles  as  much  as  possible  by  blunt  dissection.  Divide  the  membranous 
urethra  in  front  of  the  tractor. 

Step  5.^ — Depress  the  handle  of  the  tractor  markedly  and  divide  the  pubo- 
prostatic ligaments  close  to  the  prostate  after  pushing  away  the  anterior  plexus 
of  veins.  Hemorrhage  must  be  controlled  by  clamps  and  by  a  gauze  pack 
held  tightly  against  the  posterior  surface  of  the  pubes  and  the  triangular  liga- 
ment by  means  of  a  retractor.  At  this  time  the  seminal  vesicles  may  be  further 
freed. 

Step  6. — -Pull  the  prostate  as  far  as  possible  out  of  the  wound,  thus  exposing 
the  anterior  wall  of  the  bladder.  Open  the  bladder  by  a  transverse  incision 
close  to  its  junction  with  the  prostate'.     Enlarge  the  incision  until  the  trigone  is 


710 


PERINEAL   SECTION 


Fig.  868. — Prostatectomy  for  cancer.     {Voung,  Annals  of  Surg.) 


Fig.  869. — Prostatectomy  for  cancer.     (Young,  Annals  of  Surg.) 


MCKILLOP  S    OPERATION  71I 

well  exposed.  (Fig.  868.)  With  a  scalpel  continue  the  transverse  cut 
in  ^  the  bladder  across  the  trigone,  leaving  the  upper  angles  of  the  trigone  in- 
tact and  the  ureters  uninjured.  By  blunt  dissection  through  the  wound  in 
the  bladder  complete  the  exposure  of  the  seminal  vesicles,  pick  up  the  vasa 
deferentia  and  divide  them  as  high  as  possible.  Remember  that  the  vasa 
deferentia  pass  around  the  lower  end  of  the  ureters  which  must  not  be 
injured. 

Step  7. — Separate  the  deep  attachments  of  the  seminal  vesicles,  controlling 
the  resulting  bleeding  by  clamps  and  ligatures.  Remove  the  prostate,  seminal 
vesicles,  and  about  5  cm.  of  the  vasa  deferentia  in  one  piece. 

Step  8.— Pull  the  anterior  wall  of  the  bladder  down  and  form  an  anasto- 
mosis between  the  anterior  part  of  the  bladder  wound  and  the  divided  mem- 
branous urethra,  using  catgut  for  sutures.  (Fig.  869.)  Close  the  rest  of  the 
vesical  wound  by  catgut  sutures.  Introduce  through  the  penis  a  retention 
catheter. 

Step  g. — ^Approximate  the  levator  ani  muscles  with  catgut  sutures.  Par- 
tially close  the  skin  wound  after  providing  for  drainage. 

McKillop's  Operation  (Med.  Journ.  of  Australia,  Jan.  18,  1919).  Step  i. — 
Distend  the  bladder  with  Boracic  lotion  (6  or  8  oz.).  Leave  the  catheter  in 
position.  Make  a  median  incision  from  the  pubis  upwards  for  2  to  3  in.  Push 
the  peritoneal  reflection  upwards.  With  gauze  clear  the  space  of  Retzius  until 
the  muscle  wall  of  the  bladder  is  exposed.  Pack  the  space  of  Retzius  firmly 
with  gauze  so  as  to  push  the  bladder  well  down  toward  the  perineum.  With 
sutures  close  the  wound  completely  over  the  gauze  pack. 

Step  2. — Place  the  patient  in  the  lithotomy  posture.  Make  the  usual  trans- 
verse perineal  incision  until  the  perineal  muscles  are  exposed.  Open  the  plane 
of  cleavage  between  the  rectum  and  prostate  which  lies  low  because  of  the  pres- 
sure in  the  space  of  Retzius.  Expose  the  false  or  fascial  capsule  of  the  prostate 
and  dissect  externally  to  the  capsule.  Pressure  over  the  hypogastric  pack 
brings  the  prostate  almost  flush  with  the  perineum  so  that  bleeding  can  be 
controlled  under  guidance  of  the  eye.  Divide  the  pubo-prostatic  and  true 
lateral  ligaments  of  the  bladder.  Hook  the  finger  above  the  fascial  capsule 
and  separate  the  gland  from  the  base  of  the  bladder  external  to  the  internal 
sphincter. 

Step  3. — Excise  the  prostate  and  its  fascial  capsule  by  cutting  it  from  the 
bladder  (the  line  of  section  being  in  bladder  tissue)  and  by  dividing  the  vasa 
deferentia  and  the  membranous  urethra  with  its  contained  catheter. 

Step  4. — Introduce  a  fresh  catheter.  Attend  to  hemostasis.  Close  the 
redundant  bladder  wound  with  catgut  sutures  which  must  not  penetrate  the 
mucosa. 

Introduce  a  gauze  drain  covered  by  a  split  rubber  tube  to  the  bladder  wound 
and  pack  iodoform  gauze  around  this  firmly.  Suture  the  lateral  portions  of  the 
perineal  wound. 

Step  5. — Reopen  the  suprapubic  wound;  remove  the  gauze  pack  and  close 
the  wound  again  after  providing  for  drainage. 

AJter  treatment. — Change  the  perineal  pack  after  48  hours.     Remove  the 


712  PERINEAL    SECTION 

split  tube  on  the  fourth  (hi\ .  Change  the  catheter  daily  after  the  first  week. 
Later  pass  sounds. 

McKillop  writes  the  author  that  his  four  jjatients  survived  of)eralion  and 
that  one  was  alive  four  years  and  one  two  years  after  oiJtration,  both  having 
a  fair  degree  of  urinary  control. 

Diverticula  of  Urinary  Bladder. — The  method  of  operating  varies  with  the 
site  of  the  diverticulum. 

1.  The  diverticulum  is  situated  on  the  anterior  surface  or  the  side  of  the 
bladder.  Expose  the  bladder  through  a  transverse  or  a  median  incision.  Do 
not  open  the  peritoneum  but  push  it  aside  until  the  diverticulum  is  exposed. 
Excise  the  diverticulum  and  treat  the  wound  in  the  bladder  as  described  on 
p.  68i. 

2.  The  diverticulum  is  on  the  dome  of  the  bladder  and  cannot  be  exposed 
extra-peritoneally  Open  the  abdomen.  Protect  the  peritoneal  cavity  thor- 
oughly with  pads.  Excise  the  diverticulum.  Close  the  vesical  wound  and 
provide  for  drainage  as  described  on  p.  692.  As  the  diverticulum  is  always 
the  seat  of  severe  infection  it  might  possibly  be  better  to  operate  in  two  stages: 
(a)  bringing  the  diverticulum  and  part  of  the  vesical  wall  into  the  abdominal 
wound  and  suturing  the  parietal  peritoneum  to  the  bladder  around  the  diver- 
ticulum; (b)  after  the  peritoneum  has  become  protected  by  adhesion,  excising 
the  diverticulum  and  closing  the  vesical  wound. 

3.  The  diverticulum  arises  from  the  posterior  wall  of  the  bladder  and  lies 
between  the  bladder  and  rectum. 

Graser  (Kreuter,  Zent.  f.  Chir.,  Nov.  8,  1913,  p.  1740)  operates  as  follows: 

Step  I. — Drain  and  explore  the  bladder  suprapubically.  With  a  sound  in 
the  diverticulum  and  a  finger  in  the  rectum  the  size  and  location  of  the  lesion 
is  easily  defined. 

Step  2. — Place  the  patient  in  the  combined  Trendelenburg  and  lithotomy 
position.  Make  a  curved  transverse  incision  (concavity  posterior)  from  one 
ischial  tuberosity  to  the  other.  Guided  by  a  sound  in  the  urethra,  expose  the 
membranous  urethra  and  the  prostate.  A  finger  in  the  rectum  is  an  essential 
aid  in  orientation.  Separate  the  rectum  from  the  prostate  and  bladder  until 
the  diverticulum  is  reached.  Because  of  past  and  present  inflammation  the 
diverticulum  is  firmly  adherent  to  its  surroundings.  Remove  the  finger  from 
the  rectum  and  change  gloves.  Open  the  diverticulum.  With  a  finger  in  the 
diverticulum  as  a  guide,  separate  it  from  its  surroundings  by  blunt  and  sharp 
dissection,  pushing  the  peritoneum  out  of  the  way. 

Step  3.- — Excise  the  diverticulum  and  invert  its  stump  into  the  bladder  by 
means  of  stitches,  being  careful  not  to  injure  or  occlude  the  ureter. 

Step  4. — Thoroughly  drain  the  perineal  wound.  Provide  for  suprapubic 
drainage. 

INFRAPUBIC   PROSTATOTOMY  AND    CYSTOTOMY 

The  prostate  and  lower  part  of  the  bladder  may  be  exposed  immediately 
under  the  pubic  arch.  This  route  avoids  the  neighborhood  of  the  anus,  with 
its  ever  present  infection,  while  it  gives  more  direct  access  to  the  prostate  and 


VESICULOTOMY  713 

better  drainage  than  does  the  suprapubic  route.  If  the  patient  is  feeble,  the 
operation  may  be  done  in  two  sittings,  the  first  consisting  of  the  exposure  of 
the  prostate,  the  second  of  the  prostatotomy  or  prostatectomy.  (L.  Heusner, 
"  Centralblatt  f.  Chir.,"  1904,  p.  217.) 

Step  I. — Make  a  curved  incision  through  the  skin  along  the  lower  margin 
of  the  pubis  and  its  descending  rami. 

Step  2. — Divide  the  insertion  of  the  suspensory  ligament  of  the  penis,  the 
corpora  cavernosa;  the  ischio-cavernosus  muscle,  the  triangular  ligament,  and 
part  of  the  insertion  of  the  adductor  muscles.  With  a  chisel  or  rongeur  forceps 
cut  away  about  half  of  the  symphysis  pubis  and  of  the  descending  rami.  Sepa- 
rate the  prostate  from  the  posterior  surface  of  the  pubes.  When  this  is  done, 
it  is  easy  to  pull  the  prostate  downwards  and  expose  its  whole  anterior  surface. 
Bleeding  from  the  plexus  of  veins  anterior  to  the  prostate  is  liable  to  be  con- 
siderable. If  this  cannot  be  sufficiently  controlled  to  permit  of  further  progress, 
or  if,  as  in  Heusner's  case,  the  patient  is  too  weak,  it  is  easy  to  pack  the  wound 
and  resume  the  operation  after  the  lapse  of  a  few  days. 

Step  3. — Pass  a  sound  into  the  bladder  per  iirethram.  Using  the  sound  as  a 
guide,  split  the  prostatic  urethra -through  its  whole  extent  along  its  anterior 
or  ventral  surface.     This  exposes  the  prostate  exactly  as  in  a  postmortem. 

Step  4. — Remove  all  obstructing  lobes  exactly  as  is  done  when  other  methods 
of  exposure  are  employed.  If  it  is  desired  to  open  the  bladder  instead  of  the 
prostate,  this  is  easily  accomplished  by  the  removal  of  more  bone  from  the 
pubis.  The  operation  is,  however,  much  more  suitable  for  prostatic  than  for 
vesicular  disease. 

Step  5. — Close  the  wound  in  the  prostate  with  a  few  catgut  sutures.  Pro- 
vide for  drainage.     Close  the  skin-wound. 

Vesiculotomy. — Vesiculectomy  has  been  performed  a  number  of  times  but 
the  results  have  not  been  encouraging  and  the  operation  will  not  be  described 
here.  The  chronicity  of  many  urethral  infections  is  often  due  to  involvement 
of  the  seminal  vesicles,  and  for  the  treatment  of  these  lesions  Eugene  Fuller  has 
advised  emptying  the  vesicles  by  stripping  them  with  the  finger  introduced 
per  rectum.  This  treatment  must  necessarily  be  kept  up  for  months.  The 
same  surgeon,  in  inveterate  cases,  advises  drainage  of  the  vesicles  by  means  of 
vesiculotomy.  In  view  of  the  importance  of  obscure  infections  in  the  etiology 
of  the  so-called  rheumatisms,  etc.,  the  subject  of  vesiculotomy  has  become  one 
of  distinct  moment,  though  the  operation  can  scarcely  be  expected  to  become 
as  fashionable  as  has  the  removal  of  adenoids  and  of  more  or  less  innocent 
tonsils  in  the  treatment  of  rheumatism. 

Fuller^ s  Vesiculotomy  (N.  Y.  Med.  Record,  Oct.  30,  1909). — Thoroughly 
empty  the  large  bowel  by  means  of  purgatives  and  enemata.  Place  the  patient 
in  the  knee  chest  position,  the  hips  being  well  flexed  and  abducted,  the  knees 
being  flexed.  The  services  of  two  attendants  are  requisite  to  keep  the  patient 
in  correct  position. 

Step  I. — Beginning  at  a  point  near  the  base  of  the  coccyx,  and  just  inside 
the  body  of  the  ischium,  make  an  incision  past  the  tuber  ischii  to  end  at  a  point 
about  ^  inch  external  and  about  ^^  inch  anterior  to  the  anterior  border  of 


7'4 


PERINEAL   SECTION 


the  anus.     Make  a  similar  incision  on  the  opposite  side.     Unite  these  two  in- 
cisions by  a  transverse  cut  crossing  the  perineum  (Fig.  870). 

Step  2. — Through  the  lateral  incisions  divide  a  few  of  the  lower  fibres  of  the 
gluteus  maximus  muscles  and  penetrate  the  fat  of  the  ischio-rectal  spaces. 
Through  the  transverse  cut  divide  the  anterior  layer  of  the  deep  fascia  but 
carefully  avoid  injuring  the  anal  sphincter. 

Step  3.- — With  the  forefinger  of  the  left  hand  in  the  rectum  as  a  guide  sepa- 
rate the  rectum  from  the  prostate  and  seminal  vesicles  by  means  of  blunt 
dissection  with  the  right  forefinger.     "All  the  while  the  right  forefinger  tip  is 

peeling  the  rectal  wall  off  from  the  lower  structures, 
the  left  forefinger  tip  maintains  its  position  in  the 
rectum,  guiding,  as  it  were,  the  lower  finger  in  its 
work  and  preventing  it  from  directing  the  dissec- 
tion pressure  against  the  rectal  wall,  thus  endanger- 
ing perforation.  As  the  rectal  wall  only  separates 
these  two  fingers,  it  is  easy  to  appreciate  the  dis- 
tinctness with  which  the  left  finger  tip  can  feel  the 
right  as  it  accemplishes  its  work  of  separation. 
The  rectal  wall  having  been  thus  separated  from 
the  seminal  vesicles  the  left  forefinger  is  withdrawn, 
from  the  rectum  while  the  tip  of  the  right  fore- 
finger is  maintained  in  the  dissection  and  made  to 
press  gently  but  firmly  over  the  apex  of  the  right 
seminal  vesicle.  A  long,  grooved  director  is  next  passed  by  the  free  left  hand 
along  and  under  the  right  forefinger  until  the  end  of  the  instrument  reaches 
the  apex  of  the  right  seminal  vesicle  and  lies  just  under  the  right  finger  tip. 
The  left  hand  then  holds  the  director  firmly  in  that  position,  while  the  right 
forefinger  is  withdrawn.  The  right  hand  then  takes  a  scalpel,  the  blade  of 
which  is  passed  along  the  groove  of  the  director  until  the  point  of  the  knife 
enters  the  apex  of  the  seminal  vesicle.  After  the  point  has  so  entered,  the 
shaft  of  the  scalpel  is  lowered  and  a  free  cut  of  about  13-4  to  i)-^  inches  is  made 
with  the  belly  of  the  blade  along  the  course  of  the  seminal  vesicle,  freely  laying 
open  the  cavity  of  the  organ.  This  cut  is  made  with  the  belly  of  the  blade 
rather  than  with  the  point  of  the  scalpel,  for  if  made  with  the  point  the  incision 
might  be  accidentally  too  deep,  the  floor  of  the  bladder  being  opened.  The 
incision  so  made  is  then  divulsed  with  the  finger  tip,  thus  widely  opening  the 
sac  cavity.  By  an 'exactly  similar  procedure  the  cavity  of  the  left  seminal  vesi- 
cle is  next  opened.  The  cavities  thus  opened  can  be  exposed  with  the  finger 
tip  and,  if  found  filled  with  granulation  tissue,  curettage  can  be  employed. 
Oftentimes  the  finger  nail  may  be  most  efficient  for  this  purpose,  although,  in 
advanced  instances,  a  sharp  steel  instrument  may  be  necessary.  Seminal  ve- 
siculotomy is  not  a  bloody  operation,  no  vessels,  as  a  rule,  of  sufficient  size  to 
require  a  ligature  being  encountered.  The  cavities  of  the  seminal  vesicles 
so  opened  are  each  separately  packed  with  gauze,  the  end  of  each  packing 
being  left  protruding  from  the  external  wound.  Two  soft  rubber  drainage  tubes 
are  then  placed  between  the  gauze  packing  and  the  rectal  wall.  The  lateral 
edges  of  the  incision  are  next  brought  into  natural  apposition  by  sutures,  the 


INTERNAL    URETHROTOMY  715 

transverse  portion  of  the  cut  only  being  left  open  for  the  ends  of  the  drainage 
tubes  and  the  gauze  packing.  In  the  after-treatment  no  irrigation  into  the 
ends  of  the  tubes  is  advisable.  The  gauze  is  removed  at  the  end  of  the  fifth 
day;  the  drainage  tubes  at  the  end  of  the  ninth  or  tenth  day.  The  bowels  are 
moved  daily,  to  guard  against  rectal  fecal  distention.  In  some  cases  urinary 
retention  follows  operation;  consequently,  the  surgeon  should  be  prepared  to 
have  a  soft  catheter  passed  if  necessary.  There  is  generally  little  systemic 
disturbance  after  this  operation.  A  bulky  gauze  dressing  held  in  position 
by  a  T  bandage  is  the  form  of  external  dressing  employed.  The  operation 
generally  necessitates  a  stay  in  a  hospital  of  three  weeks,  the  first  two  weeks 
being  in  bed." 


CHAPTER  LI 
URETHRAL   STRICTURE 

Meatotomy. — As  a  preliminary  to  the  introduction  of  urethral  sounds  it 
is  often  necessary  to  enlarge  the  meatus. 

Introduce  a  probe-pointed  knife  into  the  urethra  for  a  distance  of  about  % 
inch,  i.e.,  to  a  point  immediately  behind  the  meatal  narrowing.  Cut  in  the 
middle  line  below,  but  do  not  cut  completely  through  to  the  external  surface, 
otherwise  a  hypospadias  will  be  produced.  The  after-treatment  consists  in 
keeping  the  wound  open  by  passing  a  sound  or  a  glass  rod  at  frequent  intervals. 

Internal  Urethrotomy. — Preparation  of  Patient. — Somtimes  it  is  wise  to  pre- 
pare the  patient  by  administering  urotropin  or  its  equivalent  for  a  day  to  two 
before  operation.  Immediately  before  operating  wash  the  penis  and  especially 
the  glans  with  soap  and  water,  cover  the  thighs  and  abdomen  with  sterile 
towels,  irrigate  the  urethra  (and  if  possible,  the  bladder)  with  a  mild  antiseptic 
solution  or  with  warm  salt  solution.  Inject  into  the  urethra  a  drachm  or  two 
of  sterile  olive  oil  and  immediately  proceed  to  operate. 

There  are  two  types  of  operation:  (A)  in  which  the  stricture  is  divided 
from  before  backwards;  (B)  in  which  the  division  is  from  behind  forwards. 
The  latter  method  presupposes  that  the  stricture  is  not  a  narrow  one  or  that 
it  has  been  already  dilated  sufficiently  to  admit  the  passage  of  the  urethrotome. 
Of  the  two  types  of  operation  there  are  many  varieties,  but  only  the  typical 
procedures  will  be  described  here.  The  number  and  varieties  of  urethro- 
tomes are  legion.  Their  description  would  take  up  much  space  and  serve  no 
useful  purpose. 

A.  Division  of  the  Stricture  from  Before  Backwards. — Prepare  the  patient 
as  above.  Determine,  if  possible,  the  site  and  extent  of  the  stricture  or  stric- 
tures by  means  of  a  bougie  a  boule.  Introduce  through  the  stricture  a  soft 
filiform  bougie  the  proximal  end  of  which  is  fitted  with  a  screw.  Screw  the 
distal  end  of  a  Maisonneuve  urethrotome  (Fig.  871)  to  the  filiform  guide. 
Push  the  urethrotome  along  the  urethra,  the  knife  blade  being  in  contact  with 
the  middle  of  the  roof  of  the  urethra.  The  knife  blade  being  blunt  at  its  apex 
cannot  cut  the  normal  urethra,  but  its  distal  edge  being  sharp  cuts  the  stric- 


7i6 


URETHRAL    STRICTURE 


ture  when  it  comes  against  it.  Having  divided  one  stricture,  remove  the 
urethrotome  and  explore  the  whole  urethra  so  as  to  find  if  other  stenoses  are 
present.     The  urethra  should  now  admit  a  full-sized  sound. 

B.  Oiis'  Operation:  Division  of  the  Stricture  from  Behind  Forwards. — Prepara- 
tion and  exploration  of  the  urethra  as  already  described.  Introduce  an  Otis' 
urethrotome  (Fig.  872)  through  the  stricture.  By  means  of  the  screw  at  the 
proximal  end  separate  the  blades  of  the  instrument  until  the  tissues  of  the 
stricture  are  put  on  the  stretch  but  not  torn.     Up  to  this  time  a  knife  blade 


Fig.  871. — Maisonneuve  urethrotome.       Fig.  872. — Otis  urethrotome. 

lies  concealed  at  the  distal  end  of  the  urethrotome.  By  using  the  proper 
mechanism,  make  the  knife  blade  protrude  and  cut  through  the  stricture  in 
the  middle  line  above.  Sheath  the  knife  blade  again.  Complete  the  dila- 
tation of  the  stricture  by  separating  the  blades  of  the  urethrotome  until  the 
urethra  is  large  enough  to  admit  a  full-sized  sound.  Remove  the  urethrotome. 
Explore  for  the  presence  of  other  strictures. 

Complications  and  Dangers  of  Internal  Urethrotomy. — i.  Hemorrhage.  B>- 
cutting  in  the  middle  line  above,  the  least  vascular  region  is  incised.  The 
stricture  itself  is  sclerosed,  non-vascular  fibrous  tissue,  hence  severe  bleed- 


EXTERNAL    URETHROTOMY  717 

ing  is  not  common.  When  serious  bleeding  arises  it  may  be  controlled  by 
the  passage  of  a  full-sized  catheter,  and  if  necessary  by  exercising  pressure 
from  the  outside  on  the  urethra  which  is  now  supported  by  the  catheter. 

2.  Urethral  Fever. — This  is  usually  a  form  of  septic  intoxication  due  to 
the  absorption  through  the  urethrotomy  wound  of  septic  products  already 
existing  in  the  urethra  or  being  discharged  with  the  urine.  Septicemia  or 
pyemia  are  rare.  Methods  of  avoiding  urethral  fever:  {a)  Preliminary  exhibi- 
tion of  substances  {e.g.,  urotropin)  calculated  to  improve  the  condition  of  the 
urine,  (b)  Rigid  asepsis,  (c)  Konig  advises  to  irrigate  the  bladder  with  a 
mild  antiseptic  solution  as  soon  as  the  operation  is  completed  and  to  leave  in 
the  bladder  a  few  ounces  of  the  solution.  This  dilutes  and  favorably  affects 
the  urine  so  that  noxious  substances  are  not  absorbed  from  it  when  it  is  next 
voided. 

Irrigation  of  the  urethra  during  convalescence  is  rarely  necessary. 

After-treatment. — The  patient  ought  to  be  kept  in  bed  for  a  few  days.  If 
there  is  retention  of  urine  a  soft  rubber  catheter  must  be  passed.  Cathe- 
terization may  often  be  voided  by  applying  moist  heat  to  the  perineum  and 
h)^ogastrium,  or  by  placing  the  patient  in  a  hot  bath  with  instructions  to 
urinate  in  the  water,  if  he  can. 

After  a  lapse  of  five  to  seven  days  pass  a  full-sized  sound  into  the  bladder. 
Before  this  can  be  done  successfully  it  may  be  necessary  to  pass  a  number  of 
smaller  instruments  of  increasing  size.  Repeat  the  passage  of  sounds  at  inter- 
vals of  two  or  three  days.  The  daily  passage  of  sounds  irritates  and  is  useless. 
The  interval  is  to  be  gradually  increased  until  a  cure  or  practical  cure  is  obtained. 

External  Urethrotomy. — Prepare  the  patient  as  for  internal  urethrotomy. 
In  addition  scrub  and  shave  the  perineum.  Clean  the  scrotum  and  the  adja- 
cent portions  of  the  buttocks  and  thighs.  Explore  the  urethra  and  locate 
the  stricture.     Put  the  patient  in  the  lithotomy  position. 


Fig.  873.— Syme's  staff. 

A.  Operation  with  a  Guide. — Various  instruments  may  be  used  as  guides 
The  best  is  probably  the  Syme's  staff  (Fig.  873).  Filiform  whalebone  bougies 
serve  the  purpose  well  and  are  more  commonly  obtainable. 

Step  I. — Pass  the  guide  into  the  bladder.  If  Syme's  instrument  is  used 
the  thin  portion  passes  through  the  stricture,  the  thick  portion  serves  as  a  guide 
to  the  urethra  on  the  meatal  side  of  the  stricture.  If  the  whalebone  filiform 
is  used,  pass  alongside  it  or  looped  on  it  (like  Gouley's  sounds)  a  large  metal 
sound  down  to  the  face  of  the  stricture.  Let  an  assistant  hold  the  sound 
steadily  in  the  middle  line  of  the  body  and  make  its  point  press  towards  the 
skin  of  the  perineum.     Retract  the  scrotum  upwards. 

Step  2. — Palpate  the  perineum  and  feel  the  point  of  the  sound.     In  the 


7l8  URETHRAL    STRICTURE 

middle  line  make  an  incision  down  to  the  point  of  the  sound.  This  opens  the 
urethra  immediately  anterior  to  the  stricture.  Retract  the  edges  of  the  ure- 
thral wound  with  sharp  hooks,  fine  volsella?,  or  with  a  couple  of  fine  sutures 
introduced  for  the  purpose.  Withdraw  the  metal  sound.  If  Syme's  guide 
is  used  leave  it  in  situ. 

Step  3. — If  possible  pass  a  fine  grooved  director  along  the  guide  and  with 
a  knife  split  the  stricture  completely.  If  it  is  impossible  to  introduce  a  grooved 
director  cut  down  upon  the  guide  from  in  front  backwards  until  the  whole 
stricture  is  divided.  It  is  convenient  at  this  stage  to  pass  through  the  perineal 
wound  a  probe-pointed  Teale's  gorget  (Fig.  874)  into  the  urethra  posterior 
to  the  stricture.  The  gorget  acts  as  a  guide  to  the  full-sized  sound  or  catheter 
which  must  now  be  passed  through  the  urethra  into  the  bladder.  The  use  of 
the  gorget  is  not  necessary. 

There  are  many  modifications  of  the  above  operation,  most  of  them  requir- 
ing special  instruments.  For  a  description  of  such  see  treatises  on  genito- 
urinary surgery.     The  operation  as  described  has  served  the  author  well. 


874. — Teale's  gorget. 


B.  Operation  Without  a  Guide. — Prepare  as  described  above. 

Step  I. — Pass  a  metal  sound  down  to  the  face  of  the  stricture.  Have  it 
held  by  an  assistant  accurately  and  steadily  in  the  middle  line. 

Step  2. — Incise  the  perineum,  expose  the  sound,  and  retract  the  edges  of 
the  urethral  wound  as  in  the  preceding  operation.     Remove  the  sound. 

Step  3. — Examine  carefully  the  face  of  the  stricture  with  the  eye  and  a 
fine  probe  for  an  opening  through  it.  Remember  that  the  opening  may  be 
in  any  position  on  the  face  of  the  stricture.  The  search  may  be  aided  by 
making  a  little  pressure  on  the  hypogastrium,  and  so  forcing  some  urine  along 
the  urethra  and  out  through  the  stricture,  where  its  point  of  emergence  should 
be  noted.  If  it  is  possible  to  find  the  passage  through  the  stricture  and  to 
introduce  a  probe  the  operation  becomes  identical  with  that  in  which  a  guide 
is  used.     If  the  introduction  of  a  probe  is  impossible  proceed  as  follows: 

Incise  the  stricture  longitudinally  exactly  in  the  middle  line  until  the  healthy 
urethra  is  reached  posterior  to  the  stricture.  If  this  is  not  promptly  accom- 
plished, do  not  waste  time  and  lacerate  the  tissues  by  making  more  incisions 
in  the  stricture  tissues,  but  boldly  endeavor  to  incise  the  urethra  posterior  to 
the  stricture,  always  cutting  in  the  middle  line.  When  the  urethra  is  opened 
at  this  point  it  is  easy  to  cut  through  the  stricture  and  pass  a  sound  from  the 
meatus  past  the  perineal  wound  into  the  bladder.  If  the  posterior  urethra 
is  not  easily  found  during  the  above  procedure  do  not  spend  much  time  looking 
for  it,  as  such  a  search  may  do  much  damage.     Open  the  bladder  above  the 


URETHRECTOMY  7 I 9 

pubis  and  pass  a  sound  through  the  bladder  to  the  perineum  (retrograde  cathe- 
terization). The  point  of  this  sound  acts  as  a  guide  and  makes  incision  of 
the  urethra  easy.  The  value  of  abstention  from  much  burrowing  in  the  peri- 
neum and  of  retrograde  catheterization  is  insisted  on,  as  the  author  has  seen 
much  damage  result  from  the  former  and  no  harm  from  the  latter  procedure. 

After-treatment. — Immediately  after  the  operation  irrigate  the  bladder. 
Stop  all  hemorrhage.     Two  methods  of  attending  to  urination  are  now  possible: 

(a)  Apply  a  gauze  pad  to  the  perineal  wound  and  permit  the  urine  to  escape 
either  through  the  meatus  or  through  the  perineum,  as  it  pleases.  In  one  of 
the  author's  cases  hardly  a  drop  of  urine  escaped  through  the  wound. 

ih  Introduce  a  catheter  (Pezzer  self-retaining  catheter  is  best)  through  the 
wound  into  the  bladder  and  keep  it  there.  It  is  easy  to  connect  the  catheter  to 
a  long  tube  and  so  drain  the  urine  into  some  convenient  receptacle. 

Keep  the  perineal  wound  clean  and  frequently  change  the  dressings.  Some 
simple  antiseptic  ointment  applied  to  the  surrounding  skin  gives  comfort 
and  lessens  scalding.  After  the  lapse  of  five  to  eight  days  pass  a  sound  through 
the  meatus  into  the  bladder.  This  is  usually  difficult.  The  writer  has  more 
than  once  found  a  spur  in  the  depth  of  the  perineal  wound  which  rendered  the 
passage  of  the  sound  impossible.  Division  of  the  spur  was  all  that  was  neces- 
sary. The  spur  itself  was  undoubtedly  the  result  of  insufficient  division  of 
the  stricture  at  the  primary  operation. 

Repeat  the  passage  of  the  sounds  at  constantly  increasing  intervals  until  a 
cure  is  effected.  The  perineal  wound  heals  rapidly  unless  some  strictures 
exist  in  the  urethra  anterior  to  it. 

Urethrectomy :  Excision  of  Stricture.^ — Complete  urethrectomy  is  com- 
paratively rarely  indicated;  it  means  excision  of  the  whole  circumference  of  the 
urethra.  Incomplete  urethrectomy  is  the  usual  operation;  in  it  a  portion  of 
the  dorsal  wall  of  the  urethra  is  preserved.  The  preservation  of  even  a  small 
strand  of  dorsal  wall  is  of  much  importance,  as  it  aids  marvelously  in  securing 
apposition  and  acts  as  a  guide  in  catheterization. 

Perineal  Urethrectomy.— 6'fe^  i . — Prepare  the  patient  and  open  the  urethra 
as  in  external  urethrotomy. 

Step  2. — If  not  already  done,  pass  a  sound  or  probe  through  the  stricture. 
With  forceps,  knife,  and  scissors  carefully  and  thoroughly  remove  every  particle 
of  the  contracted  and  deforming  scar  tissue  from  the  under  and  lateral  side 
of  the  urethra,  but  preserve,  if  at  all  possible,  a  portion  of  the  upper  wall  of 
the  urethra.     It  is  necessary  to  remove  all  the  diseased  tissue. 

Step  3. — Restoration  of  the  Urethra. — (a)  Introduce  through  the  penis  to  the 
bladder  a  retention  catheter.  Make  an  end-to-end  union  over  the  catheter 
of  the  divided  urethra  by  fine,  interrupted  catgut  sutures  which  do  not  pene- 
trate the  mucosa.  To  avoid  stenosis  it  is  necessary  to  incise  longitudinally 
the  floor  of  each  segment  to  be  united  and  convert  the  longitudinal  into  trans- 
verse wounds  when  suturing  (Fig.  875,  AA',  BB').  Be  sure  that  each  stitch 
has  a  firm  hold.  Either  close  the  superficial  perineal  wound  with  sutures  or 
permit  it  to  heal  by  granulation. 

{h)  Hartmann  usually  introduces  a  retention  catheter  and  over  it  closes 
the  wound  with  fine  catgut  sutures  which  do  not  penetrate  the  mucosa,  but 


720 


URETHRAL    STRICTURE 


grasp  all  the  perineal  tissues  except  the  skin.     The  skin  wound  he  leaves  open 
(Fig.  876). 

Methods  a  and  h  are  only  useful  when  the  separation  of  the  two  segments 
of  urethra  is  not  more  than  about  i}-^  inches  (  3  to  4  centimeters). 

(c)  When  the  urethral  defect  is  very  great,  treat  as  after  external  ure- 
throtomy.    When  all  the  diseased  tissue  has  been  excised  the  wound  heals 
readily  and  rapidly,  leaving  a  scar  which  is  much  softer 
and  less  liable  to  contract  disastrously  than  if  diseased 
tissue  has  been  left  (Hartmann). 

After-treatment. — Remove  the  retention  catheter  on 
the  eighth  day.  On  the  twelfth  day  begin  passing  sounds. 
Russell's  operation  (R.  Hamilton  Russell,  Brit.  J.  Surg., 
II)  P-  375)  promises  to  supersede  all  others.  The  male 
urethra  can  be  slit  up  from  the  membranous  portion  to 
the  meatus  (the  scrotum  being  split  at  the  same  time) 
and  healing  will  take  place  without  stricture  provided 
that  efficient  perineal  drainage  of  the  bladder  is  secured 
during  healing.  The  urethra  under  the  above  circum- 
stances is  changed  from  a  tube  of  mucosa  into  a  ribbon 
of  mucosa  and  if  left  alone,  its  edges  flanked  on  either 
Fig.  875.— Restora-  side  by  raw  tissues  which  tend  to  fall  together  and  cohere, 

^'rethrectom^'^^'^^   ^^^^^  ^^^^^'  ^^^^  ^^^^  ^^^  taken  place,  be  of  necessity  recon- 
verted into  a  tube. 

Step  I. — place  the  patient  in  the  extreme  lithotomy  postion  with  the  pelvis 
well  raised.  Make  a  A-incision  having  its  apex  at  the  central  point  of  the  peri- 
neum and  open  the  ischio-rectal  fossa  on  each  side.  Detach  the  external 
anal  sphincter  from  the  bulbo-cavernous  muscle  at  the  central  tendon.  Retract 
the  sphincter  backwards  with  a  bifid  retractor.  Pull  forwards  the  bulb  of  the 
urethra  and  the  transversus  perinei  muscles  thus  exposing  the  membranous 
urethra  and  the  apex  of  the  prostate  exactly  as  in  perineal  prostatectomy. 
Open  the  membranous  urethra  longitudinally  and  introduce  a  silk  thread  tractor 
into  each  side  of  the  wound.     Split  the  urethra  forwards  to  the  stricture. 

Step  2. — Pass  a  guide  or  sound  through  the  meatus  to 
the  face  of  the  stricture  and  on  it  open  the  urethra  longi- 
tudinally in  front  of  the  stricture,  through  a  median  cut 
which  meets  the  apex  of  the  first  incision.  Introduce 
silk  tractors  into  the  sides  of  this  urethral  wound  and  slit 
the  urethra  back  to  the  stricture.  The  stricture  now  lies 
exposed,  with  an  inch  or  two  of  spUt  open  urethra  both 
behind  and  in  front  of  it. 

Step  3. — Excise  the  stricture  along  with  the  surrounding  extra-urethral 
masses  of  scar  tissue.  This  must  be  done  thoroughly,  but  no  more  healthy 
mucosa  sacrificed  than  is  absoutely  necessary.  Mobilize  the  divided  ends 
of  the  urethra  by  undercutting  and  unite  .them  by  five  sutures  of  fine  catgut. 

Step  4. — Pass  a  catheter  through  ^he  perineal  wound  into  the  bladder  and 
anchor  it  with  sutures.  Close  the  lateral  perineal  wounds  wath  deep  silkworm- 
gut  stitches.  Do  not  place  any  sutures  in  the  perineum  in  front  of  the 
catheter.     After  about  one  week  the  catheter  may  be  removed  and  the  per- 


FiG-  876. — Suture  of 
urethra. 


KUl'TURH    URI-yrHKA  721 

ineal  wound  permitted  to  heal.  Several  weeks  after  healing  has  taken  place 
pass  full  sized  sounds.  The  occasional  subsequent  passage  of  a  sound  is  an 
advisable  precaution. 

In  a  case  in  which  "a  very  bad  stricture  in  the  bulbous  urethra  was  com- 
plicated by  multiple  strictures  in  the  penile  portion,  I  slit  up  the  urethra  from 
the  membranous  portion  to  within  an  inch  of  the  meatus,  dividing,  of  course, 
the  scrotum.  The  stricture  of  the  bulb  was  excised,  and  the  penile  strictures 
treated  plastically.  No  special  sutures  were  put  into  the  urethra  other  than 
those  at  the  seat  of  excision;  only  in  the  penile  portion  the  lateral  margins  of 
the  urethra  were  caught  up  and  approximated  by  inclusion  in  the  skin  sutures. 
The  skin  and  scrotum  were  sutured,  and  healing  took  place  uneventfully 
throughout.  A  full-sized  instrument  was  easily  passed  for  the  first  time  five 
weeks  after  the  operation"  (Russell). 

Penile  Urethrectomy. — Apply  an  elastic  constrictor  to  the  root  of  the  penis. 
Step  I. — Make  a   longitudinal  median  incision  to  expose   the  stricture. 
Excise  the  whole  cicatricial  node,  even,  when  requisite,  removing  part  of  the 
corpora  cavernosa. 

Step  2. — Suture  the  urethra  with  fine  catgut  sutures  which  do  not  penetrate 
the  mucosa.  Suture  the  cavernous  and  spongy  bodies  according  to  necessity. 
Remove  the  elastic  constrictor  so  as  to  observe  and  control  hemorrhage.  Close 
the  skin  wound. 

Step  3. — Open  the  perineal  urethra  and  through  this  wound  introduce  a 
self-retaining  catheter  to  keep  the  penile  urethra  from  being  irritated  by  the 
passage  of  urine. 

Remarks. — Urethrectomy  gives  better  results  than  external  urethrotomy, 
but  it  rarely  results  in  a  radical  cure.  Subsequent  passage  of  sounds  remains 
necessary  in  most  cases. 

R.  Muhsam  ("Berlin,  klin.  Woch.,"  1912,  No.  12)  (Ref.  "Zentralblatt 
fiir  Chir.,"  191 2,  No.  23)  excised  an  impermeable  stricture  6  cm.  in  length  and 
substituted  for  it  8  cm.  of  the  long  saphenous  vein.  The  vein  was  drawn  over 
a  catheter  (valves  facing  distally)  and  sutured  with  precision  to  the  urethral 
stumps.     The  result  was  good. 

Rupture  of  the  Urethra. — Operative  treatment  of  urethral  rupture  varies 
greatly  according  as  the  case  is  seen  early  or  late,  when  infection  and  necrosis 
have  taken  place.  Practically  every  case  of  urethral  rupture  demands  prompt 
operation.  It  is  rarely  possible  to  introduce  a  catheter  beyond  the  site  of 
rupture;  even  when  this  is  possible  perineal  section  ought  to  be  performed  to 
evacuate  effused  blood  and  provide  free  drainage. 

I.  Early  Operations. — ^Lithotomy  position.  Clean  the  perineum  and  its 
surroundings.  Pass  a  sound  through  the  penis  down  to  the  site  of  rupture. 
Expose  the  injured  urethra  exactly  as  in  external  urethrotomy.  Find  the 
opening  into  the  posterior  segment  of  the  urethra.  This  may  be  easy  but  is 
often  extremely  difi&cult.  If,  after  reasonable  search  in  the  well  retracted 
wound  aided  by  reflected  light  and  the  use  of  probes,  etc.,  the  posterior  urethra 
cannot  be  found,  it  is  usually  advised  to  incise  in  the  median  line  further  back, 
and  so  enter  the  intact  portion  of  the  posterior  urethra  and,  by  means  of  a  probe 
passed  from  behind  forwards,  find  the  desired  orifice.  To  the  author  it  seems 
much  better,  under  the  above  circumstances,  to  open  the  bladder  above  the 

46 


722  URETHRAL    STRICTURE 

pubis,  practise  retrograde  catheterization,  and  subsequently  drain  or  siphon 
the  urine  through  the  suprapubic  wound. 

When  the  site  of  injury  has  been  well  exposed,  blood  clots  evacuated, 
injured  shreds  of  tissue  removed,  the  urethral  wound  may  be  (a)  closed  as 
after  urethrectomy  or  (b)  drained  as  after  external  urethrotomy. 

If,  when  the  patient  is  seen,  he  is  in  very  poor  condition  from  shock,  do  not 
immediately  operate  as  above.  Either  evacuate  the  urine  from  the  bladder 
by  suprapubic  aspiration  and  await  reaction,  or,  guided  by  a  sound  passed 
into  the  urethra,  cut  down  to  and  freely  open  the  urethra  at  the  site  of  injury, 
and  making  no  search  for  the  posterior  opening  into  the  urethra,  trust  to 
simple  drainage.     Simple  drainage  has  stood  the  writer  in  good  stead. 

II.  Late  Operation. — ^Late  operation,  i.e.,  operation  after  there  is  much 
infiltration  of  urine,  distinct  infection  and  necrosis  of  tissues,  resolves  itself 
into  the  treatment  of  the  urinary  infiltration  and  phlegmonous  inflammation. 

The  operation  is  identical  whether  the  trouble  is  due  to  a  neglected  trau- 
matic rupture  or  to  neglected  stricture,  etc. 

A  sound  passed  per  urethram  to  the  site  of  injury  may  be  an  aid;  it  is  not  a 
necessity,  as  the  aim  of  the  surgeon  at  this  time  is  not  to  definitely  open  the 
urethra  but  to  open  the  collections  of  pus,  urine,  etc.,  in  the  tissues.  The  urine 
will  escape  sufficiently  through  the  opened  abscesses.  In  the  cases  under  con- 
sideration (only  a  few  hours  may  have  elasped  since  the  accident)  the  scrotum, 
penis,  and  perineum  are  usually  very  much  swollen. 

Lejars  writes:  "Don't  try  to  catheterize.  Don't  waste  time  by  making 
haphazard  and  insufficient  incisions  in  the  most  oedematous  zones;  at  once 
attack  the  perineum." 

The  Operation. — ^Lithotomy  position.  Cleanse  and  shave  the  perineum 
and  surroundings.  Retract  the  scrotum  upwards.  Make  a  median  perineal 
incision  about  i3^^  to  2  inches  long.  The  posterior  end  of  the  incision  must 
be  at  least  one  fingerbreadth  from  the  anus  to  avoid  injury  to  the  sphincter. 
Continue  deepening  the  incision  until  urine  and  pus  escape  freely.  On  account 
of  the  swelling,  it  may  be  necessary  to  penetrate  2  inches  or  more.  Always 
keep  to  the  middle  line  and  persist  until  the  fluid  is  found.  Lejars  makes  the 
above  incision  with  the  thermocautery;  the  author  has  always  used  the  knife. 

When  the  urine  and  pus  are  found,  explore  with  the  finger  and  open  up 
subsidiary  cavities.  If  necessary  make  counter  openings  Puncture  or  incise 
freely  all  greatly  swollen  regions,  e.g.,  on  the  scrotum  and  penis.  Apply 
plentiful  moist  dressings.  When  the  swelling  and  inflammation  subside, 
incisions  which  at  first  seemed  enormous  become  almost  invisible.  The  whole 
operation  consists  in  making  (a)  free  primary  perineal  incision,  (b)  free  sub- 
sidiary incisions  wherever  necessary.  It  is  better  to  make  too  many  and  too 
free  incisions  than  too  few  and  too  small. 

Late  Operation  in  an  Unusual  Form  of  Urinary  Infiltration. — When  the 
urine  escapes  behind  the  triangular  ligament,  the  territories  infiltrated  are 
the  pelvis,  the  ischiorectal  fossae,  and  the  hypogastrium.  The  penis,  scrotum, 
and  perineum  are  unaffected.  The  operative  treatment  required  consists  in 
free  median  incision  above  the  pubis,  in  free  opening  of  the  ischiorectal  fossae, 
and  in  drainage  of  the  bladder. 


CHAPTER  LII 


EPISPADIAS 


Epispadias  is  closely  allied  to  hypospadias,  and  when  there  is  curvature 
of  the  organ  from  fibrous  tissue  contraction  this  must  be  corrected  in  the 
same  fashion  as  in  hypospadias. 

Thiersch's  operation  is  performed  in  several  stages: 

I.  Construction  of  urethra  in  the  glans  penis.  Parallel  to  the  groove  in 
the  glans  make  two  incisions,  as  shown  in  Fig.  877,  a  and  h.  Lay  a  glass  or 
metal  rod  along  the  groove,  and  with  it  depress  the  groove,  at  the  same  time 
sliding  the  lateral  portions  of  the  glans  (mobilized  by  the  two  incisions)  over 
the  rod,  and  unite  their  raw  surfaces  by  quill  sutures  (Fig.  877,  c).  When 
the  balanic  urethra  is  safely  and  firmly  established  and  the  wounds  healed, 
proceed  to 


Fig.  877. — Thiersch's  operation.     (Esmarch  and  Kowalzig.) 


II.  Construct  the  penile  urethra.  Make  the  skin-flap  a  (Fig.  878)  along 
the  whole  length  of  the  urethral  groove  and  with  its  base  next  the  groove. 
Make  the  similar  skin-flap  h,  with  its  base  remote  from  the  urethral  groove. 
Turn  the  flap  a  over  so  that  it  covers,  and  has  its  skin  surface  next  to  the  groove. 
With  a  few  points  of  suture  fix  the  cut  edge  of  flap  a  to  the  under  or  raw  sur- 
face of  flap  h,  near  its  base  (Fig.  878).  Pull  flap  h  over  flap  a  and  suture  its 
free  edge  to  the  raw  surface  on  the  penis  left  by  the  elevation  of  flap  a  (Fig. 
879).  In  tracing  out  the  two  flaps  a  and  h,  the  former  is  made  narrower  than 
the  latter. 

III.  A  small  opening  still  exists  between  the  new-formed  tubes  in  the  penis 
and  glans.  In  epispadias  the  incomplete  but  usually  redundant  prepuce  hangs 
below  the  glans.  Make  a  transverse  hole  through  the  prepuce  near  its  base 
(Fig.  879,  c,  c)  and  push  the  glans  through  it.  The  prepuce  now  lies  on  the  top 
of  the  penis,  and  by  suturing  the  edges  of  the  wound  in  it  to  the  vivified  edges  of 
the  urethral  defect,  the  latter  can  be  closed  (Fig.  880). 

IV.  A  defect  remains  at  the  base  of  the  penis.  To  close  this,  vivify  the 
edges  of  the  defect,  and  forming  a  flap  (Fig.  881,  a'),  turn  it  over  and  suture 
its  edges  to  the  edges  of  the  defect,  thus  providing  an  epidermal  lining  to  the 
portion  of  the  urethra  covered.  Another  skin-flap  (Fig.  881,  a)  is  reflected  and 
made  to  cover  the  exposed  raw  surface  of  flap  a'.  This  procedure  is  objection- 
able in  that  the  skin-flap  a  will  assuredly  develop  hair  and  cause  trouble. 

723 


724 


EPISPADIAS 


It  is  far  better  to  cover  the  opening  with  a  single  flap — raw  surface  inwards — 
as  Cheyne  recommends.  The  contraction  which  subsequently  occurs  is  far 
less  objectionable  than  the  growth  of  hair  inseparable  from  Thiersch's  plan. 


Fig.  878.  Fig.  879. 

Figs.  878  and  879. — Thiersch's  operation.        (Esmarch  and  Kowalzig.) 


Fig.  880.        .  Fig.  881. 

Figs.  880  and  881. — Thiersch's  operation.     {Esmarch  and  Kowalzig.) 


As  is  stated  in  the  chapter  on  "Hypospadias,"  all  operations  which  provide 
an  epidermal  lining  for  the  new  urethra  from  skin  in  which  hair  is  liable  to 
grow  are  very  objectionable,  hence  Rosenberger's  ingenious  and  simple  opera- 
tion is  to  be  condemned  and  will  not  be  described. 

The  Van  Hook-Mayo  operation  for  hypospadias  is  entirely  suitable  in  cases 
of  epispadias. 


CANTWELL  S    OPERATION 


725 


Cantwell's  Operation. — This  most  ingenious  and  logical  operation  ("Annals 
Surg.,"  Dec,  1895)  seems  to  have  been  unaccountably  overlooked.  The  author 
is  indebted  to  Wetherill  for  drawing  his  attention  to  it. 

Step  I. — Open  the  bladder  through  the  perineum  and  introduce  a  Watson 
drainage-tube. 

Step  2. — Recognize  the  line  of  junction  between  the  mucosa  of  the  gutter- 
like  uretrha  and  the  skin  of  the  penis.  On  each  side  of  the  urethral  groove 
make  a  longitudinal  incision  along  the  lines  of  muco-cutaneous  junction, 
from  the  symphysis  to  the  extremity  of  the  glans.  (Fig.  882,  a.)  Unite  the 
incisions  above  the  opening  into  the  bladder.  The  incisions  penetrate  to,  but 
must  not  injure  the  corpora  cavernosa.  Separate  the  urethra,  as  a  flap,  from 
its  bed  and  hold  it  aside.     (Fig.  882,  h.) 


(a)  {d) 

Fig.  882. — Cantwell's  operation. 


Step  3. — With  sharp  and  blunt  dissection  separate  the  one  corpus  caverno- 
sum  from  the  other  until  the  skin  on  the  lower  surface  of  the  penis  is  reached. 
(Fig.  882,  c.) 

Step  4. — Place  the  mobilized  urethra  in  the  bottom  of  the  long  penile  wound 
and  fix  it  there  by  a  couple  of  sutures. 

Step  5. — ^Lay  a  sound  or  a  glass  rod  along  the  urethra  (which  is  a  mere 
groove)  and  suture  the  urethra  over  the  rod  so  as  to  form  a  tube.  Remove 
the  rod. 

Step  6. — Bring  the  corpora  cavernosa  together  over  the  urethra  and  close 
the  wound.     (Fig.  882,  d.)     The  urethra  now  occupies  its  normal  site. 

Harold  Stiles'  Operation. — ("Epispadias  in  the  female"  "Trans.  Am. 
Surg.,  Assoc,"  1911.) 

1.  Trendelenburg's  Position. — Subumbilical  right  rectus  incision. 

2.  Divide  the  peritoneum  covering  the  ureter  where  it  crosses  the  termina- 
tion of  the  internal  iliac  artery  to  go  "downwards  and  forwards  towards  the 
base  of  the  broad  ligament,  a  little  below  the  infundibulopelvic  ligament  and 
the  ovarian  vessels."  Be  careful  to  avoid  injury  to  the  ureteric  vessels.  By 
blunt  dissection  free  the  ureter  with  its  vessels,  up  to  the  pelvic  brim  and  down 
to  the  base  of  the  broad  ligament.     Ligate  the  ureter  with  catgut  close  to  the 


726  EPISPADIAS 

bladder;  apply  a  fine  clamp  to  the  ureter  a  little  above  the  ligature;  divide  the 
ureter  between  the  clamp  and  ligature;  cauterize  the  distal  stump.  Prepare 
a  fine  catgut  suture  by  threading  each  end  on  a  fine  needle.  Pass  the  needles 
from  within  outwards  through  the  whole  thickness  of  the  ureteric  wall  and  dis- 
tant from  each  other  about  one-third  the  circumference  of  the  ureter.  Wrap 
the  mobilized  ureter  and  the  catgut  suture  with  needles  still  attached,  in  a  pad 
of  gauze. 

3.  Pull  the  lowest  part  of  the  pelvic  colon  into  the  wound  and  apply  longi- 
tudinally to  it  a  fine  intestinal  clamp  in  such  a  manner  as  to  segregate  the  anti- 
mesenteric  edge  of  it  for  about  3  inches  (Fig.  883).  Make  a  very  small  cut 
transversely  through  the  gut  wall  down  to  but  not  through  the  mucosa  at 
the  junction  of  the  middle  and  lower  thirds  of  the  clamped-off  portion.     Make 


Fig.  88s.— (Stiles.) 

a  small  opening  through  the  mucosa.  Pass  the  two  needles  of  the  ureteric 
suture  through  the  mucosal  wound  and  make  them  penetrate  the  wall  of  the 
gut  from  within  outwards.  Push  the  end  of  the  ureter  into  the  gut.  Tighten 
and  tie  the  catgut  suture.  With  silk  or  hemp,  suture  two  parallel  folds  of  gut 
wall  over  the  implanted  ureter  and  the  original  catgut  stitch  in  the  Witzel 
method  (see  Gastrostomy).  The  stitches  should  pick  up  a  sero-muscular  fold 
on  the  side  of  the  ureter  but  must  not  enter  its  lumen.  Remove  the  intestinal 
clamp. 

4.  Suture  the  divided  peritoneum  on  the  floor  and  posterior  wall  of  the  pelvis 
with  catgut,  leaving  a  small  opening  at  the  uppermost  part  for  the  passage  of 
the  ureter.  It  is  important  to  make  sure  that  the  portion  of  ureter  "which 
passes  from  the  opening  left  in  the  peritoneum  to  the  site  of  implantation  should 
be  as  short  as  possible,  and  it  is  with  this  object  in  view  that  the  implantation 
in  the  pelvic  colon  is  made  as  near  the  rectum  as  possible."  This  to  avoid  risks 
of  internal  hernia. 

5.  Close  the  abdomen  without  drainage.  Stiles  operates  on  the  other  ureter 
from  three  to  six  weeks  later. 


HYPOt^rADIAS  727 


CHAPTER  LIII 

HYPOSPADIAS 

In  hypospadias,  owing  to  an  error  in  development,  the  urethral  floor  is  de- 
fective. The  defect  may  be  slight  or  great,  and  according  to  its  degree  the 
deformity  is  of  the  following  types:  (i)  Balanic,  i.e.,  confined  to  the  glans, 
the  urethral  meatus  being  immediately  behind,  while  the  balanic  urethra  is 
absent  or  represented  by  a  mere  groove  or  gutter.  (2)  Penile  type.  The 
urethral  opening  is  situated  at  any  point  between  the  scrotum  and  the  glans; 
the  anterior  urethra  is  absent  or  represented  by  a  mere  groove.  (3)  Perineo- 
scrotal type.  The  urethral  opening  is  in  the  perineum  and  the  scrotum  is 
divided. 

In  any  form  of  hypospadias  except  the  mildest  the  defective  penis  is  curved 
downwards,  and  held  in  a  position  of  chordee  by  dense  fibrous  tissue  bands 
which  exist  on  its  lower  surface.  These  bands  are  an  important  element 
in  treatment,  as  no  operation  can  be  of  any  value  which  does  not  correct  the 
curvature.  Duplay  corrects  the  chordee  deformity  by  making  transverse 
incisions  through  the  fibrous  bands.  The  incisions  may  be  subcutaneous 
or  open,  according  as  the  skin  is  contracted  or  loose.  When  the  incisions  are 
open,  they  may  be  covered  by  skin-grafts  or  rendered  longitudinal  by  means 
of  sutures.  Bleeding  is  not  great,  as  any  tissues  divided  are  sclerosed.  Some 
surgeons  excise  much  of  the  scar  tissue.  The  straightening  of  the  penis  must 
be  thorough,  if  requisite  several  incisions  being  employed.  While  healing 
is  progressing  the  corrected  position  may  be  retained  by  strapping  the  penis 
to  the  belly-wall.  (In  cases  of  epispadias  a  splint  is  requisite.)  Several  weeks 
may  be  spent  in  obtaining  a  straight  organ. 

Where  the  deformity  is  of  the  balanic  type,  the  foreskin  may  be  complete 
or  may  be  divided;  in  the  latter  case  it  is  usually  redundant  and  hangs  over 
the  glans  as  a  hood.  Operation  is  required  because  of  narrowness  of  the 
urethral  opening  and  because  of  the  great  inconvenience  arising  from  the 
impossibility  of  directing  the  stream  in  urinating.  If  the  urethra  is  represented 
by  a  groove  on  the  under  aspect  of  the  glans,  it  may  be  converted  into  a  tube 
by  freshening  its  edges  and  uniting  them  over  a  glass  rod,  or  by  an  operation 
identical  with  that  of  Thiersch.     (See  "Epispadias.") 

In  a  case  in  which  the  above  operation  had  been  unsuccessful  the  author 
obtained  a  good  result  from  utilizing  the  foreskin  in  the  following  way:  Vivify 
one  edge  of  the  urethral  groove  (x  Y,  Fig.  884).  Divide  the  foreskin  along  the 
line  X  Y.  Suture  the  raw  edge  of  the  foreskin  wound  y  p,  to  the  freshened 
edge  of  the  urethral  groove  x  Y  (Fig.  885).  Wait  until  union  has  taken  place. 
Divide  the  foreskin  along  the  line  a  b.  Fig.  885.  Freshen  the  corresponding 
edge  of  the  urethral  groove.  Unite  with  sutures  the  raw  edge  of  the  foreskin 
to  the  edge  of  the  urethral  groove.     The  result  is  shown  in  Fig.  886. 

• 


728 


HYPOSPADIAS 


Beck's  Operaiion. — Beck's  operation  is  suitable,  not  only  in  cases  where 
the  urethra  is  defective  at  the  glans,  but  where  it  is  defective  for  a  short  distance 
behind  it. 


Fig.  884. 


Fig. 


Fig.  886. 


Dissect  the  distal  end  of  the  complete  urethra  free  from  its  surroundings 
for  a  suitable  distance  (Figs.  887,  888,  889,  890).  This  mobilizes  the  tube  so 
that  it  can  be  pulled  forwards  and  sutured  to  the  vivified  urethral  groove 
on  the  under  surface  of  the  glans.     Where  there  is  no  urethral  groove  on 


Fig.  887.  Fig. 

Figs.  887  and  88S.— {Beck.) 


the  glans,  some  surgeons  perforate  the  glans  from  before  backwards  or  from 
above  downwards  and  backwards  (Ochsner)  and  pull  the  mobilized  end  of 
the  urethra  through  the  tunnel,  suturing  it  there.  When  the  defect  belongs 
to  the  penile  or  scroto-perineal  type,  other  operations  are  required. 


DUPLAY  S    OPERATION 


729 


Dnplay^s  Operation. — First  sitting:  Straightening  of  the  penis. 

Second  sitting:  Correction  of  the  deformity  in  the  glans,  as  in  Thiersch's 
operation  for  epispadias. 

Third  sitting:  Establish  perineal  drainage,  by  the  boutonniere  operation. 
C.  H.  Mayo  advises  the  introduction  of  a  Pezzer's  self-retaining  female  catheter 
through  the  perineal  wound.  Correct  the  urethral  deformity  as  follows :  Make 
a  longitudinal  incision  (a,  b,  Fig.  891)  parallel  to  and  about  ^4  inch  distant 
from  the  edge  of  the  urethral  groove.  At  each  end  of  this  incision  make  a  trans- 
verse incision  beginning  at  the  edge  of  the  urethral  groove  and  ending  at  a  point 
well  external  to  the  longitudinal  cut.     These  cuts  outline  two  flaps,  one  of  which 


1 

l^Jt 

i 

mtf- 

J 

Fig.  889.  Fig.  890. 

Figs.  889  and  890. — (Beck.) 


(x.  Fig.  891)  has  its  base  at  the  urethral  groove;  the  other,  p,  has  its  base  towards 
the  side  of  the  penis.  Reflect  these  flaps.  On  the  opposite  side  of  the  urethral 
groove  duplicate  the  above  incisions  and  form  the  flaps  y  and  q.  Pass  a  rod 
through  the  lately  formed  urethra  of  the  glans  and  permit  it  to  lie  in  the  urethral 
groove.  Reflect  the  flaps  x,  y,  on  to  the  rod  (Fig.  892)  so  that  their  epidermal 
surfaces  next  to  the  rod  and  their  raw  surfaces  are  exposed.  These  two  flaps 
should  not  be  so  wide  that  their  edges  meet  over  the  rod.  Approximate  the  flaps 
p  and  Q  by  means  of  the  suture  s  s^  (Fig.  892).  The  skin  is  so  loosely  attached 
to  the  penis  that  it  is  easy  to  slide  the  flaps  p  and  q  inwards  so  that  their  raw 
surfaces  are  partly  in  contact  with  those  of  x  and  y  and  partly  with  one  another. 
The  sutures,  of  silkworm-gut  or  silver  wire,  should  be  fastened  to  perforated  lead 
plates  which  extend  the  whole  length  of  the  wound  on  each  side  of  it  (quill 


730 


HYPOSPADIAS 


sutures).     The  lead  plates  prevent  the  sutures  cutting  out  and  assist  in  keeping 

the  parts  at  rest. 

The  above  operation  is  a  modification  of  Duplay's  operation  for  epispadias. 

After  the  penile  urethra  is  completely  formed  there  is  still  a  hiatus  between  it 
and  the  urethra  leading  from  the  bladder.  This  hiatus 
is  closed  in  the  manner  described  in  the  chapter  on 
"Epispadias." 

Thiersch's  operation  for  epispadias  is  also  suitable  in 
hypospadias. 

Many  ingenious  operations  have  been  devised  by  which 
a  new  urethra  is  formed  from  the  skin  of  the  scrotum 
(Rosenberger,  Wood,  etc.).  All  these  are  objectionable  in 
that  hair  will  grow  on  the  skin  used  in  the  making  of  the 
new  urethra  and  cause  an  infinity  of  trouble. 

Nove-Josserand  has  devised  a  most  ingenious  method 
of  operating,  but  whether  it  will  prove  of  much  value  or 
not  is  still  doubtful.  The  operation  is  performed  as  fol- 
lows: Divide  the  skin  transversely  immediately  in  front  of 
the  urethral  opening  (a.  Fig.  893).  From  this  cut  make 
a  subcutaneous  tunnel,  by  means  of  a  trocar,  to  the  point 
of  the  penis.  Cut  a  large  Thiersch  skin-graft  and  roll  it 
around  a  glass  rod,  fixing  it  to  the  rod  by  means  of  a  liga- 
ture at  each  end  (Fig.  894).     Pass  the  rod  covered  with 

891.— Duplay's   ^-j^g  graft  through  the  newly  made  tunnel  in  the  penis. 
operation.  .       ,       ,        .  .  r  •  ,        1  ,  ,       -r 

Apply  dressmgs.     After  eight  days  remove  the  rod.     It 

will  be  wise  to  drain  the  bladder  by  means  of  a  Pezzer's  self-retaining  catheter 
introduced  through  a  perineal  incision,  and  thus  avoid  contamination  of  the 
wound  with  urine.  For  a  few  months  after  recovery  pass  sounds  at  intervals, 
as  there  is  a  tendency  to  contraction.  Various  materials  have  been  used  to 
take  the  place  of  skin  in  the  Nove-Josserand  operation.  Schmieden  has  im- 
planted a  ureter  obtained  during  an  operation  for  hydronephrosis;  experi- 
mentally an  artery  has  been  utilized.  Tanton  published  in  1909  an  experi- 
ment in  which  he  replaced  the  urethra  by  implanting  a  segment  of  vein.  Tan- 
ton,  Tuflier,  Stettiner,  have  applied  this  experiment 
to  man  and  have  been  successful  ("Journal  de 
Chir.,"  June,  1910). 

The  operation  for  the  posterior  penile  type  of 
hypospadias  is  performed  in  two  stages  at  an  inter- 
val of  from  two  to  five  weeks. 

First  Stage. — (a)  Correct  the  chordee  as  already  described. 

(b)  Provide  for  suprapubic  drainage  through  as  small  an  incision  as  possible 
and  without  suturing  the  bladder  to  the  skin.  Keep  the  bladder  clean  by 
frequent  irrigations  with  a  mild  antiseptic  solution.  Change  the  drainage  tube 
at  intervals  as  it  becomes  encrusted  with  urinary  salts. 

Second  Stage. — (a)  Excise  a  segment  of  the  internal  saphenous  vein. 


Fig. 


2. — Duplay's  operation. 


The 


segment  ought  to  be  about  50  per  cent,  longer  than  the  portion  of  urethra  to 


HYPOSPADIAS 


731 


be  constructed,  as  the  excised  vein  shrinks  greatly.     Wash  the  vein  and  pre- 
serve it  in  warm  salt  solution. 

(b)  Introduce  a  sound  into  the  hypospadiac  opening  and  mobilize  the 
urethra  around  the  sound  by  careful  dissection. 

(c)  Make  a  tunnel  as  in  the  Nove-Josserand  operation  from  the  glans 
through  the  penis  to  the  incision  around  the  mobilized  urethral  opening. 

((f)  With  vaseline  lubricate  a  bougie  and  pass  it  through  the  segment  of 
vein  obtained  in  step  a. 

{e)  Pass  the  bougie,  with  the  vein  on  it,  through  the  tunnel  made  in  the 
penis  and  make  the  point  of  the  bougie  go  into  the  mobilized  urethral  orifice. 


Fig.  893. 


Fig.  894. 


Figs.  893  and  894. — Nove-Josserand's  operation.     {Monod  and  Vanverls.) 


if)  Suture  the  open  end  of  the  vein  to  the  open  end  of  the  mobilized  urethral 
orifice  by  means  of  mattress  sutures  which  cause  eversion.  (To  the  author  this 
seems  bad  practice,  as  it  must  bring  the  inner  surface  of  the  vein  into  apposi- 
tion with  the  inner  or  epithelial  surface  of  the  urethra,  a  condition  which  must 
be  inimical  to  healing.) 

(g)  Having  anastomosed  the  implanted  vein  to  the  urethral  orifice,  close 
the  wound  on  the  under  surface  of  the  penis  (or  perineum)  with  one  or  two 
rows  of  sutures.  Place  a  very  small  drain  under  the  skin  for  twenty-four 
or  forty-eight  hours. 

{h)  Unite  the  other  end  of  the  vein  to  the  edges  of  the  wound  in  the  glans. 
Remove  the  bougie. 

After-treatment. — Remove  the  drain  after  twenty-four  to  forty-eight  hours. 
After  the  lapse  of  five  or  six  days  inject,  most  gently,  enough  sterile  olive  oil 
to  slightly  distend  the  new  urethra.     Repeat  the  injection  daily.     After  about 


732 


HYPOSPADIAS 


two  weeks  begin  the  use  of  sounds,  but  use  them  gently  and  at  intervals  of 
two  or  three  days.  Only  after  the  lapse  of  about  one  month  is  it  proper  to 
pass  sounds  large  enough  to  really  dilate  the  new  urethra.  When  the  new 
urethra  has  become  thoroughly  acclimatized  introduce  a  catheter  and  leave 
it  in  place  until  the  hypogastric  fistula  has  closed. 

Tanton's  operation  promises  well,  but  late  results  have  not  yet  been  reported. 


Fiu.  895. 


Fig.  6gb. 


Figs.  895  and  896.  —(C.  //.  Mayo.) 

Van  Hook  ("Annals  of  Surgery,"  April,  1896)  and  C.  H.  Mayo  (''Journ 
Am.  Med.  Assoc,"  April,  1901)  have  devised  very  similar  operations  which 
may  be  performed  as  follows: 

"The  prepuce  is  extended  as  for  circumcision  and  two  incisions  are  made, 
about  I  inch  apart,  e.xtending  from  its  border  to  its  attachment  at  the  penile 
cervix;  the  prepuce  is  unfolded,  forming  a  loop  of  thin  skin  about  2^9  inches 

in  length.  Should  this  not  be  considered  sufficient 
to  reach  from  its  attachment  to  the  hypospadiac 
opening,  the  two  incisions  are  extended  back 
along  the  dorsum  of  the  penis  until  sufl&cient 
tissue  is  obtained,  where  the  two  incisions  are 
connected  by  a  transverse  one,  and  the  flap  of 
skin  lifted  but  left  attached  to  the  cervix  by  the 
inner  surface.  Several  sutures  now  close  the 
lateral  integument  over  the  denuded  area  (Fig.  895). 
The  pedunculated  flap  of  prepuce  is  constructed 
into  a  tube  with  its  skin  or  outer  surface  inside, 
by  means  of  a  number  of  catgut  sutures.  The 
penis  is  tunneled  by  means  of  a  narrow  bistoury  or  medium  trocar 
and  cannula,  through  the  glans,  above  its  groove,  along  the  penis  to 
a  point  beneath  the  hypospadiac  opening,  when  it  is  made  to  emerge 
at  one  side  of,  but  close  to,  the  urethra;  the  tube  of  prepuce  is  drawn 
through  the  tunmel  and  sutured  where  it  enters  the  glans  and  also 
where  it  emerges  (Fig.  8g6).  At  the  end  of  ten  days  the  pedicle  of  the  flap 
is  cut  through  close  to  the  new  meatus.  The  second  operation,  made  at  a 
later  period,  consists  of  a  perineal  opening  into  the  urethra  and  insertion  of 


Fig.  897.— (C.  H.  Mayo.) 


AMPUTATION    PENIS 


733 


a  Pezzer's  self-retaining  female  catheter;  this  is  the  least  irritating  form  of 
catheter  and  can  be  left  as  long  as  needed — usually  from  five  to  eight  days. 
An  incision  at  the  termination  of  the  two  urethras  now  admits  of  accurate 
coaptation  by  sutures,  or  the  normal  urethra  may  be  mobilized  (Beck  method) 
to  a  sufficient  extent  to  admit  of  its  insertion  into  the  new  urethra,  where 
it  is  held  by  sutures  and  the  external  parts  closed  over  this  (Fig.  897).  Oc- 
casionally a  little  urine  escapes  into  the  urethra,  and  the  entire  canal  is  best 
drained  by  passing  several  strands  of  silkworm-gut  or  horse-hair  through  the 
urethra  and  out  alongside  the  catheter  in  the  perineal  opening." 


CHAPTER  LIV 
AMPUTATION   OF  PENIS 

Partial  Amputation. — I.  Amputation  of  Glans  and  Fart  of  Penis. — Step  i. — 
Apply  an  elastic  constrictor  to  the  root  of  the  penis.  Make  an  incision  through 
the  skin  completely  round  the  penis  and  at  least  ^^  inch  distant  from  the 
disease.  Retract  or  reflect  the  skin  upwards  for  about  3^^  inch.  (The  natural 
elasticity  of  the  skin  will  produce  enough  retraction  without  the  aid  of  the 
surgeon.) 

Step  2. — Expose  and  ligate  the  dorsal  artery  and  veins  of  the  penis. 

Step  3. — Divide  the  corpora  cavernosa  transversely.  At  a  point  nearly 
}^  inch  farther  forward  divide  the  urethra  transversely. 

Step  4. — With  catgut  suture  the  ends  of  the  corpora  cavernosa  (Fig.  898). 
This  assures  haemostasis. 

Step  5. — In  the  middle  line  below  make  a  short  incision  through  the  skin. 
Make  a  corresponding  cut  in  the  urethra  (Figs.  898  and  899).  Suture  the 
split  urethra  to  the  skin.  This  splitting 
and  suturing  prevents  contraction. 

NicoU,  most  sensibly,  modifies  the 
operation  as  follows:  Step  (a):  Make 
an  incision  over  each  inguinal  region. 
Unite  these  incisions  in  the  middle  line 
at  the  root  of  the  penis  and  from  their 
point  of  union  make  an  incision  along 
the  mid-dorsal  line  of  the  penis  to  the 
place  chosen  for  amputation.  Step  (6): 
Beginning  at  each  groin  dissect  free,  from 
the  outside  inwards,  the  lymphatics  of  the 
groins  and  then,  from  above  downwards, 
those  of  the  dorsum  of  the  penis.  Re- 
move all  these  lymphatics  in  one  piece.     After  this  proceed  to  amputate. 

II.  Complete  Amputation.     (Gould's  method.)— Place  in  lithotomy  position. 

Step  I.— Split  the  scrotum  completely  along  raphe,  and  thoroughly  expose 
the  corpus  spongiosum. 

Step  2. — Pass  a  sound  through  the  urethra  to  the  triangular  ligament. 
Separate  the  corpus  spongiosum  from  the  corpora  cavernosa.     Remove  the 


Fig.  898. 
Figs  898  and  899. 


Fig.  899. 
-Amputation  of  penis. 


734  AMPUTATION   OF   PENIS 

sound.  Divide  the  corpus  spongiosum  and  isolate  the  urethra  as  far  as  the 
triangular  ligament. 

Step  3. — Continue  the  scrotal  incision  through  the  skin  around  the  root 
of  the  penis.  Divide  the  suspensory  ligament.  Separate  the  crura  from  the 
pubic  bones.  The  only  vessels  requiring  ligation  are  those  of  the  crura.  This 
completes  the  amputation. 

Step  4. — Make  a  short  split  in  the  urethral  stump.  Suture  the  edges  of 
the  split  urethra  to  the  posterior  portion  of  the  scrotal  wound. 

Step  5. — Suture  the  skin  wound  after  providing  for  drainage. 

Remarks. — Very  good  results  have  been  obtained  by  the  above  operations 
with  or  without  removal  of  the  inguinal  lymph  glands.  Cancer  of  the  penis 
is  usually  of  comparatively  slow  growth.  Recurrence  usually  is  in  the  lymph 
glands.  Butlin  advises  removal  of  the  inguinal  glands  as  a  secondary  opera- 
tion. If  the  urethra  is  split  and  united  to  the  skin  as  described,  difficulties 
in  micturition  are  largely  avoided.  Amputation  at  the  junction  of  the  middle 
and  distal  third  or  at  the  middle  of  the  penis  does  not  necessarily  destroy 
the  power  of  coitus  and  begetting  (Butlin).  The  danger  of  the  operations 
described  is  not  much  over  2  per  cent. 

III.  Emasculation. — If  the  disease  is  extensive  or  of  rapid  growth  a  much 
more  serious  and  radical  operation  is  proper.  This  operation  is  based  on  a 
study  of  the  penile  lymphatics. 

The  lymphatics  of  the  penile  skin  and  of  the  prepuce  anastomose  freely 
and  drain  into  the  superficial  lymphatic  glands  on  both  sides.  The  lymphatics 
of  the  glans  pass  up  along  with  the  dorsal  veins  of  the  penis  to  a  few  lymphatic 
glands  which  lie  in  front  of  the  pubis;  from  this  point  they  take  two  courses: 
{a)  to  deeply  located  glands  lying  on  the  inner  side  of  the  femoral  vein,  {h) 
along  the  inguinal  canal  under  the  spermatic  cord. 

From  the  above  (see  "Traite  d'Anatomie  Humaine,"  Poirier  et  Charpy, 
Tome  II)  it  is  evident  that  it  is  safe  to  make  a  difference  in  the  extent  of  opera- 
tion according  as  the  glans  is  involved  or  not.     If  the  glans  is  not  affected 

a  theoretically  complete  operation  means  removal 
of  the  superficial  lymph  glands  from  both  inguinal 
regions,  removal  of  the  penis  and  removal  of  the 
lymph  channels  between  the  penis  and  the  lymph 
glands.  If  the  glans  is  also  involved  a  theoretically 
complete  operation  means  removal  of  the  above 
^^"  tron7f  cX'wghup"^   ^'^^' structures  plus  the  deep  inguinal  glands  to  the 

inner  side  of  the  femoral  vein  and  plus  the  lym- 
phatics under  the  cord  in  the  inguinal  canal  and  plus  the  prepubic  glands. 
Technically  it  may  be  possible  to  do  all  this  and  preserve  the  scrotum  and 
testicles,  practically  it  seems  better  to  remove  these  organs  also.  In  the 
operation  to  be  described  it  is  assumed  that  the  glans  is  affected.  The  method 
is  one  which  the  writer  elaborated  for  his  own  use,  but  which  is,  of  course, 
not  original. 

Step  I. — After  the  usual  cleansing  and  shaving  of  the  whole  operative 
territory,  clean  the  diseased  parts  as  well  as  possible,  swabbing  them  with 
Harrington's  solution  or  liquid  carbolic  or  even  touching  them  with  the  cautery. 


EMASCULATION 


735 


Apply  dressings  to  the  disease  and  cover  them  with  oiled  silk.  Suture  the 
dressings  or  coverings  to  the  skin  of  the  penis.  These  precautions  are  taken 
to  prevent  infection.     Once  more  clean  the  operative  territory. 

Step  2. — Make  an  incision  over  the  inguinal  canal  parallel  to  Poupart's 
ligament.  Open  the  canal  by  splitting  the  aponeurosis  of  the  external  oblique. 
Lift  up  and  mobilize  the  spermatic  cord  and  all  the  fat  surrounding  it.  Doubly 
ligate  and  divide  these  structures  as  high  up  as  possible  (Fig.  900).  Obliter- 
ate the  now  empty  inguinal  canal  by  suturing  the  wound  in  the  aponeurosis 
(Fig.  901). 


Fig.  901. — Closure  of  inguinal  canal. 

Step  3. — Through  the  original  wound,  supplemented  if  necessary  by  a 
subsidiary  incision,  expose  Scarpa's  triangle  above  the  saphenous  opening 
(Fig.  901).  Beginning  at  the  lower  and  outer  sides  of  the  exposed  area,  dissect 
the  superficial  inguinal  glands,  along  with  the  fat  surrounding  them,  upwards 
and  inwards  towards  the  pubis. 

Step  4. — Expose  and  remove  the  deep  inguinal  glands.  These  vary  in 
number  from  i  to  3.  When  three  are  present  one  lies  just  below  the  long 
saphenous  vein,  one  in  the  femoral  canal,  and  one  in  the  femoral  ring.  All 
are  to  the  inner  side  of  the  femoral  vein. 

Step  5. — Repeat  steps  2,  3,  4  on  the  opposite  side.  Incise  the  skin  imme- 
diately above  the  root  of  the  penis,  uniting  by  this  cut  the  two  incisions  over 
the  inguinal  canals.     On  each  side  of  the  root  of  the  penis  make  an  incision 


736 


AMPUTATION    OF    PENIS 


downwards  over  the  root  of  the  scrotum.  Dissect  downwards  the  fat  in  front 
of  the  pubis,  until  the  crura  of  the  penis  are  exposed.  Divide  the  suspensory 
ligament.  The  results  of  the  work  accomplished  up  to  this  point  are:  (a) 
All  the  lymphatic  glands  and  tissue  which  may  presumably  be  affected  are 


Fig.  902. — Operation  of  emasculation. 

dissected  free  and  now  hang,  along  with  the  spermatic  cords  and  the  prepubic 
fat,  attached  to  the  penis  and  scrotum  (Fig.  902).  The  inguinal  canals  which 
were  opened  have  been  closed.  Any  wound  which  may  have  been  made  to 
expose  Scarpa's  triangle  may  now  be  closed. 


Fig.  903. 

;.  /.  Inguinal  wounds.    SF.  Scrotal  flap.     U.  Urethral  opening. 

Step  6. — Working  from  above  downwards,  separate  the  crura  of  the  penis 
from  the  pubic  bones.  Complete  the  incision  through  the  scrotum  below 
and  behind.  Expose  and  mobilize  the  corpus  spongiosum  at  the  root  of  the 
scrotum.     Di\'ide  the  corpus  spongiosum  and  urethra.     A  few  catgut  sutures 


CIRCUMCISION 


737 


through  the  cavernous  tissue  prevent  hemorrhage.  It  is  now  easy  to  remove, 
in  one  piece,  the  penis,  scrotum  with  its  contents,  superficial  inguinal  glands, 
and  the  lymphatics  of  the  inguinal  canal.  (The  deep  inguinal  glands  were 
removed  separately.) 

Step  7. — Make  a  slight  split  in  the  urethral  stump  and  suture  the  edges 
of  the  urethral  wound  to  the  most  posterior  part  of  the  cutaneous  wound. 
Close  the  extensive  skin  wound  with  sutures  after  providing,  where  necessary, 
for  drainage. 

N.B. — When  removing  the  scrotum  it  is  well  to  leave  enough  of  its  pos- 
terior wall  to  be  brought  forward  and  upward  and  united  to  the  edge  of  the 
wound  across  the  pubis.  When  this  is  done  the  urethra  can  be  brought  through 
a  button-hole  cut  in  the  base  of  the  scrotal  flap  (Fig.  903).  When  removing 
the  scrotum  v.  Dittel  retained  a  portion  of  the  posterior  scrotal  skin  which 
he  wrapped  around  the  stump  of  the  corpus  spongiosum  (left  long  for  this  pur- 
pose). The  effect  of  this  detail  was  the  formation  of  a  sort  of  "spout"  which 
enabled  the  patient  to  urinate  without  taking  down  his  trousers. 


CHAPTER  LV 
CIRCUMCISION 


There  are  several  methods  of  performing  circumcision;  most  of  these  are 
merely  modifications  of  the  following: 

Classical  Method. — Feel  an(i  locate  the  corona  or  groove  behind  the  glans 
penis;  the  prepuce  being  in  normal  position  is  not  retracted.     Place  a  clamp 


Fig.  904. 

Figs.  904  and  905 


Circumcision. 


(the  handles  of  a  long  scissors  form  an  efficient  clamp)  on  the  skin  correspond- 
ing to  the  corona.  Gently  tighten  the  clamp  so  as  to  hold  the  skin  between 
its  blades  and  yet  permit  the  glans  to  be  pushed  back  behind  it.  Push  back 
the  glans  so  that  it  lies  in  safety  behind  the  clamp.  Tighten  the  grasp  of 
the  clamp.     The  whole  skin  and  part  of  the  mucous  membrane  of  the  prepuce 


47 


738 


CIRCUMCISION 


now  lie  in  front  of  the  clamp;  the  glans  and  part  of  the  mucous  membrane 
of  the  foreskin  lie  behind  it. 

Remove,  with  a  knife,  all  the  structures  in  front  of  the  clamp.  Remove  the 
clamp.  The  skin  retracts  to  the  root  of  the  penis;  the  glans  is  covered  by  a  tube 
of  mucous  membrane  having  a  raw  and  bleeding  external  surface.  Cut  away 
(Fig.  904)  all  except  about  3^  inch  of  the  mucous  membrane.  If  the  frenum 
is  short  and  pulls  the  glans  downwards  and  backwards,  divide  that  structure 
transversely  and  in  suturing  convert  the  transverse  into  a  longitudinal  wound, 
thus  lengthening  the  frenum  (Fig.  905).  Pull  the  skin  forwards  and  suture 
it  to  the  mucous  membrane.  Apply  vaseline  or  some  ointment  to  the  wound 
and  protect  with  a  small  piece  of  gauze.  No  elaborate  dressings  are  of  any 
value.  Warn  the  patient  or  his  mother  that  the  penis  will  become  swollen 
and  discolored;  this  warning  may  prevent  the  operator  being  summoned  to 
treat  non-existent  hemorrhage.  Serious  post-operative  hemorrhage  is  rare. 
Before  operating,  especially  if  cocaine  is  used,  it  is  well  to  apply  an  elastic 
constrictor  round  the  root  of  the  penis. 

A  Typical  Operation. — With  scissors  or  knife  split  the  prepuce  in  the  mid- 
dorsal  line  to  the  corona.     Beginning  at  the  angle  of  the  wound  trim  away 

as  much  of  the  redundant  tissues  as  may  seem  neces- 
sary.    Stitch  the  skin  to  the  mucous  membrane. 

Many  surgeons  omit  the  removal  of  any  tissue 
after  splitting,  but  this,  at  least  temporarily,  leaves 
the  foreskin  hanging  below  the  glans  like  an  elephant's 
ear  and  causes  much  annoyance  to  the  sensitively 
inclined. 

The  adhesions  which  so  commonly  exist  between 
the  prepuce  and  the  glans  are  as  a  rule  easily  sepa- 
rated, but  occasionally  they  are  so  firm  as  to  require 
sharp  dissection.  In  such  a  case  the  author,  after 
dissecting  the  prepuce  from  the  glans,  folded  the 
redundant  prepuce  on  itself  so  that  a  short  prepuce 
was  formed  lined  with  epidermis  and  so  reformation 
of  adhesions  was  prevented.  Possibly  it  would  have 
been  well  to  have  covered  the  raw  surface  of  the  glans 
with  skin  grafts. 

Paraphimosis. — The  foreskin  is  retracted,  swollen, 
and  cannot  be  brought  forwards.  The  constricting 
band  obstructing  reduction  is  the  margin  of  the  preputial  orifice  (the  muco- 
cutaneous junction).  The  retracted  foreskin  forms  two  swellings  surrounding 
the  penis;  the  constricting  band  lies  in  the  groove  between  the  swellings. 

A.  By  manipulations  endeavor  to  push  back  the  glans  and  bring  forwards 
the  prepuce.  If  successful,  advise  or  perform  circumcision  to  prevent 
recurrence. 

B.  If  manipulation,  fails,  operate.  With  the  fingers  separate  the  anterior 
from  the  posterior  penile  swellings  and  so  expose  the  constricting  band.  Divide 
the  band  in  the  mid-dorsal  line;  reduction  is  now  easy  (Fig.  906).  Advise 
or  practise  circumcision. 


Fig.  906. — Paraphimosis. 

{Veau.) 


OPERATIONS   ON   THE   TESTICLES  739 

CHAPTER  LVI 
OPERATIONS  ON  THE  TESTICLES 

CASTRATION;  ORCHIDECTOMY;  ORCHI-EPIDIDYMECTOMY 

I.  Simple  Castration. — Step  i . — Make  an  incision  2  or  2}^  inches  in  length 
downwards  from  the  level  of  the  external  abdominal  ring.  Through  this  isolate 
the  spermatic  cord  by  blunt  dissection. 

Step  2. — If  the  cord  is  not  very  thick,  crush  it  forcibly  with  powerful  forceps. 
In  the  groove  formed  by  the  clamp  tie  a  ligature  tightly  around  the  whole 
cord.  Thread  one  end  of  the  ligature  on  a  needle  and  pass  it  through  a  small 
portion  of  the  cord  distal  to  the  main  ligature.  Once  more  tie.  This  stitch 
obviates  any  possibility  of  the  ligature  slipping.  Some  surgeons  carefully 
avoid  including  the  vas  deferens  in  the  ligature  lest  pain  result.  Jacobson  be- 
lieves that  if  the  ligature  be  applied  very  tightly  pain  will  not  develop.  Crush- 
ing the  cord  before  applying  the  ligature  has  the  same  ejffect.  When  the 
cord  is  large,  or  if  for  any  reason  a  single  ligature  seems  objectionable,  two 
or  more  interlocked  ligatures  may  be  applied.  Absorbable  or  non-absorbable 
ligatures  may  be  used  at  the  option  of  the  surgeon.  Plain  or  iodized  catgut 
serves  every  purpose  excellently.  Apply  a  clamp  to  the  cord,  about  one 
inch  distal  to  the  ligature.  Divide  the  cord  between  the  clamp  and  ligature. 
Examine  the  ligated  stump,  which  may  be  allowed  to  retract  into  the  inguinal 
canal  if  it  is  healthy  and  is  not  bleeding. 

Step  3. — With  the  hand  on  the  scrotum  make  the  testicle  with  its  coverings 
protrude  through  the  wound.  By  blunt  dissection,  separate  it  with  its  cover- 
ings from  the  scrotum,  and  so  remove  it. 

Step  4. — Carefully  review  the  wound  and  stop  all  bleeding.  If  drainage 
is  required,  perforate  the  scrotum  at  a  dependent  point,  and  through  the 
perforation  introduce  a  capillary  or  tubular  drain. 

Step  5. — Close  the  wound  with  sutures.  The  objects  in  making  the  skin- 
incision  at  a  high  rather  than  a  low  level  are:  (a)  It  is  more  easy  to  separate 
the  cord  and  the  testicle  from  their  surroundings ;  (6)  the  whole  vascular  supply 
is  under  control  from  the  beginning:  (c)  it  is  much  easier  to  retain  suitable 
dressings  over  the  wound. 

n.  Castration  for  Malignant  Disease. — This  operation  as  commonly 
performed  is  a  farce  and  recurrence  is  certain.  The  usually  described  method 
is  that  of  simple  castration,  which  is  as  ineffective  as  simple  excision  of  the 
cancerous  breast  when  the  axillary  glands  are  involved.  When  the  testicle 
is  the  seat  of  malignant  disease,  the  same  principle  holds  good  as  in  the  case 
of  the  breast,  viz.,  to  remove  en  masse  the  whole  organ  plus  all  the  accessible 
lymphatic  tissue  through  which  it  is  normally  drained.  Unfortunately,  the 
terminal  lymphatics  are  not  accessible.  The  lymphatics  of  the  testicle,  epididy- 
mis, and  visceral  layer  of  the  tunica  vaginalis  run  along  the  spermatic  cord  to 
the  lumbar  region.  They  are  usually  superficial  to,  but  in  contact  with,  the 
blood-vessels.     In  the  lumbar  region  they  leave  the  spermatic  vessels  and 


740  OPERATIONS    ON    THE    TESTICLES 

run  towards  their  terminal  glands.  The  terminal  glands  are  grouped  around 
the  aorta  (right  and  left  juxta-aortic  glands)  (Cuneo).  The  lymphatics  of 
the  scrotum  terminate  in  the  inguinal  glands. 

Cumston  and  Rolfe  ("American  Med.,"  1903,  607)  have  given  a  good  de- 
scription of  the  methods  to  be  employed;  the  following  is  largely  based  on 
their  paper. 

Step  I. — Make  an  incision  parallel  to  and  one  inch  above  Poupart's  liga- 
ment from  a  point  a  little  below  the  external  inguinal  ring  to  «,  point  about 
one  inch  above  the  internal  ring. 

Step  2. — Expose  the  fascia  of  the  external  oblique  and  split  it,  as  in  Bassini's 
hernial  operation,  from  the  external  ring  to  a  little  above  the  internal  ring. 
Retract  the  flaps  of  fascia  thus  formed. 

Step  3. — Push  the  internal  oblique  muscle  aside  and  thus  expose  the  inguinal 
canal  and  spermatic  cord.  Dissect  the  cord  from  its  bed.  Open  the  posterior 
wall  of  the  inguinal  canal  and  invade  the  iliac  fossa. 

Step  4. — The  elements  composing  the  cord  become  separated  at  the  internal 
ring,  the  vas  going  down  towards  the  small  pelvis,  the  spermatic  vessels  and 
lymphatics  going  up  towards  the  lumbar  region,  on  the  psoas  muscle.  Follow 
the  vas  deferens  as  far  as  possible  towards  the  deep  pelvis  and  there  ligate 
and  divide  it.  Cauterize  its  stump  with  pure  carbolic  acid  or  the  cautery. 
Follow  the  spermatic  vessels  up  towards  the  lumbar  region  as  far  as  possible 
and  there  doubly  ligate  and  divide  them. 

Step  5. — Beginning  above  at  the  site  of  division  of  the  vas  and  of  the  sper- 
matic vessels,  separate  the  cord  and  its  envelopes  downwards,  to  a  point  below 
the  external  inguinal  ring.  By  pressing  on  the  scrotum  it  is  easy  to  deliver 
the  testicle  with  its  envelopes  through  the  wound  and  remove  them  together 
with  the  cord.  If  the  scrotum  is  adherent  to  the  testicle,  make  a  liberal  ex- 
cision of  the  scrotal  skin  and  all  the  structures  between  it  and  the  testicle. 
This  is  done  by  continuing  the  original  incision  downwards  and  making  it 
surround  the  affected  area.  Remember  that  if  the  scrotum  is  involved  the 
inguinal  lymphatic  glands  may  be  affected  and  should  be  removed,  as  it  is 
into  them  that  the  scrotal  lymphatics  drain. 

Step  6. — Review  the  wound  with  care  and  attend  to  hemostasis.  Close 
the  wound  exactly  as  in  an  operation  for  the  radical  cure  of  hernia. 

Radical  Operation  for  Teratoma  Testis. — Cuneo  resected  the  lumbar  gland 
bearing  area  in  a  case  of  teratoma  testis  in  1906,  the  patient  remained  well 
until  lost  sight  of  three  years  later.  Gregoire  and  Chevassu  later  performed 
four  similar  operations  with  encouraging  results.  Hinman  (Surg.,  Gyn.  and 
Obst.,  May,  1919)  reports  five  cases  in  which  he  operated  successfully. 

Step  I. — Dorsal  position.  Make  an  incision  into  the  inguinal  canal.  Ex- 
pose and  free  the  cord  high  up.  Divide  the  cord  with  the  cautery  between 
clamps.  Excise  the  testicle.  If  immediate  examination  of  the  specimen  proves 
it  non-malignant  complete  the  operation  by  attending  to  hemostasis  and  closing 
the  canal  and  wound.     If  malignancy  is  present  proceed  to 

Step  2. — Place  the  patient  midway  between  the  lateral  and  dorsal  positions 
(diseased  side  uppermost)  with  a  medium  sized  pad  under  the  opposite  costal 
margin.     The  position  is  bent  dorso-lateral. 


TERATOMA    TESTIS 


741 


Continue  the  original  incision  ui)war(ls  and  outwards,  sjilitting  the  external 
oblique  in  the  direction  of  its  libers  to  a  point  about  2  cm.  (%  in.)  internal 
to  the  anterior  superior  spine. 


f^va  glanola 


-^x-terrial    iViac     a 


--j^SmMStOi^^it^i^ 


Fig.  907. —  {Hinman,  Surg.  Gyn.  &°  Ohsl.) 


From  this  point  continue  the  cut  in  a  curved  direction  to  about  i  cm.  below 
the  tip  of  the  twelfth  rib  and  carry  the  cut  parallel  to  the  rib  for  about  half  its 
length.  Divide  the  internal  oblique,  transversalis  and  latissimus  dorsi  in  the 
line  of  incision.  In  this  exposure  the  iliac  branch  of  the  ilio-hypogastric  nerve 
is  necessarily  sacrificed.     Expose  but  do  not  injure  the  peritoneum,  Fig.  907. 


74: 


OPERATIONS    ON    THE   TESTICLES 


Step  3. — Separate  the  parietal  peritoneum  from  the  posterior  abdominal 
wall.  The  spermatic  vessels  as  well  as  the  ureter  tend  to  strip  up  \\\xh.  the 
peritoneum.  To  overcome  this  exercise  gentle  traction  on  the  cord  during  the 
stripping.  At  this  point  where  the  vas  deferens  passes  down  behind  the  blad- 
der the  peritoneal  boundaries  may  be  with  difficulty  outlined.  This  dissection 
should  be  carefully  completed  before  proceeding  with  that  above.  Divide  the 
vas  where  it  disappears  behind  the  bladder.  While  exerting  gentle  traction 
on  the  cord  strip  the  peritoneum  from  the  iliac  vessels  and  the  bifurcation  of  the 
aorta.  In  this  way  expose  the  psoas  muscles  with  the  ureter  overlying  them, 
the  lower  pole  of  the  kidney,  the  aorta  and  vena  cava.  Continue  the  peritoneal 
dissection  as  high  as  the  renal  pedicle. 

Step  4. — Dissect  the  lymphatic  Ussnts,  first  from  the  iliac  vessels  and  aortic 
bifurcation  beginning  below  and  working  upwards  and  second  from  the  pre- 
aortic area.  Hinman  found  that  'in  all  instances  by  careful  dissection,  it  was 
possible  to  remove  the  spermatic  and  lymph  areas  in  toto.  The  spermatic 
artery  can  be  easily  clamped  as  it  leaves  the  aorta,  and  the  spermatic  vein  as  it 

enters  the  vena  or  renal  vein,  the  points  being 
easily  found  when  gentle  traction  is  placed  on 
the  vessels. 

Step  5. — Drainage. — Hinman  advised  the 
use  of  a  'long  rubber  tube  over  the  aorta 
down  to  its  bifurcation  and  curving  back  above 
the  ilium  with  exit  at  the  upper  back  portion 
of  the  wound  as  for  kidney  drainage.'  He  also 
suggests  that  a  50  milligram  tube  of  radium 
might  be  laid  along  side  the  drain  and  moved 
certain  distances  at  intervals  of  one  or  two 
hours.  The  propriety  of  using  a  rubber  tube 
is  problematical  as  rubber  dam  would  serve  the 
same  purpose  and  present  less  danger  of  causing 
pressure  necrosis. 

Step  6. — Close  the  wound  in  layers. 

Epididymectomy. — This  operation  may   be 

done  alone  or  vasectomy  may  be  added  to  it. 

Step  I. — Make  an  incision  into  the  tunica  vaginalis,  just  external  and 

parallel  to  the  epididymis.     If  the  epididymis  is  adherent  to  the  skin  or  fistulae 

are  present,  such  adherent  skin  and  fistulae  should  be  surrounded  by  elliptical 

incisions  and  removed  with  the  epididymis. 

Step  2. — Make  an  incision  along  the  junction  between  the  epididymis 
and  testicle  on  the  outer  side.  This  incision  divides  the  serous  membrane 
alone  opposite  the  body  of  the  epididymis,  while  at  the  head  and  tail  (globus 
major  and  minor)  it  divides  the  tunica  albuginea.  With  knife  or  scissors 
separate  the  head  (globus  major)  from  the  testicle.  Next  separate  the  body 
of  the  epididymis  from  the  testicle  (Fig.  908).  As  the  inner  side  of  the  junction 
between  the  epididymis  and  testicle  is  reached,  proceed  with  great  care,  be- 
cause here  the  vessels  going  to  the  testicle  are  in  contact  with  the  epididymis. 


Fig.   g  o  8  .  —  Epidid\'mectomy. 
{Monod  and  Vanverts.) 


ANASTOMOSIS   VAS    DEFERENS  743 

By  making  slight  traction  and  putting  the  structures  of  the  cord  gently  on 
the  stretch,  it  becomes  easy  to  separate  the  epididymis  from  the  vessels. 

Step  3. — The  epididymis  being  free,  continue  the  dissection  by  separating 
the  vas  from  its  surroundings  up  to  the  internal  ring,  "where  it  is  grasped  on 
both  sides  of  its  circumference  with  hemostatic  forceps,  divided,  and  the  lumen 
of  the  proximal  end  cauterized  with  95  per  cent,  carbolic  acid  on  the  end  of 
a  needle.  The  needle  is  to  be  worked  upwards  in  the  lumen  for  y^o.  i^^ch 
and  the  mucous  membrane  thoroughly  cauterized."  Ligate  the  proximal  end 
of  the  vas.  This  is  important  in  that  it  prevents  infectious  material  being 
voided  from  the  vas  into  the  tissues. 

Step  4. — Review  the  wound  made  in  the  testicle  by  the  removal  of  the 
epididymis.  If  any  foci  of  disease  are  found,  excise  them  by  wedge-shaped 
incisions  and  close  the  wounds  with  fine  catgut.  Suture  with  catgut  any 
wound  in  the  tunica  albuginea.  If  the  condition  of  testicle  makes  one  suspect 
disease  in  it,  it  is  proper  to  make  an  exploratory  incision  into  it.  Such  incision 
must  be  closed  with  catgut  sutures  should  no  further  procedure  be  indicated. 

Step  5. — Having  attended  to  hemostasis,  close  the  external  wound  with 
sutures.     It  is  well  to  provide  drainage  for  twenty-four  or  forty-eight  hours. 

In  some  cases  it  is  possible  to  remove  disease  from  the  epididymis  by  partial 
or  complete  excision  of  that  organ,  without  removing  so  much  of  the  vas  as 
was  recommended  in  the  preceding  paragraphs.  When  this  is  possible,  one  may 
foUow  the  suggestion  of  Bardenheuer,  which  was  first  carried  out  by  Rasum- 
owsky  ('^\rchiv  f.  klin.  Chir.,"  Ixv,  p.  557),  viz.,  to  make  an  anastomosis 
between  the  vas  and  the  rete  testis  or  the  remnants  of  the  epididymis. 

Suture  of  the  Vas  Deferens  after  Division. — Accurate  end-to-end  anas- 
tomosis may  be  difficult  because  of  the  small  lumen  of  the  vas.  W.  I.  deC. 
Wheeler  (Brit.  Med.  Journ.,  Feb.  7,  1914)  recommends  the  following  method: 
Pass  the  point  of  a  fine  sewing  needle  into  the  lumen  of  one  of  the  segments 
of  vas  and  slip  the  other  segment  of  vas  over  the  eye  end  of  the  needle  until 
the  two  segments  meet.  Suture.  After  suturing  make  the  needle,  which  is 
inside  the  vas,  penetrate  its  wall.  Extract  the  needle.  Cover  and  reinforce 
the  line  of  suture  with  neighboring  fascia. 

Anastomosis  between  the  Vas  Deferens  and  the  Rete  Teslis. — Step  i. — 
Completely  excise  the  epididymis,  removing  as  little  of  the  vas  deferens  as 
possible. 

Step  2. — Pass  a  fine  probe  or  director  into  the  vas  and  with  this  as  a  guide 
split  the  vas  for  a  little  less  than  half  an  inch. 

Step  3. — With  fine  catgut  sutures,  introduced  in  the  Lembert  fashion, 
unite  the  gaping  end  of  the  vas  to  that  part  of  the  testicle  from  which  the  head 
of  the  epididymis  was  removed  (rete  testis,  beginning  of  the  coni  vasculosi). 

Step  4. — Partially  bury  in  the  testicle  the  site  of  anastomosis,  by  means 
of  a  few  heavy  sutures  introduced  in  the  Lembert  fashion  (Fig.  909). 

Step  5. — Cover  the  line  of  sutures  in  the  testicle  by  closing  with  catgut 
the  wound  in  the  tunica  vaginalis  etc.     Close  the  skin-wound. 

Anastomosis  between  the  Vas  Deferens  and  the  Epididymis  after  Partial 
Excision  of  the  Latter. — Step  i. — Excise  the  tail  and  part  of  the  body  of  the 
epididymis,  dividing  the  body  transversely. 


744 


OPERATIONS    ON   THE   TESTICLES 


Step  2. — Split  the  vas  for  about  3^^  inch,  and  introduce  into  it  (in  the  Lem- 
bert  fashion)  two  fine  catgut  sutures. 

Step  3. — Perforate  or  tunnel  the  remaining  portion  of  the  epididymis  (head 
and  part  of  body)  with  a  pointed  knife  introduced  through  its  cut  surface. 
Through  this  tunnel  pass  by  means  of  needles  the  catgut  sutures  attached  to 
the  vas  (Fig.  910). 


Fig.  909. — Anastomosis  of  vas 
to  testis. 


Fig.  910. — Anastomosis  of  vas  to 
epididymis. 


Step  4. — By  pulling  on  the  catgut  threads  insinuate  the  open  end  of  the 
vas  into  the  tunnel  and  fix  it  there  by  tying  the  catgut  sutures.  One  or  two 
extra  sutures  may  be  used  to  complete  the  union. 

Step  5. — Close  the  wound  in  the  overlying  tissues  by  one  or  more  layers  of 
catgut  sutures. 

Excision  of  the  Vas  Deferens  with  or  without  the  Seminal  Vesicle ;  Vasec- 
tomy.— The  term  "vasectomy"  is  properly  applied  to  this  operation,  but  custom 
seems  to  have  limited  its  use  to  the  mere  division  or  removal  of  a  small  seg- 
ment of  the  vas  in  cases  of  prostatic  hypertrophy.  Vasectomy,  in  the  latter 
limited  sense,  is  peformed  by  incising  the  skin  immediately  below  the  external 
abdominal  ring,  exposing  the  cord,  separating  the  vas  from  the  other  structures 
of  the  cord,  and  dividing  it  between  two  ligatures.  J.  W.  White  and  R.  Harrison 
have  found  much  benefit  result  from  this  simple  operation.  Vasectomy, 
in  the  wider  and  proper  sense  of  the  term,  is  a  much  more  serious  procedure — 
so  difficult,  indeed,  that  a  number  of  operators  have  discarded  its  use.  Vasec- 
tomy may  be  partial  or  complete. 

Partial  Vasectomy. — The  scrotum  has  been  opened  and  the  testicle  or 
the  epididymis  has  been  excised.  The  divided  end  of  the  vas  (if  not  still 
attached  to  the  testis  or  epididymis)  is  seized  in  forceps  to  prevent  its  retraction. 
Continue  the  skin-incision  upwards  and  outwards.  Open  the  inguinal  canal 
by  incising  the  aponeurosis  of  the  external  oblique.  Separate  the  vas  from 
the  cord  up  to  or  within  the  internal  abdominal  ring.  Doubly  ligate  the 
vas  at  as  high  a  point  as  possible  and  divide  it,  being  careful  to  cauterize  the 
stump.  Attend  to  hemostasis  and  close  the  wound.  In  many  cases  this 
partial  operation  suffices. 

Von  Bungner,  instead  of  excising  the  vas  as  above,  merely  follows  it  to 
the  external  abdominal  ring  and  endeavors  to  remove  the  rest  of  it  by  avulsion, 
in  the  same  manner  as  Thiersch  extracts  nerves.     This  method  might  be 


VASECTOMY  745 

practicable  if  the  vas  to  be  removed  was  sound,  but  it  is  diseased  and  gives 
way  at  its  weakest  point,  which  is  a  diseased  point.  Theoretically,  the  method 
is  bad. 

Complete  Vasectomy  with  or  without  Excision  of  the  Seminal  Vesicle. — 
Baudet  and  Duval  have  systematized  this  operation  very  thoroughly.  Place 
the  patient  in  Trendelenburg's  position.     Excise  the  testis  or  epididymis. 

Step  I. — Continue  the  scrotal  wound  up  to  the  external  abdominal  ring 
and  along  the  inguinal  canal  to  a  point  two  fingerbreadths  internal  to  the  an- 
terior superior  iliac  spine. 

Step  2. — Open  the  inguinal  canal  by  incising  the  aponeurosis  of  the  ex- 
ternal oblique.  Divide  the  internal  oblique  and  transversalis  along  the  line 
of  the  skin-incision.  Divide  the  transversalis  fascia  without  injuring  the 
peritoneum. 

Step  3. — With  the  finger  strip  the  peritoneum  off  the  iliac  fossa.  Do 
not  strip  off  any  of  the  fascia  with  the  peritoneum.  It  is  important  to  keep 
between  these  two  structures. 

Step  4. — Incise  the  sheath  of  the  spermatic  cord  and  look  "^or  the  vas  beside 
the  pubic  spine.  With  blunt  dissection  follow  and  isolate  the  vas  first  towards 
the  iliac  fossa  and  then  on  the  peritoneum,  which  is  retracted  inwards  by  a 
wide  retractor.  Do  not  exert  any  traction  on  the  vas.  Use  the  eye  rather 
than  the  finger  as  a  guide.  During  this  dissection  retract  the  epigastric  artery 
forwards,  the  umbilical  downwards  and  outwards.  As  the  wound  becomes 
deeper  carry  out  the  dissection  with  forceps.  When  a  point  deep  down  in  the 
pelvis  is  reached,  note  a  "tent-like"  ridge  passing  transversely  inwards  from 
the  pelvic  wall.  This  is  composed  of  the  vesicular  vessels  covered  by  apo- 
neiurosis,  and  here  the  vas  deferens  enters  the  vesicular  space.  If  the  operation  is 
to  consist  of  complete  vasectomy  alone,  doubly  ligate  the  vas,  divide  and 
remove  it.     If  it  is  desired  to  remove  the  seminal  vesicle,  proceed  to  Step  5. 

Step  5. — Make  a  transverse  tear  in  the  fascia  covering  the  vesicular  vessels. 
Retract  the  edges  of  the  fascial  wound.  Doubly  ligate  and  divide  the  vessels. 
Beneath  the  vessels  lies  the  pale,  rather  sinuous  seminal  vesicle. 

Step  6. — Seize  the  base  of  the  vesicle  with  a  clamp  and  isolate  it  from  its 
sheath,  being  careful,  during  the  dissection,  to  keep  in  close  contact  with 
the  vesicle  so  as  to  avoid  hemorrhage.  The  deep  portion  of  the  vas  is  easily 
separated  from  the  peritoneum  and  bladder;  it  lies  along  the  inner  side  of 
and  is  closely  attached  to  the  vesicle. 

Step  7. — With  scissors  separate  the  vas  and  seminal  vesicle  from  the  pros- 
tate.    Cauterize  the  stump. 

Step  8. — The  most  of  the  huge  wound  promptly  closes  itself  as  soon  as 
the  retractors  are  removed.  It  is  well  to  place  a  cigarette  drain  into  the  depth 
of  the  wound.  Close  the  wound  in  the  parietes  in  the  same  fashion  as  in  the 
radical  cure  of  hernia. 

Young's  Operation. — ("Annals  of  Surgery,"  Oct.,  1900,  and  Nov.,  1901.) 
"Suprapubic  retrocystic  extraperitoneal  resection  of  the  seminal  vesicles 
and  vasa  deferentia."  In  several  cases  Young  has  successfully  performed 
this  most  difficult  operation,  and  has  at  the  same  time  excised  portions  of 
the  urinary  bladder. 


746  OPERATIONS    ON    THE    TESTICLES 

]\Iake  a  vertical  median  incision  from  the  pubis  to  a  point  above  the  um- 
bilicus. At  the  upper  end  of  this  make  a  transverse  incision  dividing  both 
recti  muscles.  These  incisions  penetrate  to  but  do  not  involve  the  peritoneum. 
Retract  the  edges  of  the  wound.  Beginning  below,  dissect  the  peritoneum 
from  the  anterior  bladder-wall  up  to  and  including  the  vertex  of  the  bladder. 
At  the  vertex  the  separation  is  difficult.  Continue  the  separation  down  the 
posterior  bladder-wall  until  the  seminal  vesicles  and  vasa  deferentia  are  ex- 
posed. Remove  these,  and  with  them  any  diseased  portions  of  the  prostate 
and  bladder.  (Young  has  removed  about  one-half  of  the  bladder.)  Close 
the  bladder  wound  by  sutures.  Provide  for  drainage.  Close  the  abdominal 
wound. 

Several  methods  have  been  devised  for  the  exposure  and  removal  of  the 
seminal  vesicles  through  the  peritoneum.  These  are  so  similar  to  some  of 
the  methods  described  for  the  exposure  of  the  prostate  that  they  need  not 
be  dilated  upon.  Schede  has  used  the  sacral  and  parasacral  routes  to  reach 
the  seminal  vesicles,  but  other  routes  seem  as  efficient  and  much  less 
formidable. 

Remarks  on  Castration,  Epididymectomy,  Vasectomy,  and  Vesiculectomy. 
— In  cases  of  malignant  disease  of  the  testicle  or  epididymis  it  is  necessary 
to  abide  by  the  rule,  do  too  much  rather  than  too  little.  The  freest  possible 
excision  of  all  tissue  which  may  possibly  be  infected  is  compulsory,  whether 
that  tissue  shows  any  signs  or  not.  Only  by  conscientiously  working  along 
the  lines  of  thoroughness  can  improved  results  be  obtained.  When  the  disease 
necessitating  operation  is  tuberculosis,  no  such  "hard-and-fast"  rules  meet 
with  universal  approval.  Konig  more  than  any  other  surgeon  has  advanced 
our  knowledge  of  the  surgery  of  tuberculosis,  and  hence  his  opinion  ought  to 
carry  great  weight.  This  surgeon  and  with  him  Kocher,  Terrilon,  Senn,  etc., 
declares  in  favor  of  castration  (orchidectomy)  in  cases  of  tuberculosis  suitable 
for  operation.  When  epididymectomy  is  performed,  it  is  feared  that  tuber- 
culous foci  may  be  left  in  the  testicle  and  cause  further  trouble,  and  it  is  as- 
sumed that  no  useful  function  can  be  performed  by  the  imperfect  organ  left 
behind.  J.  B.  Murphy,  Tillaux,  and  others  draw  attention  to  the  fact  that  the 
testicle  has  a  useful  influence  on  the  general  metabolism  which  must  not  be 
disregarded.  The  glandular  portion  of  the  testicle  is  practically  never  pri- 
marily and  rarely  secondarily  affected  to  a  serious  extent.  The  results  of 
Bardenheuer  and  Murphy  show  that  epididymectomy  is  as  curative  as  is 
castration.  In  suitable  cases  it  may  be  well  to  attempt  anastomosing  the  vas 
to  the  testicle.  Bogoljuboff's  experiments  ("Archiv  f.  klin.  Chir.,"  Ixxii,  p. 
449)  show  that  this  operation  does  actually  provide  direct  communication  be- 
tween the  tubules  of  the  testicles  and  the  vas.  The  status  of  the  operation  is, 
however,  by  no  means  fixed  as  yet. 

J.  B.  Murphy  considers  epididymectomy  contraindicated  (i)  where  there 
are  extensive  tuberculous  lesions  elsewhere  which  will  shortly  terminate  the 
patient's  life.  (2)  Where  the  disease  has  extended  to  and  destroyed  the  greater 
part  or  all  of  the  testis  proper.  Here  castration  should  be  done.  (3)  Where 
the  scrotum  is  riddled  with  discharging  sinuses.  The  indication  is  usually 
here  also  for  castration.     Apart  from  these  three  conditions,  in  every  case  a  re- 


EPIDIDYMOTOMY  747 

section,  typical  or  atypical,  should  be  done.  Murphy  also  points  out  that  after 
epididymectomy  (without  anastomosis)  "sexual  desire  and  potency,  even  to 
emissions,  are  retained;  power  of  procreation,  however,  is  lost." 

Horwitz  comes  to  conclusions  which  are  very  similar  to  and  support  those  of 
Murphy. 

In  a  large  number  of  cases  in  which  there  has  been  evidence  of  involvement 
of  the  vas,  seminal  vesicle,  and  even  bladder,  simple  epididymectomy,  with  or 
without  any  extensive  vasectomy,  has  given  excellent  results.  In  these  cases 
it  appears  as  if  nature  was  able  successfully  to  combat  the  secondary  lesions 
when  the  primary  one  was  eliminated.  The  profound  influence  exerted  on  the 
prostate,  etc.,  by  castration  or  epididymectomy  probably  effectually  aids  nature 
in  her  combat. 

When  the  gravity  of  operations  for  complete  vasectomy  and  vesiculec- 
tomy is  considered,  and  the  frequency  with  which  all  evidences  of  disease  dis- 
appear from  the  neck  of  the  bladder  after  simple  epididymectomy  and  partial 
vasectomy,  it  appears  wise  to  be  conservative.  Young's  advice  is  excellent, 
viz.,  to  abstain  from  operations  on  the  seminal  vesicles  and  prostate  until  such 
time  as  it  is  demonstrated  that  removal  of  the  testicular  foci  has  failed  to  arrest 
the  progress  of  the  disease  in  these  organs  and  it  has  spread  to  the  bladder. 
According  to  Young  serious  involvement  of  distant  parts,  pulmonary,  urinary, 
osseous,  etc.,  does  not  contraindicate  operation.  Removal  of  the  local  lesions 
often  has  a  very  satisfactory  effect  on  the  distant  foci. 

Epididymotomy. — C.  P.  Knight  ("Journ.  A.  M.  A.,"  Jan.  31,  1914)  warmly 
recommends  epididymotomy  in  the  treatment  of  acute  epididymitis  as  it  is 
without  danger,  relieves  pain  promptly  and  saves  much  time. 

Local  anaesthesia.  Make  an  incision  about  i)-^  inches  below  the  lower 
border  ol  the  external  ring  and  prolong  it  sufi&ciently  to  permit  free  delivery  of 
the  testicle  and  the  tunica  vaginalis.  Wrap  the  testicle  in  gauze  moistened 
with  warm  salt  solution.  Make  a  small  incision  in  the  tunica  vaginalis.  Expose 
the  epididymis  and  puncture,  10  or  12  times,  that  part  of  it  which  appears 
inflamed.  Use  a  large  blunt  needle  for  making  the  punctures.  Wash  with 
sterile  water.  Reduce  the  testicle.  Suture  the  cut  in  the  tunica  vaginalis, 
Close  the  skin  wound.  Dress.  The  anaesthetic  agent  (i  per  cent,  novocaine) 
is  injected  into  the  skin,  the  tunica  vaginalis  and  the  epididymis. 

A.  B.  James  (Jour.  A.  M.  A.,  May  24,  191 9)  makes  the  incision  one-half 
inch  external  to  the  raphe  and  large  enough  to  permit  the  delivery  of  the  testicle 
with  its  membranes  intact,  any  hydrocele  fluid  present  being  of  course  evacu- 
ated. He  then  incises  the  tunica  vaginalis  covering  the  epididymis  and  peels 
it  from  the  tunica  albuginia  for  about  one-half  inch  in  all  directions.  The  length 
of  incision  in  the  tunica  vaginalis  is  about  13^2  inches  and  is  in  the  long  axis 
of  the  epididymis.  The  tunica  albuginia  is  similarly  incised  and  peeled  from 
the  epididymis  to  a  considerable  extent.  A  blunt  probe  is  inserted  into  the 
epididymis  in  various  places  and  if  pus  pockets  are  found  the  probe  track  is 
dilated  with  forceps.  A  fenestrated  rubber  tube  is  laid  along  the  epididymis 
and  the  membranes  sutured  over  it  with  catgut.  The  skin  is  closed  except 
where  the  tube  emerges.  The  tube  may  usually  be  removed  in  two  days, 
rarely  three. 


748  OPERATIONS    ON    THE    TESTICLES 

VASOSTOMY 

Belfield  (Journ.  A.  M.  A.,  Jan.  17,  1920)  remarks  that  epididymectomy 
leaves  undisturbed  the  infection  in  the  seminal  vesicle  and  that  consequently 
recurrent  infection  is  not  prevented.  He  advises  puncture  of  the  vas  and  in- 
jections through  it  into  the  vesicle. 

Method  I. — Through  a  scrotal  incision  expose  the  vas  and  lift  it  out  of  its 
sheath  in  which  it  normally  slides  freely  like  a  tendon.  Pass  the  handle  of  a 
scalpel  behind  the  vas  to  support  it  outside  the  skin  wound.  Open  the  small 
lumen  of  the  vas  and  inject  as  in  ^Method  IT. 


Fig.  qii.— {Belfield,  Jour.  A.  M.  A.) 

Method  II. — Step  i. — With  the  fingers  press  the  vas  against  the  lateral  wall 
of  the  scrotum  and  fix  it  there  by  tenaculum  forceps  (Fig.  911)  applied  about 
one-half  inch  apart.  Apply  gentle  traction  to  the  forceps  to  make  tense  the 
tissues  over  the  vas.     Expose  the  vas  through  an  incision  one-half  inch  long. 

Step  2. — Puncture  the  lumen  of  the  vas  with  the  point  of  a  knife,  sufficiently 
to  introduce  a  fine  thread  of  silkworm  gut.  Introduce  this  thread  in  the  direc- 
tion a-way  from  the  epididymis.  Thread  a  blunt  hv-podermic  needle  or  its 
equivalent,  over  the  thread  and  so  guide  it  into  the  lumen.  Remove  the 
guiding  thread. 

Step  3. — ^Slowly  inject  through  the  needle  10  c.c.  methylene  blue  solution 
(i  :  25,000).  This  should  cause  a  desire  to  urinate.  If  the  urine  passed  is  not 
stained  blue,  an  error  in  operation  has  occurred  and  must  be  corrected  or  the 
operation  abandoned.     Belfield  has  found  the  vas  occluded  in  more  than  i  per 


UNDESCENDED    TESTICLE  749 

cent,  of  his  operations.  If  the  second  vas  is  operated  on  at  the  same  sitting, 
Fuchsin  should  be  used  as  the  test  injection.  When  stained  urine  has  proved 
correct  operation  and  patent  duct,  slowly  inject  20  cc.  collargol  solution  (5  per 
cent.)  and  after  two  minutes  inject  i  cc.  water.  This  last  is  done  to  lessen  the 
chance  of  the  collargol  escaping  through  the  puncture  wound. 

Step  4. — Reintroduce  a  strand  of  silkworm  gut  through  the  needle  into  the 
duct.  Withdraw  the  needle.  Thread  a  sharp  hypodermic  needle  over  the 
strand  of  silkworm  gut  and  thus  guided  push  it  into  the  lumen.  Make  the 
point  of  this  needle  pass  through  the  wall  of  the  vas  and  out  through  the  skin 
at  a  point  about  one-half  inch  distant  from  the  original  puncture.  Withdraw 
the  needle  leaving  the  thread  with  its  ends  projecting  from  the  skin.  Do  not 
tie  the  ends  of  the  thread  together.  The  thread  acts  as  a  drain  and  also  as  a 
guide  for  the  introduction  of  the  blunt  needle,  should  further  injection  be  re- 
quired.    Remove  the  thread  within  five  days. 

Operative  Treatment  of  Undescended  and  Misplaced  Testicle. — There  are 
several  types  of  undescended  and  misplaced  testicle.  The  testis  may  be 
situated  (a)  in  the  abdomen  near  its  original  position;  {h)  at  the  internal  ring; 
(c)  in  the  inguinal  canal;  {d)  outside  the  external  ring;  {e)  in  the  perineum; 
(/)  on  the  thigh  below  Poupart's  ligament. 

No  matter  where  the  testis  is  located,  the  principles  of  treatment  are  identi- 
cal. These  principles  are:  (i)  Proper  exposure  of  the  organ.  (2)  Thorough 
relief  of  tension  so  that  the  organ  may  be  brought  into  the  desired  place  (the 
scrotum)  and  may  tend  to  stay  there  of  itself.  (3)  Proper  preparation  of  the 
bed  in  which  the  testis  is  to  lie.  (4)  Selection  of  proper  time  for  operation. 
Undoubtedly  the  changes  incident  to  puberty  will  take  place  more  completely 
in  the  testicle  when  it  lies  in  its  natural  position  in  the  scrotum;  hence  the  age 
of  selection  for  operation  is  before  puberty,  when  the  patient  is  from  six  to  twelve 
years  old. 

A.  D.  Bevan  ("Jour.  Am.  Med.  Assoc,"  Sept.  19,  1903)  has  throwTi  much 
light  on  the  condition  under  discussion,  and  the  following  paragraphs  are  based 
on  his  writings: 

(A)  The  testicle  is  in  the  inguinal  canal  or  outside  the  external  ring. 

Step  1. — Make  an  incision  from  the  external  ring  upwards  and  outwards 
for  a  distance  of  three  inches.  This  incision  is  like  that  made  in  Bassini's 
operaton  for  inguinal  hernia  and  does  not  involve  the  scrotum.  Divide  and 
retract  the  aponeurosis  of  the  external  oblique  as  in  the  hernia  operation. 
Divide  the  cremasteric  and  thin  transversalis  fasciae  throughout  the  length  of 
the  wound. 

Step  2. — Note  the  peritoneal  pouch  containing  the  testicle.  Open  this 
pouch  and  expose  the  testicle.  Divide  the  peritoneum  above  the  testicle  and 
carefully  separate  it  from  the  cord,  as  in  a  hernia  operation.  Close  the  stump 
of  peritoneum  by  suture  or  ligature.  With  a  purse-string  sutmre  close  the 
portion  of  peritoneal  sac  in  contact  with  the  testicle  and  so  form  a  tunica 
vaginalis  (Fig.  912). 

Step  3. — ^Lift  the  testicle  out  of  its  bed.  Pull  gently  on  the  cord  to  lengthen 
it  as  much  as  possible.  Shortened  bands  of  connective  tissue  will  be  seen  as 
tense  bands  in  the  cord.     Tear  through  these  bands  with  forceps.     Strip  the 


750 


OPERATIONS    ON   THE    TESTICLES 


cord  of  all  the  surrounding  fascia,  leaving  nothing  but  the  vessels  and  the  vas. 
Separate  the  spermatic  vessels  and  vas,  which  lie  behind  the  posterior  layer  of 
peritoneum  of  the  abdominal  cavity,  from  the  peritoneum  by  blunt  dissection. 
"The  spermatic  vessels  will  be  found  passing  upwards  and  inwards,  and  the 


Punt  if  rim 
suture  to  form 


■'  a  hjnu)  fbqmatii. 


Fig.  912. 
Figs.  912  and  913.- 


4/- Sffrmohc  i/*sS4/i- 


(.J/ai  dtfrrtml 


\3p*rma/ic  rtiU/i 

Ifui  It  nJ^om  ntcmtry 


-Bevan's  operation. 


Fig.  913. 

(Bevan.) 


vas  downwards  and  inwards  from  the  internal  ring."  The  above  manoeuvres 
should  so  lengthen  the  cord  that  the  testicle  may  be  laid  on  the  thigh  three  or 
four  inches  below  Poupart's  ligament  (Fig.  914).  Unless  lengthening  of  the 
cord  is  obtained  to  the  extent  mentioned,  other  measures  must  be  adopted  to 
secure  the  requisite  relief  of  tension. 


Fig.  914. — Bevan's  operation.     (Bevan.) 


Step  4. — Pass  the  fingers  from  the  wound  into  the  scrotum  and  form  a  pocket 
there.  Into  this  pocket  tuck  the  testicle.  Close  the  mouth  of  the  pocket  by 
a  purse-string  suture  passing  through  both  the  external  and  internal  pillars  of 
the  external  abdominal  ring,  above  the  cord.  Do  not  let  the  suture  exercise 
pressure  on  the  cord. 


UNDESCENDED    TESTICLE 


751 


Ombredanne  (''La  Presse  Med.,"  Oct.  8,  1910)  passes  a  finger  from  the 
wound  into  the  bottom  of  the  scrotum  on  the  same  side  and  then  pushes  the 
finger  transversely  through  the  septum  into  the  other  side  of  the  scrotum  where 
he  incises  the  skin  (Fig.  915).  A  forceps  passed  through  the  scrotal  skin  wound 
follows  the  finger  as  it  is  withdrawn  to  emerge  at  the  inguinal  wound  where 
it  grasps  a  suture  inserted  into  the  tunica  vaginalis  formed  in  Step  2.  By- 
pulling  on  the  suture  the  testicle  is  pulled  through  the  septum  to  the  opposite 
side  of  the  scrotum,  where  it  is  easily  fixed  by  a  few  stitches. 

Step  5. — Close  the  wound  as  in  a  Bassini  operation,  but  instead  of  dislocat- 
ing the  cord,  sew  the  conjoined  tendon  and  Poupart's  ligament  together  above, 
i.e.,  superficial  to  the  cord. 


Fig.  915. — Ombredanne's  operation.     {Omhredanne.) 


(B)  Where  it  is  impossible  to  get  the  requisite  lengthening  of  the  cord  by  the 
means  described  in  Step  3,  or  when  the  testicle  is  intra-abdominal,  the  following 
measures  suffice:  Open  the  inguinal  canal.  Expose  the  testis;  if  necessary, 
"hook"  it  out  of  the  abdominal  cavity  with  the  finger.  The  obstacle  to  the 
descent  of  the  testicle  is  not  the  vas,  but  the  spermatic  vessels.  Division  of 
these  does  no  harm  to  the  testis.  This  was  pointed  out  many  years  ago  by 
Bennet,  and  agrees  with  the  T^Titer's  experience.  The  testicle  gets  a  sufficiency 
of  nourishment  through  the  artery  of  the  vas.  Doubly  ligate  and  divide  the 
spermatic  vessels  (Fig.  913).  When  this  is  done,  it  is  easy  to  bring  the  testicle 
down  into  the  scrotum. 


752 


HYDROCELE 


CHAPTER  LVII 


HYDROCELE 


Tapping  a  Hydrocele. — Clean  the  scrotum.  Ascertain  the  position  of  the 
testicle  by  palpation;  the  patient's  sensations  aid,  so  does  the  translucency 
test.  Place  the  left  hand  behind  the  scrotum  and  grasp  it  so  as  to  render  its 
anterior  surface  tense.  Choose  a  point  on  the  lower  anterior  surface  free  from 
veins  and  at  this  place  thrust  a  trocar  and  cannula  upwards  and  backwards  to 
a  depth  of  about  one  inch.  Avoid  thrusting  towards  the  testicle.  Withdraw 
the  trocar  and  let  the  fluid  escape  through  the  cannula,  keeping  up  pressure 
with  the  left  hand.  When  the  fluid  is  all  evacuated  withdraw  the  cannula. 
Dress  the  puncture  with  collodion  or  leave  it  to  the  care  of  nature  which  is 
usually  equally  good. 

Radical  Cure  of  Hydrocele. — I.  Injection  Method. — A.  Iodine  Injection. — 
Tap  the  hydrocele  completely.     Inject  through  the  cannula  about  half  an  ounce 

of  tincture  of  iodine.  Withdraw  the  cannula. 
Rub  the  scrotum  gently  between  the  hands  to 
insure  even  distribution  of  the  iodine  throughout 
the  sac.  Within  twenty-four  to  thirty-six  hours 
there  is  much  swelling  and  pain  in  the  scrotum 
but  this  soon  subsides.  After  two  or  three  weeks 
recovery  ensues  though  a  suspensory  bandage  is 
often  required  for  some  time. 

B.  Carbolic  Acid  Injection. — Tap  and  inject 
about  ten  drops  of  liquefied  carbolic  acid  in  the 
same  manner  as  with  iodine.  It  is  difficult  to  inject 
through  the  cannula  such  a  small  quantity  of 
liquid,  hence  the  following  method  is  better. 
By  tapping  withdraw  most  but  not  all  of  the 
liquid.  Charge  a  hypodermic  syringe  with  the 
carbolic  acid.  Puncture  the  hydrocele  with  the 
hypodermic  needle  until  the  needle  touches  the 
cannula,  thus  making  sure  that  its  point  is  really 
inside  the  sac.  Permit  the  rest  of  the  hydrocele 
fluid  to  escape  through  the  cannula.  Withdraw  the 
cannula.  Discharge  the  hypodermic  syringe  and  withdraw  it.  The  results 
of  injecting  carbolic  acid  are  as  good  and  less  painful  than  when  iodine  is  used. 
The  author  cannot  recommend  the  injection  method  of  treatment.  It  is  less 
sure,  more  painful  and  less  free  from  danger  than  is  open  operation. 

II.  Incision. — Volkman's  operation.  Make  an  incision,  not  less  than  z.}^ 
inches  long,  into  the  sac.  Suture  the  wound  in  the  sac  to  the  skin.  Drain 
with  tube  or  gauze.     Apply  dressings. 

III.  Excision. — Bergmann's  operation.  Through  the  skin  make  an  incision 
extending  from  near  the  upper  to  near  the  lower  end  of  the  hydrocele.  Expose 
the  sac  and  by  blunt  and  sharp  dissection  separate  it  from  its  coverings  until 


Fig.  916. — Jaboulay's  operation. 
{Duval.) 


VARICOCELE  753 

its  connections  with  the  testicle  are  reached.  Open  the  sac  and  trim  it  off 
close  to  the  testicle.  Attend  to  hemostasis.  Close  the  wound  with  or  without 
drainage.  In  scrotal  wounds  the  writer  usually  inserts  a  very  few  interrupted 
sutures  between  which  it  is  easy  for  fluids  to  escape.  Apply  dressings  and 
support  the  scrotum. 

IV.  Eversion  of  Hydrocele  Sac. — Jaboulay's  operation.  Make  an  incision 
into  the  hydrocele.  Bring  the  testicle  out  through  the  wound.  Ligate  and 
divide  the  gubernaculum  testis.  Fold  the  two  sides  of  the  divided  sac  behind 
the  testicle  and  fix  them  there  by  a  few  sutures,  one  of  which  must  interest  the 
superficial  tissues  of  the  cord.  Reduce  the  testicle.  Close  the  scrotal  wound 
by  a  few  sutures  (Fig.  916).  This  is  a  very  satisfactory,  easy  and  rapid 
operation. 

Hydrocele  of  the  Cord. — A.  Small  hydroceles  or  cysts  of  the  cord.  Expose 
the  sac  by  an  incision  almost  as  long  as  itself.  Pick  up  the  upper  end  of  the  sac 
in  the  fingers  and  remove  it  if  possible  unbroken  by  gauze  dissection.*  Close 
the  wound. 

B.  Hydrocele  of  larger  size  than  the  preceding. 

{a)  Incise  and  drain. 

{h)  Excise  most  of  the  sac  wall. 

(c)  Eversion  method.  Incise.  Turn  the  walls  of  the  sac  back  and  fix  with 
sutures  on  the  other  side  of  the  cord. 


CHAPTER  LVIII 
VARICOCELE 


Open  Operation. — Step  i. — Make  an  incision  parallel  to  and  directly  over 
the  cord.  The  incision  should  be  i  to  i)-^  inches  long  and  its  upper  end  cor- 
respond to  the  external  abdominal  ring.  Layer  by  layer  divide  the  tissues 
until  the  cord  is  exposed. 

Step  2. — Pick  up  the  whole  cord  and  isolate  it  from  the  external  abdominal 
ring  to  the  testicle.  This  is  easy.  Recognize  the  vas  which  feels  like  whip- 
cord. Separate  the  vas  and  with  it  a  very  few  veins,  from  the  rest  of  the  struc- 
tures forming  the  cord  and  hold  it  aside. 

Step  3. — Apply  a  crushing  forceps  near  the  external  abdominal  ring  to  the 
mass  of  veins  to  be  removed.  Similarly  apply  a  crushing  forceps  or  clamp  to 
the  same  mass  of  veins  near  the  testicle.  Remove  the  crushing  clamps.  Tie 
catgut  ligatures  round  the  veins  in  the  grooves  left  by  the  clamps.  Cut  away 
the  veins  between  the  ligatures  leaving  sufficient  stump  to  prevent  slipping  of 
the  ligatures.  The  only  objects  in  using  the  crushing  clamps  are  to  provide  a 
groove  in  which  the  ligatures  can  lie  and  to  permit  the  use  of  a  finer  thread  than 
would  otherwise  be  necessary, 

*  Gauze  dissection.  Blunt  dissection  may  be  carried  out  with  instruments  or  with  the 
fingers.  If  a  "sponge"  or  "wipe"  of  gauze  is  used  over  the  tips  of  the  finger  the  dissection  is 
more  satisfactory.     This  constitutes  gauze  dissection. 

48 


754  VARICOCELE 

Step  4. — Bring  the  two  venous  stumps  together  and  keep  them  together  by 
a  stitch  or  by  tying  the  upper  to  the  lower  ligature. 

Step  5. — Close  the  wound  with  or  without  drainage. 

Remarks. — The  incision  is  made  at  the  level  of  the  external  abdominal  ring 
because  at  this  place  (a)  it  is  easy  to  isolate  the  cord,  {b)  it  is  very  easy  to 
apply  dressings  after  the  operation. 

On  recovery,  a  suspensory  bandage  ought  to  be  worn  for  some  months. 
The  junior  surgeon  may  be  warned  that  a  hard  swelling  about  the  testicle 
usually  persists  for  a  few  weeks  after  healing,  which  may  alarm  the  patient 
unless  he  is  warned  of  the  possibility  before  hand. 

R.  Frank's  Operation  ("Zent.  f.  Chir.,"  iv,  April,  1914). — Frank  avoids 
ligation  and  resection  of  the  veins  with  consequent  fibrous  degeneration  of 
the  parenchyma  of  the  testicle. 


Fig. 


917. 


Expose  the  fascia  of  the  external  oblique  and  the  external  inguinal  ring 
exactly  as  in  an  operation  for  hernia.  Strengthen  the  external  inguinal  ring 
with  a  stout  stitch.  Do  not  divide  the  fascia  propria  or  the  tunica  vaginalis. 
Pull  the  testicle  up  out  of  the  scrotum  to  the  bottom  of  which  it  is  attached 
by  the  gubernaculum.  Divide  the  gubernaculum  between  forceps;  ligate  the 
scrotal  stump  but  leave  the  forceps  atached  to  the  testicular  stump.  From 
the  apneurosis  of  the  external  oblique  reflect  downwards  a  flap  (pedicle  at  the 
external  ring)  5  cm.  (2  in.)  long  and  2-3  cm.  {^iri}4r  in.)  wide.  Suture  the 
distal  end  of  the  aponeurotic  flap  to  the  testicular  stump  of  the  gubernaculum 
(Fig.  917).  The  length  of  the  fascial  flap  must  be  sufficient  to  support  the 
testicle  in  its  physiological  position  just  under  the  root  of  the  penis.  Reduce 
the  testicle  into  the  scrotum.  Close  the  wound.  The  testicle  now  lies  upside 
down  in  the  scrotum. 


PART  v.— THE  SPINE 


CHAPTER  LIX 
OPERATIONS  ON  THE  SPINE 

It  is  important  to  recognize  certain  easily  remembered  relations  which 
exist  between  the  spinal  cord  and  the  spinous  processes.  These  relations  are 
thus  described  by  Chipault:  (Fig.  918.) 

(a)  The  terminal  cul-de-sac  of  the  dura  mater  corresponds  to  the  fifth  lum- 
bar interspinous  space. 

(b)  The  inferior  limit  of  the  spinal  cord  is  situated  in  men  at  the  level  of  the 
first,  in  women,  of  the  second,  in  infants,  of  the  third,  lumbar  spinous  process. 

(c)  The  cervical  segment  of  the  cord  terminates  at  the  level  of  the  sixth 
cervical  interspinous  space;  the  dorsal,  at  the  ninth  dorsal;  the  lumbar,  at  the 
inferior  border  of  the  twelfth  dorsal  spine;  the  sacral  segment  ends  at  the 
superior  border  of  the  first  lumbar  spine. 

(d)  The  relations  of  the  summits  of  the  spinous  processes  to  the  nerve  roots 
may  be  expressed  by  a  simple  formula  which,  while  not  mathematically  correct, 
is  sufficiently  so  to  act  as  a  guide  in  surgical  intervention. 

For  adults  the  formula  is:  In  the  cervical  region  to  find  the  nerve  which 
emerges  at  the  level  of  the  individual  spinous  process,  add  the  numeral  one  to 
the  number  of  the  process,  e.g.,  it  is  the  third  cervical  root  which  emerges 
opposite  the  second  spinous  process.  In  the  superior  dorsal  region  add  the 
numeral  two  to  the  number  of  the  process.  From  the  sixth  to  the  eleventh 
dorsal  processes  add  the  numeral  three.  The  inferior  part  of  the  eleventh 
dorsal  spinous  process  and  the  subjacent  interspace  correspond  to  the  origin  of 
the  sacral  nerves. 

For  children  under  the  age  of  six  or  seven  years  the  following  modification  of 
the  formula  holds  good:  In  the  superior  dorsal  region  (from  the  first  to  the 
fourth  apophysis)  add  three  to  the  number  of  the  spinous  process  to  obtain  the 
number  of  the  corresponding  nerve  root;  in  the  mid-dorsal  region  (fifth  to  ninth 
apophyses)  add  the  numeral  four. 

LUMBAR  PUNCTURE 

Lumbar  puncture  is  the  operation  by  which  the  lumbo-sacral  cerebro- 
spinal cistern  is  tapped. 

Objects  of  the  operation,     (a)  Diagnostic:  Observation  of  the  tension,  the 

755 


756 


OPERATIONS    ON    THE    SPINE 


III 


VII 


chemical  composition,  the  freezing  point,  the  cellular  composition,  the  bacteri- 
ology of  the  fluid  and  the  permeability  of  the  meninges  to  chemical  substances 
introduced  into  the  blood,  (b)  Therapeutic:  Relief  of  cerebro-spinal  tension. 
(c)  A  step  in  the  production  of  spinal  anesthesia. 

One  must  remember  that  there  is  no  means  of  knowing  whether  the  fluid 
obtained  by  puncture  in  any  individual  case  is  from  the 
subarachnoid  or  the  subdural  space  (Ballance). 
^^/C 57  ^n^^  '■  The  commonest  site  for  the  puncture  is  between 

fourth  and  fifth  lumbar  vertebrae,  though  Chipault  thinks 
the  lumbo-sacral  space  better  as  it  is  larger,  surrounded 
by  good  landmarks  and  is  opposite  the  terminal  en- 
largement of  the  dural  sheath. 

Puncture  in  fourth  lumbar  interspace. 
It  will  be  most  convenient  to  describe  the  operation 
as  performed  for  the  production  of  spinal  anesthesia. 

Step  I. — Seat  the  patient  with  his  legs  and  arms 
hanging  in  front  and  body  bent  well  forwards.  Clean 
the  whole  lower  part  of  the  back.  Palpate  the  crest  of 
the  iliac  bones;  note  their  high  points;  join  these  points 
by  a  line.  This  line  bisects  the  fourth  lumbar  space 
(Figs.  919,  920).  Place  and  keep  a  finger  on  the  point 
of  the  fourth  lumbar  spine. 

Step  2. — Take  a  hollow  needle  about  3  inches  long 
and   about  3^2  ii^ch  (i  mm.)  in  diameter.     Probably 
Dawbarn's  is  the  best  needle.     Introduce  the    needle 
\n  about  ^-^  inch  from  the  middle  line  and  slightly  below  the 

spinous  process.  Push  the  needle  slowly  and  steadily 
forwards  and  slightly  inwards  until  the  cerebro-spinal 


XI 


Viii 


.w 


Fig.  918. — Relation 
between  spinal  cord 
and  spinous  processes. 
[Poirier  and  Charpy.) 


Fig.  919. — Spinal  puncture.     {Marion.) 


fluid  escapes  drop  by  drop.  If  the  operation  is  performed  for  diagnosis  or 
relief  of  tension  collect  the  fluid  in  sterile  test-tube.  In  children  the  needle 
must  usually  penetrate  i  to  i}/i  inches,  in  adults  i}4,  to  2^  inches  or  more. 


SPINAL    MEXIXGITIS  757 

Step  3. — As  soon  as  the  liquid  begins  to  escape  fix  a  hypodermic  syringe  to 
the  needle.  The  syringe  should  contain  the  sterilized  powder  to  be  injected 
(tropacocain;  stovain;  novocain).  Slowly  withdraw  the  piston  of  the  syringe 
and  thus  draw  cerebro-spinal  fluid  into  the  syringe.  As  soon  as  the  fluid  has 
dissolved  the  powder  reinject  slowly.  Remove  the  needle.  Dress  the  puncture 
wound  with  collodion.  The  operation  may  be  performed  with  the  patient  in 
the  lateral  posture,  lying  down  with  the  back  thoroughly  flexed. 


Fig.  920. — Spinal  puncture.     {Marion.) 

SPINAL   MENINGITIS 

The  operative  treatment  of  spinal  meningitis  is  in  its  infancy.  A  case 
reported  by  Kiimmel  ("Archiv  fiir  klin.  Chir.,"  Ixxvii,  938)  gives  hope  for  the 
future.  A  sacral  tumor  had  been  removed  from  a  woman,  aged  tw^enty-seven; 
a  fistula  resulted  and  became  infected;  an  extensive  pelvic  phlegmon  formed; 
the  patient  became  very  restless  and  stupid,  later  comatose.  Pulse  160.  Temp. 
105°.  Cerebro-spinal  meningitis  was  clearly  present.  By  lumbar  puncture 
there  w-as  drawn  off  cloudy  purulent  fluid  which  was  under  pressure.  In 
spite  of  the  desperate  condition  of  the  patient,  the  spinal  canal  was  opened  from 
the  fistula  up  to  the  second  lumbar  vertebra;  bad-smelling  pus  escaped;  the 
discolored  dura  was  widely  opened;  the  arachnoid  was  injected  and  infiltrated 
with  pus. 

The  patient  regained  consciousness,  headache  disappeared,  vomiting  ceased, 
spinal  rigidity  almost  vanished.  Owing  to  extreme  weakness  the  patient  died 
within  forty-eight  hours.  The  autopsy  showed  extensive  suppurative  cerebro- 
spinal meningitis;  pelvic  phlegmon  and  peritonitis;  pericarditis.  This  case, 
in  spite  of  its  fatal  outcome,  is  encouraging. 

Murphy  formulates  the  indications  for  operative  intervention  in  acute 
meningitis  as  follows: 

"i.  Lumbar  spinal  puncture  for  the  diagnosis  as  well  as  for  the  relief  of 
cerebro-spinal  tension.    Large  quantities  of  fluid  may  be  withdrawn  at  in- 


758  OPERATIONS    ON    THE    SPINE 

dividual  sittings  in  this  way,  and  the  sittings  may  be  as  frequent  as  the  symp- 
toms of  cerebral  pressure  recur.  A  cannula  with  a  double  opening  at  its  lower 
end  may  be  substituted  for  the  needle  in  cases  of  rapidly  recurring  cases  of  hyper- 
pressure.  This  must  be  very  cautiously  protected  against  the  entrance  of 
air  and  micro-organisms. 

"2.  Continuous  drainage  of  the  spinal  canal  with  secondary  drainage  of 
the  ventricles  may  be  established  by  a  single  laminectomy  with  the  insertion  of 
a  very  small  tube.  This,  however,  will  be  rarely  indicated  if  the  cannula  is 
used  judiciously  and  to  its  best  purpose. 

"3.  Ventricular  drainage,  transoccipital,  can  be  made  through  a  musculo- 
cutaneous flap  with  a  trephine  opening  in  the  occipital  bone  to  the  right  or 
left  of  the  median  line,  an  inch  posterior  to  the  foramen  magnum.  The  dura 
may  then  be  excised,  the  bony  opening  enlarged,  if  necessary,  with  bone- 
forceps,  the  velum  exposed,  opened  if  indicated,  or  the  tube  may  be  inserted  in 
the  subarachnoid  space  without  opening  the  velum.  This  can  be  utilized  in 
connection  with  spinal  puncture  or  laminectomy. 

"4.  Transparietal  ventricular  drainage  can  be  established  by  following  the 
description  given  in  the  average  work  on  surgery  for  the  insertion  of  the  tube 
into  the  lateral  ventricles.  A  small  trephine  opening  is  all  that  is  necessary 
for  this  procedure.  It  is  an  operation  that  will  be  rarely  undertaken,  as  lateral 
ventricular  is  the  least  common  of  the  meningeal  infections.  The  duration  of 
the  drainage  is  governed  by  the  general  surgical  principles  of  drainage.  I  pre- 
fer rubber  to  the  metallic  type  of  drain." 

Operation  for  Acute  Lepto-meningitis.— Drainage  and  Spinal  Irrigation. — 
Place  the  patient  in  a  position  with  maximum  flexion  of  the  lumbo-sacral 
region. 

Step  I. — Make  a  three-inch  longitudinal  incision  on  each  side  of  the 
sacrum,  following  the  lines  of  the  postero-external  tubercles.  Unite  the 
lower  ends  of  the  incision  by  a  curved  transverse  cut  at  the  level  of  the 
last  sacral  tubercles.  Reflect  upwards  the  U-shaped  flap  until  the  sacral 
foramina  are  exposed. 

Step  2. — With  bone-forceps  divide  the  sacral  laminae  from  below  upwards 
until  the  dura  is  exposed  at  the  third  body.  This  portion  of  the  dura  forms  the 
lower  boundary  of  sacral  cerebro-spinal  cistern.     Attend  to  hemostasis. 

Step  3. — Make  a  small  longitudinal  incision  through  the  dura.  Permit  the 
escape  of  enough  fluid  to  relieve  tension.  Close  the  dural  wound  with  a  hemo- 
stat.     Temporarily  cover  the  wound  with  dressings. 

Step  4. — Make  an  incision  parallel  to  and  below  the  occipital  ridges  on  one 
side  down  to  the  bone.  From  the  inner  end  of  this  incision  make  a  median  cut 
downwards  to  within  }4  inch  of  the  foramen  magnum.  Reflect  the  soft  parts. 
Open  the  skull  near  the  middle  line  over  one  cerebellar  fossa. 

Step  5. — Make  a  small  opening  through  the  dura  into  the  cerebellar  cistern. 
Introduce  a  blunt  cannula,  such  as  is  used  in  the  intravenous  infusion  of  salt 
solution.     Attach  an  irrigator  charged  with  salt  solution  to  the  cannula. 

Step  6. — Remove  the  forceps  from  the  dural  opening  at  the  sacrum.  Permit 
salt  solution  to  flow  through  the  cannula  into  the  subdural  space,  through 


LAMINECTOMY 


759 


CeTe&Cyslcnv 


the  spine  and  out  through  the  sacral  wound.  To  demonstrate  that  the  salt 
solution  introduced  above  is  escaping  below  Murphy  suggests  coloring  it  with 
carmine. 

Step  7. — Insert  rubber  drainage-tubes  into  both  the  upper  and  lower  open- 
ings.    Close    the   wounds   around    the 
tubes.    Regulate  the  cerebro-spinal  ten- 
sion by  clamps  applied  to  the  tubes. 

Murphy,  who  has  systematized  the 
above  operation,  writes:  "The  irriga- 
tion may  not  be  needed,  as  a  simple 
drainage  with  relief  of  pressure  or  pus 
tension  is  often  all  that  is  needed  to 
conduct  to  a  cure.  It  is  the  tension 
that  favors  absorption  and  tissue  nec- 
rosis, and  tiding  over  the  primary 
acute  pressure  of  the  products  of  infec- 
tion is  life-saving." 

LAMINECTOMY 

Laminectomy  is  the  operative  means 
by  which  the  spinal  canal  is  opened  for 
exploratory  or  therapeutic  purposes. 

Method  A. — Step  i. — Make  a  verti- 
cal median  incision  over  the  spinous 
processes.  This  cut  reaches  directly  to 
the  spinous  processes,  and  is  at  least 
four  inches  in  length. 

Step  2. — On  one  side  of  the  spine 
separate  by  sharp  and  blunt  dissection 
the  muscles  from  the  side  of  the  spinous 
processes  and  from  the  back  of  the 
laminae  of  the  vertebrae.  Bleeding  is 
usually  severe.  Quickly  pick  up  the 
bleeding  vessels  with  forceps  and  pack 
the  wound  with  gauze  wrung  out  of 
very  hot  water.  Separate  the  muscles 
on  the  opposite  side  in  the  same  way. 

Step  3. — Choose  the  point  at  which 
to  enter  the  spinal  canal.  Divide  the 
interspinous  ligament.  Cut  away  the 
spinous  processes  with  bone-cutting 
forceps.  Proceed  to  the  division  of  the  laminae  for  which  several  methods  are 
available:  {a)  Apply  an  osteotome  to  the  lower  edge  of  the  lamina  and  with 
blows  of  a  mallet  drive  it  through  the  bone.  It  is  important  to  keep  the  long 
axis  of  the  osteotome  parallel  to  the  plane  of  the  bone  lest  the  instrument  pene- 
trate and  injure  the  contents  of  the  canal.     It  is  also  important  to  have  the 


cisterns.       {Murphy 
after  Poirier.) 


760 


OPERATIONS    ON   THE    SPINE 


Improper  line 
of  division 


Proper  line 
of  division 


bone  incision  at  right  angles  to  the  lamina,  otherwise  the  instrument  may  cut 
its  way  into  the  pedicle  of  the  vertebra  and  much  time  be  lost  (Fig.  922). 
Having  divided  one  lamina  divide  the  lamina  on  the  opposite  side  of  the  same 

vertebra  and  remove  the  bone.  The 
laminae  of  the  vertebrae  above  and  below 
may  be  divided  as  required  with  osteotome 
or  with  forceps. 

(b)  Perforate  a  lamina  with  Doyen 
burr  or  with  a  trephine  and  complete  its 
division  with  forceps  (Keen's;  "De  Vil- 
biss,"  etc.). 

(c)  Divide  the  laminae  with  a  saw. 
(Hay's,  "MacEwen's,  Doyen's.") 

Step  4. — Inspect  carefully  the  contents 
of  the  spinal  canal.  Examine  the  anterior 
as  well  as  the  posterior  surface  of  the 
cord.  The  cord  may  be  gently  pulled  to 
one  side  without  damage  resulting.  Note 
the  condition  of  the  posterior  surface  of 
the  vertebral  bodies. 
^^'  ^^~'  Carry  out  any  therapeutic  measures 

which  may  be  indicated.  If  it  seems  necessary  to  open  the  dura  mater,  do  so, 
and  close  the  opening  with  fine  catgut  sutures.  Having  completed  the  ex- 
ploration or  whatever  operative  measures  may  have  been  necessary,  close 
the  external  wound  by  deep  and  superficial  sutures,  with  or  without  drainage. 
Generally  drainage  during  the  first  twenty-four  hours  is  advisable.  Apply 
the  usual  dressings  and  carry  out  subse- 
quent treatment  on  the  ordinary  principles 
of  surgery. 

Method  B. — Frazier's  Method. — To  in- 
crease insurance  against  infection  and  to 
arrest  promptly  the  flow  of  cerebro-spinal 
fluid  when  the  meninges  have  been  opened 
Frazier  divides  the  skin,  fascia  and  muscles 
in  different  planes. 

Step  I.— Reflect  a  skin  flap,  A  B  C  D 
(Fig.  923),  so  as  to  expose  the  desired  area. 

Step  2. — Make  a  vertical  incision  through  the  aponeurosis  a  little  to  one 
side  of  the  median  line  and  by  reflecting  the  aponeurosis  slightly  from  the 
deeper  structures  gain  access  to  the  muscles  on  each  side  of  the  spinous 
processes. 

Step  3. — Separate  the  muscles  from  the  spinous  processes  and  laminae  in 
the  usual  manner. 

In  closing  the  wound  suture  the  different  structures  separately. 
Method    C.—Urban's    Osteoplastic    Method.— M&ke    a    U-shaped    incision 
around  the  area  of  spine  to  be  attacked.     Through  the  vertical  limbs  of  the 
TJ  expose  and  divide  the  vertebral  laminae  with  chisel,  saw,  or  forceps.     Divide 


Fig. 


923- 


LAMINECTOMY 


761 


the  interspinous  ligament  opposite  the  transverse  part  of  the  U  cut.  Expose 
the  spinal  canal  by  reflecting  the  U-shaped  flap  which  contains,  besides  the 
skin  and  soft  structures  of  the  back,  the  spinous  processes  and  part  of  the 
vertebral  laminaj.  (Fig.  924).  The  rest  of  the  operation  is  the  same  as  in 
Method  A. 

Method  D. — Abbes  Osteoplastic  Method. — Make  an  incision   through   the 
soft  parts  about  }4  inch  to  the  side  of  the  spinous  processes.     Expose  one  side 


■m%  »'^i 


v^.v £s-  > 


Fig.  924. — Osteoplastic  laminectomy.     {Urban,  Archiv  Jilr  Klin.  Chir.) 
a.  Divided  laminae;  b,  post,  wall  of  spinal  canal  reflected  in  flaps;  c,  cord. 


of  the  spinous  processes.  With  a  chisel  or  osteotome  divide  the  spinous  proc- 
esses near  the  laminae.  Turn  the  spines  back  along  with  the  soft  parts  as  a 
flap  on  the  other  side  of  the  wound.     Proceed  with  the  laminectomy. 

Method  E. — Ropke's  Temporary  Laminectomy. — (''Zentralblatt  flir  Chir.," 
1910,  No.  33.) 

Step  I. — Make  a  longitudinal  incision  over  the  spinous  process  of  the  selected 
vertebrae.  Separate  the  soft  parts  on  each  side  from  these  processes  and  down 
to  their  bases.  Remove  each  spinous  process  by  cutting  it  at  its  base  with  a 
bone  forceps. 

Step  2. — With  a  wide  chisel  applied  to  the  osseous  wound  cut  off  a  slice  of 


762 


OPERATIONS    ON   THE    SPINE 


Fig.  925. — Ropke's  method.        F1G.92C. — Osteoplastic  laminectomy.   (Marion.) 


TUBERCULOUS    PARAPLEGIA  763 

each  lamina  (Fig.  925)  and  retract  these  mobilized  portions  of  laminae  along 
with  the  soft  parts. 

Step  3. — With  a  chisel  or  rongeur  forceps  excise  the  remaining  portions  of 
the  laminae.  This  gives  free  access  to  the  spinal  cord.  Ropke  in  one  case  was 
able  to  remove  two  tumors  from  the  sides  of  the  cord  and  one  from  inside  the 
cord  itself. 

Step  4. — After  completing  the  operation  on  the  cord  and  suturing  the  dura, 
replace  the  bone-periosteal  flaps  and  close  the  wound  with  sutures. 

To  the  author  it  seems  that  Ropke's  operation  will  prove  useful  in  cases  of 
tumor  of  the  cord  and  where  division  of  the  posterior  nerve  roots  is  indicated 
(Foerster's  operation). 

Method  F. — Osteoplastic  Method  of  Cavicchia  and  Durante. — This  method, 
very  similar  to  Abbe's  is  most  highly  recommended  by  Marion. 

Step  I. — Make  a  slightly  curved  incision  (Fig.  926)  to  outline  a  skin  flap 
which  when  reflected  will  expose  the  region  to  be  attacked.  As  in  craniectomy 
it  is  necessary  to  open  the  spine  widely  to  avoid  missing  the  lesion  present.  A 
minimum  of  four  arches  ought  to  be  opened  except  in  cases  of  localized  osseous 
lesions;  hence  a  large  skin  incision  is  necessary."      (Marion.) 

Step  2. — ^Leaving  the  supra- and  interspinous  ligaments  intact,  separate  the 
soft  parts  on  each  side  from  the  spinous  processes  and  laminae.  Retract  the 
soft  parts.  With  the  chisel  as  in  Abbe's  operation  divide  the  bases  of  the  spines 
or  do  the  same  thing  by  means  of  special  forceps  (Fig.  927).  Retract  the  line 
of  mobilized  spinous  processes  which  remain  attached  to  each  other  and  to  the 
body  by  the  supra-  and  interspinous  ligaments. 

Step  3. — As  in  Method  A.  When  wound  is  closed  the  chain  of  spinous 
processes  is  left  in  place  and  is  believed  to  give  support  to  the  back. 

To  the  author  it  seems  that  the  simplest  manner  of  opening  the  spine  is  the 
best.  The  loss  of  the  laminae  of  four  vertebrae  does  not  seem  to  appreciably 
lessen  the  stability  of  the  spine. 

TUBERCULOUS  PARAPLEGIA 

A  tuberculous  lesion  situated  in  the  body  of  a  vertebra  (usually  lower 
dorsal  or  upper  lumbar)  may  spread  backwards  and  form  a  tuberculoma  which 
presses  on  the  front  of  the  cord.  The  cord  is  usually  bent  and  flattened  but 
for  a  long  time  there  may  be  no  trophic  or  degenerative  changes  in  the  cord. 
In  a  case  favorable  for  operation  the  disease  is  practically  an  extra  dural  tumor 
on  the  posterior  surface  of  the  vertebral  body  and  hence  the  early  paraplegic 
symptoms  are  purely  motor.  Operation  is  indicated  before  degeneration  of  the 
cord  becomes  established  and  after  proper  treatment  by  hygiene  and  im- 
mobilization has  failed.  According  to  Gowers  paralysis  due  to  vertebral  caries 
is  the  most  favorable  of  all  types  of  paralysis. 

Operative  Treatment. 

Step  I. — Open  the  spine  by  laminectomy.     Do  not  open  the  meninges. 

Step  2. — Displace  the  cord  to  one  side.  Expose  the  granuloma  and  thor- 
oughly remove  it  with  the  curette.  Dry  the  bone  cavity  carefully  and  fill 
it  with  a  Mosetig-Moorhof  bone  plug. 


764  OPERATIONS    ON    THE    SPINE 

[Iodoform,  60;  spermaceti  and  oleum  sesami,  aa,  40;  heated  slowly  to  100** 
C.  in  a  flask  on  a  water-bath;  kept  at  this  temperature  for  fifteen  minutes,  then 
removed  and  allowed  to  cool  and  solidify,  while  shaken  constantly.  Before 
using,  melt  and  heat  to  50°  C.  in  a  thermostat.] 

If  the  wound  heals  without  suppuration  and  operation  has  not  been  too 
long  delayed,  the  paraplegia  rapidly  disappears. 

Harte  ("Trans.  Am.  Surg.  Assoc,"  1905)  has  collected  records  of  ninety- 
two  operations  for  spinal  tumors  with  a  total  mortality  of  47  per  cent.;  the 
mortality  due  to  the  operation  was,  however,  only  28  per  cent.  Even  when  a 
cure  could  not  be  obtained  relief  from  pain  was  almost  always  secured.  The 
large  number  of  sarcomata  removed  and  the  striking  absence  of  recurrence 
exhibited  (seventeen  out  of  thirty-seven)  makes  it  probable  either  that  there 
was  a  mistake  in  the  histologic  diagnosis  or  that  sarcomata  in  this  region  are 
of  comparative  benignity. 

In  some  of  Harte's  cases  the  symptoms  of  tumor  were  due  to  meningeal 
thickenings  or  adhesions.  In  the  discussion  of  Harte's  paper  J.  C.  Munro 
stated:  "In  a  number  of  cases  that  I  have  had — cases  of  syringomyelia  and 
of  chronic  fracture — I  have  found  that  which  at  one  time  was  denied  by  patholo- 
gists, a  definite,  localized  collection  of  clear  fluid  in  the  subarachnoid  space 
which  produces  by  its  presence  more  or  less  complete  paralysis.  By  opening 
this  small  sac  of  fluid  the  symptoms  may  be  absolutely  relieved."  These 
remarks  of  Munro's  are  quoted  here  because  they  bear  out  remarkably  some 
observations  of  F.  Krause  (Proceedings,  "German  Surg.  Soc,"  1907).  Krause 
has  opened  the  spinal  canal  twenty  times  for  tumor-like  symptoms,  and  has 
found  tense  subdural  collections  of  fluid  eight  times.  On  section  of  the  dura 
the  fluid  forced  itself  out  and  the  arachnoid  protruded  in  bladder-like  manner 
through  the  dural  wound.  Adhesions  existed  between  the  dura  and  the  pia. 
The  disease  is  a  local  collection  of  fluid  in  the  arachnoid  and  has  been  named 
meningitis  serosa  spinalis.  The  results  obtained  from  evacuation  of  the  fluid 
and  closure  of  the  wound  have  been  good. 

In  operating  for  tumors  one  must  remember  the  tendency  to  locate  the 
tumors  at  a  lower  level  than  that  at  which  they  actually  exist  and  that  there- 
fore, if  no  growth  is  found  on  opening  the  spine,  one  should  remove  the  laminae 
of  one  or  two  higher  vertebrae. 

TUMOR  OF  THE   SPINAL  MENINGES 

Expose  the  spinal  canal  by  Method  A.  If  the  tumor  is  external  to  the 
meninges  extirpate  it,  being  careful  to  avoid  injury  to  the  nerve  roots.  If 
any  nerve  leaving  the  cord  is  divided,  it  should,  if  possible,  be  immediately 
reunited  by  suture.  The  posterior  surface  of  the  meninges  is  generally  sepa- 
rated from  the  bone  by  a  collection  of  fat  containing  many  veins;  thus  hemor- 
rhage may  be  troublesome,  but  this  can  be  readily  stopped  by  packing  with 
strips  of  gauze  wrung  out  of  very  hot  water.  When  the  tumor  is  inside  the 
dura,  that  membrane  must  be  divided,  the  limits  of  the  growth  defined,  and 
its  removal  efi'ected  by  careful  blunt  dissection.  After  attending  to  hemostasis 
the  wounded  dura  may  be  sutured  or  not,  according  to  indications. 

Tumors  of  the  cord  itself  are  not  amenable  to  surgical  treatment. 


INJURIES    TO    THE    SPINE  765 

INJURIES   TO   THE   SPINE 
It  is  extremely  difficult  to  lay  down  precise  rules  for  guidance  as  to  when 
and  when  not  to  operate  in  injuries  of  the  spine  and  spinal  cord.     J.  B.  Murphy 
has  formulated  certain  guiding  principles,  of  which  an  abstract  is  here  given: 

A.  Paralysis  from  contusion  may  be  due  to  "traumatic  zonal  inflammation," 
may  have  no  initial  symptoms  and  may  only  develop  days  or  even  weeks  after 
the  injury.  Such  cases  are  more  liable  to  be  cured  without  than  with  surgical 
intervention. 

B.  When  immediately  after  the  injury  there  is  uniformly  transverse,  complete 
paralysis  of  motion  and  sensation  operation  is  useless,  as  the  cord  is  completely 
divided  and  regeneration  is  impossible. 

C.  Fracture  of  the  spine  is  present,  but  there  is  no  great  displacement. 
Paralysis  appears  hours,  days  or  weeks  after  the  injury.  The  paralysis  is  not 
complete  and  annular  of  both  motion  and  sensation.  It  is  impossible  to  diag- 
nose whether  the  cord  lesion  is  due  to  contusion  or  to  pressure.  Murphy 
advises  strongly  against  operation. 

D.  If  under  the  above  circumstances  (C)  there  is  marked  displacement  it 
is  proper  to  diagnose  compression,  and  immediate  operation  is  indicated. 

E.  Fracture  of  the  spine  is  present  below  the  twelfth  dorsal  vertebra.  The 
rules  given  above  no  longer  apply.  At  the  twelfth  dorsal  vertebra  the  spinal 
cord  ends  and  the  cauda  equina  begins. 

"The  Cauda  equina,  which  begins  here,  is  made  up  of  essentially  peripheral 
nerve  fasciculi,  and  not  of  spinal  cord  fasciculi,  as  the  axones  of  the  motor 
root  in  this  portion  have  their  ganglion  trophic  cells  above  this  level  in  the 
conus,  and  the  motor  axones  in  the  cauda  are  covered  with  the  sheath  of 
Schwann,  or  neurilemma.  They  therefore  degenerate  after  division,  and  have 
the  power  of  regenerating,  the  same  as  peripheral  motor  axones.  The  sensory 
neurones  of  the  posterior  roots  of  the  cauda  have  their  ganglion  cells  just  inside 
the  sacral  and  lumbar  foramina.  Their  proximal  axones,  which  run  through  the 
cauda  to  the  spinal  cord  are  medullated,  and  have  a  sheath  of  Schwann.  They 
are  capable  of  regenerating,  at  least  up  to  the  posterior  commissures,  and  from 
clinical  observation,  we  believe,  can  again  functionally  contact  with  the  pos- 
terior horn  of  gray  matter.  In  other  words  both  the  motor  and  sensory  neurones 
in  the  cauda  outside  of  the  cord  are  histologically  capable  of  regeneration  under 
favorable  conditions;  that  is,  after  accurate  suture  and  exact  approximation  of 
the  ends  of  the  divided  caudal  fasciculi  under  aseptic  conditions." 

Every  case  of  fracture  of  or  injury  to  the  spine  in  the  lumbar  reigon  accom- 
panied by  paraplegia  demands  operation.  Causes  of  compression  must  be  re- 
moved; divided  fasciculi  must  be  united  by  suture.  "It  is  easy  to  determine 
which  are  the  right  and  left  fasciculi  by  a  mild  faradic  current  up  to  the  seventh 
day  after  the  injury." 

F.  In  cases  of  bullet  wound  of  the  spine,  when  the  bullet  is  shown  by 
the  X-rays  to  be  inside  the  spinal  canal,  operation  is  demanded.  Other 
cases  of  bullet  wounds  of  the  spine  should  be  treated  by  the  rules  already 
laid  down. 

The  principles  or  rules  which  have  been  outlined  in  the  preceding  para- 
graphs are  given  by  Murphy  in  his  classical  monograph  ("Surg.,  Gyn.  and 


766  OPERATIONS    ON    THE    SPINE 

Obstetrics,"  April,  1907)  and  are  the  outcome  of  large  experience  and  untir- 
ing study.  It  would  be  improper,  however,  to  omit  giving  the  opinions  of 
some  other  experienced  and  judicious  surgeons.  Chipault  advises  early 
operation,  except  when  functional  disturbance  is  very  slight  or  shock  is  very 
severe.  Reduction  by  extension  and  local  pressure  is  condemned,  as  such 
manoeuvres  are  very  liable  to  press  fragments  of  bone  into  the  cord  and  increase 
the  damage  immensely. 

A.  J.  McCosh  advocates  early  operation  before  there  is  time  for  secondary 
degenerations  to  become  established.  He  has  seen  good  follow  in  cases  where 
the  symptoms  pointed  to  total  transverse  lesions.  Mixter  and  Chase  have 
pointed  out  that  in  spite  of  the  absence  of  conduction,  normal  fibres  may  pass 
through  the  crushed  portion  of  the  cord.  Kocher  writes,  "If  one  has  had 
Munro's  experience,  that  out  of  thirty  cases  of  injury  to  the  upper  dorsal  and 
the  cervical  vertebrae  one  only  within  ten  years  lived  and  had  partial  restoration 
of  function,  while  in  the  same  period  of  time  operative  treatment  resulted  in 
three  complete  cures,  then  one  will  tend  to  advise  operation  in  every  case. 
The  cases  must  be  very  carefully  examined:  if  the  temperature  sinks  low  (as 
is  often  the  case  in  high  lesions  of  the  cord)  on  operation  is  proper.  Munro 
lost  all  the  patients  on  whom  he  operated  for  acute  crushing  of  the  cervical 
cord.  It  remains  undoubtedly  true  that  we  must  diagnose  irreparable  total 
transverse  destruction  of  the  cord  in  the  great  majority  of  patients  who  exhibit 
sudden  and  complete  loss  of  motion  and  sensation  with  immediate  and  total 
loss  of  the  tendon  reflexes;  but  it  is  also  true  that  if  the  transverse  lesion  is  not 
total  then  remnants  of  sensation  are  present  from  the  first  or  appear  in  a  few 
hours  or  days." 

Jacobson  ("Operations  of  Surg.,"  ii,  1091  ed.  1908)  is  averse  to  any  surgical 
interference  in  cases  of  fractured  spine,  owing  to  the  amount  of  damage  to  the 
cord  being  usually,  from  the  first,  irreparable.  Thorburn  has  the  same  opinion 
as  Jacobson  regarding  fractures  above  the  level  of  the  first  lumbar  vertebra; 
regarding  fractures  below  this  level,  he  advocates  surgical  interference  on  the 
following  grounds: 

"i.  We  may  here  expect  a  regeneration  of  the  nerve  roots,  the  physiological 
evidence  being  strongly  in  favor  of  such  regeneration,  and  not  against  it  as  in 
the  case  of  the  cord. 

"2.  The  absence  of  spontaneous  recovery  in  such  cases  in  itself  indicates 
the  presence  of  a  mechanical  obstacle,  such  as  permanent  compression  by 
bone,  blood-clot,  or  cicatrix,  otherwise  we  should  expect  the  roots  of  the  cauda 
equina  to  recover  as  other  peripheral  nerves  after  severe  injuries." 

Burrell  ("Trans.  Am.  Surg,  Assoc,"  1915)  studied  the  records  of  cases  of 
spinal  fracture  treated  in  the  Boston  City  Hospital  and  came  to  the  following 
conclusions: 

"i.  That  fractures  of  the  spine  may  well  be  divided  into  two  classes;  first, 
fractures  of  the  spine  with  injury  to  the  cord;  and,  second,  fractures  of  the 
spine  without  injury  to  the  cord. 

"2.  That  it  is  not  best  to  decide  what  the  treatment  of  an  individual  case 
of  fracture  of  the  spine  should  be  from  the  statistics,  because  the  lesion  varies 
so  widely. 


SYRINGOMYELIA  767 

"3.  That  in  many  cases  of  fracture  of  the  spine  it  is  impossible  to  primarily 
state  whether  the  cord  is  crushed  or  pressed  upon  by  bone,  blood  or  exudate, 
except  by  an  open  operation. 

"4.  That  only  by  the  persistence  of  total  loss  of  reflexes,  complete  insensi- 
bility to  touch  and  pain,  and  motor  paralysis  below  the  level  of  the  lesior.  can 
total  transverse  destruction  of  the  cord  be  diagnosticated. 

"5.  That  if  pressure  on  the  cord  is  allowed  to  remain  for  many  hours, 
irreparable  damage  to  the  cord  may  take  place. 

"6.  That  unless  it  is  perfectly  clear  that  the  cord  is  irremediably  damaged, 
an  open  operation  to  establish  the  condition  of  the  cord  and  to  relieve  pressure 
is  imperative  as  soon  as  surgical  shock  has  been  recovered  from. 

"7.  That  in  certain  cases  of  fracture  of  the  spine,  when  the  cord  is  not 
injured,  but  is  liable  to  injury  from  displacement  of  the  fragments  of  a  vertebra, 
rectification  of  the  deformity  and  fixation  of  the  spine  may  be  used. 

"8.  That  if  the  cord  is  crushed,  no  matter  what  treatment  is  adopted, 
there  will,  of  necessity,  be  a  high  rate  of  mortality." 

Open  the  spinal  canal  by  Method  A.  Remove  all  blood-clot  and  severely 
damaged  tissues.  Stop  bleeding.  Examine  thoroughly  the  posterior  surface 
of  the  cord.  Examine  the  anterior  wall  of  the  spinal  canal.  If  there  are 
displacements  of  bone  in  this  location,  interfering  with  the  cord  or  lessening  the 
calibre  of  the  spinal  canal,  try  to  reduce  such  by  manipulations  under  the 
guidance  of  the  eye  and  finger.  If  manipulations  fail,  cut  away  such  pieces  of 
bone  as  threaten  the  integrity  of  the  cord  or  jut  into  the  canal.  This  may  be 
done  with  the  chisel  or  rongeur  forceps.  The  amount  of  bone  removed  may 
be  considerable.  Examine  the  cord  once  more.  If  it  does  not  pulsate  and 
presents  a  distended  and  bluish  appearance,  open  the  dura  and  clear  out  the 
blood-clot  which  will  be  found.  If  the  cord  is  flabby  and  small,  there  are 
probably  adhesions  existing  between  the  membranes  and  the  cord  or  between 
the  various  nerve  roots.  This  condition  calls  for  the  dura  to  be  opened  and 
the  adhesions  separated. 

Any  operation  undertaken  must  be  done  thoroughly.  The  wound  in  the 
dura  should  be  closed,  unless  this  is  contraindicated.  The  external  wound 
is  sutured  as  usual,  dressings  applied,  and  the  trunk  immobilized.  Harte  and 
Stewart  ("Trans.  Am.  Surg.  Assoc,"  xx)  report  the  case  of  a  woman  twenty-six 
years  of  age  who  was  shot  at  the  level  of  the  seventh  dorsal  vertebra.  Opera- 
tion showed  that  the  spinal  cord  was  completely  severed,  a  gap  of  ^'^  inch 
existing  between  the  segments.  After  removal  of  lacerated  and  fragmented  tis- 
sues the  cord  was  united  by  three  chromicized  catgut  sutures.  Sixteen  months 
after  operation  "the  patient  voluntarily  flexes  the  toes,  flexes  and  extends  the 
thighs,  and  rotates  the  hips.  While  sitting  the  extended  leg  can  be  raised  from 
the  floor ;  thepatient  can  slide  out  of  bed  into  her  chair  by  her  own  efforts.  .  .  . 
The  bowels  move  every  second  day  and  are  under  perfect  control,  except  in  the 
presence  of  diarrhoea." 

SYRINGOMYELIA 

J.  B.  Murphy  ("Surg.,  Gyn.,  Obstetrics,"  April,  1907)  writes: 

"While  neuropathologists  disagree  as  to  the  origin  of  syringomyelia,  their 
findings  are  uniformly  the  same.     Examination  of  a  cord,  even  before  its  section. 


768  OPERATIONS    ON    THE    SPINE 

reveals  a  bulging  on  ihe  posterior  half  of  the  cord,  which  fluctuates  on  palpa- 
tion. On  section,  one  or  several  cavities  are  found  extending  upwards  and 
downwards,  either  for  a  limited  distance  or  through  the  entire  cord  up  to 
the  bulb,  and  occasionally  involving  the  latter.  Primarily  the  cavity  is'  more 
commonly  found  in  the  cervical  swelling  of  the  cord.  The  cavity  occupies, 
almost  invariably,  one  or  both  posterior  horns,  just  behind  the  commissure 
and  close  to  the  central  canal.  The  latter  is  not  necessarily  dilated,  and  in 
some  cases  is  so  contracted  that  it  is  almost  impermeable.  Again,  the  syrin- 
gomyelic cavity  may  communicate  with  the  central  canal  and  form  one  large 
cavity,  impressing  one  that  the  condition  might  be  a  primary  hydromyelia. 
The  tube  may  be  patent  or  may  be  subdivided  by  septa,  either  lengthwise 
or  laterally,  making  single  or  multiple  cavities.  It  may  communicate  with 
the  fourth  ventricle  or  end  near  it  in  subarachnoid  space.  The  shape  of  the 
cavity  is  tubular  or  triangular,  and  it  is  lined  with  cylindrical  epithelium  similar 
to  that  of  the  central  canal. 

"It  seems  to  us,  from  a  theoretical  standpoint,  that  this  disease,  at  least 
in  its  circumscribed  form,  ofifers  a  field  for  surgical  intervention.  As  soon  as 
opportunity  presents  itself,  I  will  perform  a  subdural  drainage  with  an  inab- 
sorbable  seton  which  will  keep  a  permanent  communication  between  the 
syringomyelic  canal  and  subdural  space,  and  insure  an  equalization  of  pressure, 
which  should  stop  the  advancement  of  the  disease,  even  if  it  does  not  permit 
restoration  of  function  in  some  of  the  compressed  ganglion-cells  and  axones. 
This  operation  suggested  by  Murphy  is  along  the  lines  of  those  successfully 
performed  by  Sutherland  and  by  Ballance  in  the  treatment  of  hydrocephalus." 

SPASTICITY ' 

Foerster's  Operation. — Operative  Treatment  of  Spasticity  and  Athetosis. 
Division  oj  posterior  or  sensory  roots  in  spastic  paraplegia  and  in  the  crisis  of 
tabes.  Frazier  writes  ("Surg.,  Gyn,,  Obstet.,"  Sept.,  1910):  "If  we  admit 
that  spasticity  or  spastic  muscular  contractures  are  reflex  disturbances,  unre- 
strained by  cortical  impulses,  one  way,  if  not  the  only  way  of  controlling  them, 
is  to  remove  at  least  one  link  in  the  chain  of  the  reflex  arc.  Naturally  the  motor 
portion  of  the  arc,  the  anterior  horns,  the  roots,  or  the  peripheral  nerves  can- 
not be  broken,  otherwise  the  limb  would  be  hopelessly  paralyzed;  for  the 
same  reason  the  sensory  nerves,  many  of  which  are  mixed  nerves,  must  be 
left  intact,  so  that  by  a  process  of  exclusion  there  remain  the  sensory  roots." 
(For  Sir  R.  Jones'  criticism  of  Foerster's  operation,  see  p.  774) 

Stubborn  cases  of  radiculitis  causing  various  distressing  symptoms  may 
be  suitable  for  Foerster's  operation. 

Division  of  the  posterior  roots  was  first  suggested  by  Spiller  in  1905  ("Journ. 
of  Nervous  and  Mental  Diseases,"  May,  1905)  but  Foerster  seems  to  have 
pushed  the  matter  more  vigorously  and  reported  five  cases  of  his  own  in  which 
Tietze  operated.  (Foerster,  "Zeitschrift  fiir  Orthop.  Chir.,"  xxii;  Mittheil- 
ungen  aus  "d.  Grenzgeb.  d.  Med.  und  Chir.,"  xx;  Tietze,  Mittheilungen  aus 
"d.  Grenzgeb.  d.  Med.  und  Chir.,"  xx.) 

A  number  of  different  methods  of  operating  have  been  devised  by  various 
surgeons.     Tietze  and  others  divide  the  operation  into  two  stages:  first,  per- 


SPASIKITY 


769 


forming  laminectomy  and  some  days  later  opening  the  dura  and  completing 
the  work.  Undoubtedly  a  two-stage  operation  facilitates  the  finding  of  the 
posterior  roots  in  that  there  is  less  blood  to  obscure  the  view,  but  bleeding  can 
be  well  controlled  by  pressure  with  pads  of  hot  gauze  against  the  spinal  muscles, 
and  by  packing  narrow  strips  of  gauze  between  the  dura  and  the  lateral  portions 
of  the  vertebrae  after  the  spinal  canal  has  been  opened.  Danger  from  infection 
is  distinctly  less  in  a  one-stage  than  in  a  two-stage  operation.  (For  Frazier's 
method  of  exposing  the  cord  see  p.  760.)  To  distinguish  the  posterior  roots  it 
is  necessary  to  have  free  exposure  of  the  posterior  surface  of  the  cord;  if  blood 
obscures  the  view  it  ought  to  be  removed  by  gentle  douching  with  warm  salt 
solution  (Fig.  928). 


Spinous  proc. 


Epidural  space 


Dura 
Subarachnoid  space 


Spinal  ganglion 


Ant.  root. 


{Poirier  and  Charpy.) 


After  the  dura  is  opened  attempts  to  remove  blood  by  means  of  sponging 
are  liable  to  do  much  damage  to  the  delicate  nerve  structures  exposed. 

How  many  and  which  of  the  posterior  roots  ought  to  be  divided? 

Frazier  writes:  "It  is  known  that  the  supply  of  each  muscle  or  group  of 
muscles  is  represented  in  most  instances  by  three  segments  of  the  cord  and 
by  as  many  roots  and,  according  to  the  observations  of  Sherrington,  the  cutane- 
ous nerve  supply  of  any  given  area  is  derived  from  at  least  three  roots.  Theo- 
retically we  plan  to  break  the  reflex  arc  of  the  muscles  involved,  by  cutting 
off  as  many  peripheral  stimuli  as  possible;  we  should  not,  however,  remove 
every  source  of  sensory  stimulation,  otherwise  we  would  substitute  a  condition 
of  absolute  anesthesia  and  flaccidity  for  one  of  spasticity.  In  selecting  the 
roots  to  be  sacrificed  it  is  necessary  obviously  to  remove  at  least  two  of  the 
three  possible  sources  of  sensory  stimulation,  or,  in  other  words,  two  of  the 
three  roots  from  which  a  given  group  of  muscles  derives  its  sensory  supply. 
The  following  table  gives  the  sensory  distribution  to  the  muscles  of  the  lower 
extremities: 

Flexors  of  the  thigh,  L1L2L3L4L5S1 

Extensors  of  the  thigh,  L5S1S2 

Adductors  of  the  thigh,  lj^^i(Li) 
49 


770  OPERATIONS    ON    THE    SPINE 

Abductors  of  the  thigh,  L5S1S2 

Exter.  rotators  of  the  thigh,  L6S1S2 

Int.  rotators  of  the  thigh,  L3L4L5S1S2 

Extensors  of  the  leg,  L2L3L4 

Flexors  of  the  leg,  L3S1S2 

Dorsal  flexors,  foot,  L4L3S1 

Plantar  flexors,  foot,  L5S1S2 

In  considering  an  operation  for  spastic  paraplegia  there  are  seven  roots  to 
be  considered,  namely,  the  five  lumbar  and  the  first  two  sacral  roots.  Accord- 
ing to  Foerster's  first  dictum  at  least  four  roots  should  be  sacrificed  and  he 
selected  for  the  lower  extremity  the  second,  third,  and  fifth  lumbar  and  the 
second  sacral,  leaving  intact  the  first,  the  fourth  lumbar,  and  the  first  sacral. 

"The  general  rule  has  been  not  to  remove  more  than  two  successive  roots. 
If  the  results  of  some  of  the  operations  have  been  accurately  recorded  our 
views  regarding  the  sensory  distribution  of  the  spinal  roots  may  have  to  be 
revised.  Thus  Taylor  in  one  case  resected  six  successive  roots,  from  the 
twelfth  dorsal  to  the  fifth  lumbar  inclusive,  on  one  side  with  full  retention  of 
sensation,  and  in  another  case  seven  successive  roots  from  the  fourth  cervical 
to  the  second  dorsal  inclusive,  without  loss  of  reflexes.  This  is  absolutely 
at  variance  with  our  present  conception  of  the  distribution  of  the  spinal  roots 
and  suggests  the  possibility  of  the  operator  having  left  some  fibres  undivided. 
The  difficulty  in  separating  the  sensory  from  the  motor  roots  may  be  attributed 
to  the  inadequate  exposure  of  a  unilateral  opening. 

"Whether  or  not  it  may  be  possible  to  resect  a  series  of  five,  six,  or  seven 
successive  roots  without  permanent  disturbance  of  sensation  or  reflexes  in  a 
given  extremity,  it  is  unquestionably  true  that  the  desired  end  may  be  attained, 
the  spasticity  relieved,  by  resecting  four  out  of  seven  of  the  total  number  of 
roots  supplying  a  given  area.  Thus  in  one  of  Foerster's  cases,  one  of  Gottstein's, 
and  two  of  my  own  the  spasticity  was  relieved  by  resection  of  three  lumbar,  or 
three  lumbar  and  one  sacral  root. 

"On  the  other  hand,  if  too  few  roots  are  resected  the  results  may  not  be  as 
satisfactory.  This  was  the  case  in  one  of  Foerster's  patients  where  he  resected 
only  the  third  and  fifth  lumbar  and  the  second  sacral,  and  in  one  of  my  own, 
where  although  four  successive  roots  were  resected — namely,  the  fifth,  sixth, 
seventh  and  eighth  cervical — the  spasticity  was  only  partially  relieved.  There- 
fore, at  this  juncture  it  is  not  possible  to  lay  down  any  hard  and  fast  rule, 
suffice  it  to  say  that  for  the  lower  extremity  perfectly  satisfactory  results 
have  been  obtained  after  resection  of  the  following  combinations: 

1.  L2L3L5, 

2.  L2L3L5S2,  or 

3.  LzLsLbSi. 

"For  the  upper  extremity  the  following  combination,  C4C5C5C7,  was  wholly 
effective  in  one  case  (Taylor's  third  case)  while  CsCeCyCs  only  partially  so  in 
another  (Frazier's  case). 

"We  may  conclude  from  this  that,  until  further  observations  are  made,  the 
fourth  cervical  should  be  included,  with  or  without  the  eighth." 

Immediately  after  operation  pain  and  spasticity  may  apparently  be  in- 


SPASTICITY  771 

creased,  just  as  after  amputation  of  the  leg  severe  pains  are  experienced  and 
thought  to  be  in  the  foot  which  has  been  removed.  Soon  such  distressing 
symptoms  decrease  and  disappear.  It  is  necessary,  however,  in  cases  of 
spasticity,  to  correct  deformities  which  have  become  estabhshed  and  to  institute 
well  regulated  muscular  exercises. 

Foerster's  operation  ought  to  be  reserved  for  severe  cases  of  spasticity  and 
of  the  crisis  of  tabes. 

The  published  results  have  been  good  and  the  death  rate  has  not  been  very 
high  considering  the  gravity  of  the  procedure. 

Hofniaii's  Method  of  Performing  Foerster's  Operation. — Temporary  Laminec- 
tomy.    C'Zentralblatt  fiir  Chir.,"  1910,  No.  20.) 

Step  I. — Make  an  incision  of  the  desired  length  over  the  spinous  processes 
of  the  vertebrce  to  be  reflected,  and  separate  the  musculature  by  blunt  dissection 
from  the  spinous  processes  and  from  the  laminae  on  both  sides  as  far  as  the 
lateral  processes.  The  sharp  bleeding  which  comes  from  the  muscles  is  easily 
controlled  by  gauze  pressure.     The  periosteum  has  not  been  injured. 

Step  2. — Divide  the  laminae  on  each  side  by  means  of  an  osteotome  held 
as  horizontally  as  possible. 

Step  3. — Divide,  transversely,  the  interspinous  ligament  either  above  or 
below  the  series  of  vertebrae  attacked,  according  as  the  bone  flap  is  to  be  re- 
flected downwards  or  upwards.  After  division  of  any  remaining  connections 
reflect  the  flap  (consisting  of  periosteum,  spinous  processes,  laminag  and  inter- 
spinous ligaments)  upwards  or  downwards  as  may  be  desired.  The  dura  is  now 
at  least  partially  exposed  and  can  be  fully  exposed  by  nipping  away  some  more 
bone  with  rongeur  forceps.  If  the  chisel  is  properly  applied  Hofman  claims 
that  injury  to  the  dura  or  cord  is  hardly  possible.  This  claim  is  in  full  accord 
with  the  experience  of  the  late  D.  J.  Hamilton  who,  in  the  postmortem  room, 
similarly  exposed  innumerable  spinal  cords  without  injury  to  their  structure. 

Step  4. — Incise  the  dura  longitudinally  and  divide  the  desired  posterior 
spinal  roots. 

Step  5.- — -Close  the  dural  wound  by  a  continuous  suture. 

Step  6. — Replace  the  reflected  bone  flap.  Suture  the  muscles  and  fascia 
over  the  spinous  processes.     Close  the  skin  wound. 

Hofman  performed  the  above  operation  in  one-half  hour,  which  would 
have  seemed  totally  incredible  to  the  author  had  he  not  known  of  Hamilton's 
remarkably  rapid  work  in  the  autopsy  room,  to  which  reference  has  already 
been  made. 

(Further  information  regarding  Foerster's  operation  is  to  be  found  in  the 
discussion  before  the  German  Surgical  Association.  "Zentralblatt  fiir  Chir.," 
1910,  No.  31;  Codivilla,  "Muenchner  med.  Woch.,"  Ivii,  p.  1438;  Florcken, 
"Muenchner  med.  Woch.,"  Ivii,  p.  1441;  Bierens  de  Haan,  "Journal  de  Chir.," 
Sept.,  1910.     Discussion,  Brit.  J.  Surg.,  II,  Oct.,  1914.) 

Stoflfel  ("La  Presse  Med.,"  March  30,  191 2)  writes  regarding  the  spastic  con- 
tractures of  cerebral  hemiplegia  or  Little's  disease  "certain  muscles  and  groups 
of  muscles  are  particularly  the  site  of  these  spasmodic  contractures.  (The 
gastrocnemii,  the  flexors  of  the  knee,  the  adductors  of  the  thigh,  the  pronators 
and  flexors  of  the  hand.)     When  these  muscles  are  involved,  they  respond  to 


772  OPERATIONS    ON    THE    SPINE 

Stimulation  with  excessive  force;  their  contraction  is  violent,  exaggerated.  They 
dominate  and  annihilate  their  antagonists,  they  completely  upset  the  muscular 
equilibrium.  *  *  *  The  power  of  voluntary  muscular  contraction  is  almost 
never  absent,  it  is  only  impeded  and  masked  by  the  spasm."  Foerster's  opera- 
tion is  entirely  too  serious  to  be  considered  except  in  very  grave  cases. 

StofTel  considers  that  the  motor  nerves  are  like  telephone  cables  and  contain 
many  filaments,  each  going  without  fail  to  its  own  muscular  fibre  or  bunch  of 
fibres.  Thus  any  one  muscle  may  be  considered  as  composed  of  numerous 
individual  muscles  (the  fibres)  each  supplied  by  its  own  nerve.  If  a  proper 
number  of  the  individual  muscle  fibres  or  bundles  of  fibres  could  be  paralyzed 
by  division  of  their  nerve  filaments,  the  rest  of  the  muscle  being  left  intact  then 
there  would  be  so  much  weakening  of  the  muscle  as  a  whole  that  it  could  not 
overpower  its  antagonists.  Such  division  of  nerve  filaments  may  be  accom- 
plished at  several  points  on  the  course  of  the  motor  nerve.  "The  simplest  case 
is  where  one  can  expose  and  follow  the  nerve  to  its  point  of  entry  into  the  muscle, 
e.g.,  at  the  upper  extremity  of  the  gastrocnemius.  At  this  level  the  various 
branches  of  the  nerve  are  separated  and  one  can  easily  divide  some  of  them." 
Where  it  is  impossible  to  follow  the  nerve  as  above,  e.g.,  in  the  case  of  the 
quadriceps  and  the  flexors  of  the  knee,  it  is  easy  to  expose  the  nerve,  transfix  it 
with  a  very  fine  tenotome  and  divide  a  very  limited  portion  of  it.  "If  we  wish 
to  weaken  the  pronator  radii  teres  we  attack  the  median  nerve  in  the  middle  of 
the  arm.  To  weaken  the  tibiales  anticus  and  posticus  we  expose  the  anterior 
and  posterior  tibial  nerves  and  section  part  of  their  fibres."  Stofifel's operation 
properly  carried  out  "ought  to  fulfill  a  double  aim  to  suppress  the  spastic  con- 
tracture and  to  reestablish  at  once  the  function  of  the  muscle  which  was  con- 
tracted. The  first  object  is  easily  attained  by  complete  division  of  the  motor 
nerve  supply,  but  this  completely  suppresses  the  active  function  of  the  muscle 
as  well  as  its  contracture  and  so  does  not  attain  the  second  object  of  the  opera- 
tion. We  ought  to  divide  only  part  of  the  nerve  supply.  If  we  divide  too  little 
the  contracture  is  not  removed,  if  too  much,  function  is  destroyed.  Can  one 
determine  exactly  how  much  of  the  motor  nerve  ought  to  be  divided  to  obtain 
the  exact  degree  of  energy  desired  in  the  muscle?  To  this  question  I  answer 
affirmatively.  By  taking  into  consideration  the  degree  of  the  contracture,  the 
anatomy  and  physiology  of  the  contracted  muscles,  the  value  of  the  synergic 
and  of  the  antagonistic  muscles,  it  is  easy  to  determine  how  much  of  the  nerve 
ought  to  be  divided.  Practice  naturally  plays  a  great  role  in  this  estimation  and 
as  in  any  new  method,  one  learns  in  every  case.  At  first  one  divides  too  much 
or  too  little,  but  one  soon  acquires  the  necessary  experience."  After  operation 
the  antagonistic  muscles  should  be  strengthened  by  gymnastics,  massage,  elec- 
tricity, etc.     (For  Jones'  treatment  of  Little's  Disease,  see  p.  773.) 

In  spastic  contracture  of  the  adductors  of  the  thigh  R.  Selig  (Arch.  f.  Klin. 
Chir.,  ciii,  994)  advocates  division  of  the  obturator  nerve  before  its  entrance 
into  the  obturator  canal.  The  fact  that  the  adductor  magnus  gains  part  of  its 
nerve  supply  from  the  sciatic  nerve  explains  why  after  section  of  the  obturator 
nerve,  while  spastic  contraction  is  prevented,  active  contraction  remains  pos- 
sible. The  obturator  nerve  arises  from  the  second,  third  and  fourth  lumbar 
nerves,  crosses  the  sacro-iliac  joint  and  the  internal  iliac  artery  to  find  its  way 


DIVISION   OBTURATOR    NERVE 


77.3 


along  the  lateral  wall  of  the  true  pelvis  until  it  enters  the  obturator  foramen. 
In  its  course  it  follows  the  lower  margin  of  the  horizontal  ramus  of  the  pubes  a 
little  below  the  innominate  line.  The  nerve  forms  a  thick  palpal)le  cord  of  easy 
access. 

Exposure  and  Division  of  the  Obturator  Nerve. — Make  a  vertical  incision  about 
3  inches  in  length  along  the  border  of  the  rectus  muscle  low  down.  Expose, 
but  do  not  divide,  the  peritoneum  and  the  transversalis  fascia.     By  blunt  dis- 


FiG.  929. — {Selig,  Arch,  fur  klin.  Chir.) 
,  Peritoneum  pushed  back.     2.  Prevesical  space  containing  connective  tissue  and  fat.     3.  Obturator 
nerve.     4.  Anastomosis  between  deep  epigastric  and  obturator  veins.     5.  Horizontal  ramus  of  pubis. 


section  separate  the  peritoneum  from  the  overlying  structures  in  the  lower 
part  of  the  wound  until  the  horizontal  ramus  of  the  pubis  is  reached.  Pass  the 
finger  behind  the  horizontal  ramus  and  palpate  the  obturator  foramen.  To 
the  outer  side  of  the  foramen  the  cord-like  nerve  can  be  felt.  Fig.  929  shows 
the  relations  of  the  nerve.  Expose  the  nerve  and  divide  it.  Close  the  wound 
as  in  any  abdominal  operation. 

Sir  Robert  Jones  writes  (Treatise  on  Regional  Surg.,  Binnie  III,  666): 
"Briefly  our  belief  is  that  the  continuance  of  the  state  of  disability  lies  in  the 
large  contracted  over-excitable  muscles,  and  that  these  are  the  origin  of  a  con- 


774  OPERATIONS    ON    THE    SPINE 

tinuous  stream  of  afferent  impulses  which  keep  the  spinal  motor  system  in  a 
slate  of  excitement  and  ])revent  the  upper  neurone  from  exercising  a  proper 
control,  especially  inhibitory  control.  Therefore  the  attack  should  be  directly 
on  the  muscles  to  put  them  out  of  action,  so  allowing  the  nervous  system  to  rest. 
(See  chapter  on  Tenotomy.) 

Forster's  operation  of  division  of  the  posterior  nerve  roots  has  received 
much  attention  in  recent  years.  The  idea  of  the  operation  is  to  cut  off  the 
afferent  impulses  from  the  large  spastic  muscles  and  so  give  the  spinal  nervous 
system  a  rest  before  commencing  re-education. 

Our  criticism  is,  first  that  Forster's  operation  involves  laminectomy  and 
opening  the  spinal  theca  is  unnecessarily  severe;  second,  we  think  he  is  cutting 
the  nerve-muscle  cycle  at  the  wrong  place,  for  if  our  interpretation  of  Magnus 
experiments  and  our  deductions  from  them  with  regard  to  spastic  paralysis  are 
correct,  the  fault  lies  in  the  state  of  the  muscle. 

Our  clinical  experience  is  that  by  putting  the  spastic  muscles  out  of  action, 
b}-  completely  over-stretching  them  or  better  by  dividing  them,  we  stop  the 
afferent  impulses  just  as  effectively  as  by  dividing  posterior  nerve  roots  with 
much  less  risk  to  the  patient." 

SPINA  BIFIDA 

To  understand  the  operative  treatment  of  spina  bifida  and  the  limitations 
thereof,  it  is  absolutely  necessary  to  have  clear  notions  as  to  its  pathological 
anatomy.  The  usual  surgical  text-books  rarely  provide  such  notions,  hence 
the  author  will  try  to  describe,  very  briefly,  the  conditions  which  should  influence 
operation. 

A.  Meningocele. — A  defect  of  the  posterior  osseous  wall  of  the  spinal 
canal  is  present.  The  skin,  spinal  membranes,  and  cord  are  intact.  There 
is  a  hernia  of  the  dura  through  the  osseous  defect.  Fluid  in  greater  or  less 
quantity  is  present  in  the  dilated  subdural  space  (Fig.  930  ). 

B.  Meningocele. — The  conditions  are  the  same  as  in  A,  except  that  the 
arachnoid  is  involved  in  the  hernia  and  the  collection  of  fluid  is  in  the  sub- 
arachnoid space  (Fig.  931). 

C.  Meningocele. — A  defect  exists  in  the  dura  as  well  as  in  the  bone. 
Through  these  defects  there  protrudes  a  hernia  consisting  of  the  arachnoid 
with  fluid  accumulated  in  the  subarachnoid  space.  The  skin,  pia,  and  cord 
are  intact. 

D.  Myelo-cystocele  (Fig.  932). — There  exists  a  defect  in  the  posterior 
osseous  wall  of  the  spinal  canal  and  also  in  the  corresponding  portion  of  the 
dura.  The  arachnoid  and  pia  are  intact.  The  central  canal  of  the  spinal 
cord  is  highly  distended  by  fluid,  so  that  a  hernia  is  formed  having  the  arach- 
noid and  pia  as  sac.  The  cord  substance  is  tliinly  spread  out  over  the  inside 
of  the  sac — so  thinly  that  in  places  it  is  absent.  The  spreading  out  of  the  cord 
is  due  to  the  distention.  As  will  be  seen  by  reference  to  the  diagram,  nerve 
roots  run  forwards  in  the  hernial  sac.     This  is  of  importance  to  the  operator. 

E.  Myelocele. — A  defect  exists  in  the  skin,  in  the  posterior  osseous  wall 
of  the  spinal  canal,  and  in  the  corresponding  portions  of  the  dura,  arachnoid, 
and  pia.  The  posterior  surface  of  the  cord  itself  is  split  or  absent.  The 
central  canal  of  the  cord  is  open  to  the  air  (Fig.  933).     Fluid  collects  between 


SPINAL   BIFIDA 


775 


the  pia  and  arachnoid  anterior  to  the  cord,  and  gives  rise  to  a  spinal  hernia. 
As  will  be  seen  by  referring  to  the  diagram,  skin  is  present  only  at  the  base 
of  the  tumor;  the  hernial  sac  consists  of  pia  mater  with  a  covering  of  cord  sub- 

5KIN 


SKIN 


Fig.  930. — Meningocele  A. 
SKIN 


Fig.  932. — Myelo-cystocele. 


Fig.  931. — Meningocele  B. 


Fig.  933. — Myelocele  E. 


SKIN 
ARACHNOID 


Fig.  934. — Myelocele  F. 


stance.  The  nerve  roots  run  from  the  cord  forwards  through  the  sac.  Should 
a  collection  of  fluid  form  in  the  arachnoid  instead  of  in  front  of  it,  then  the 
arachnoid  will  form  part  of  the  hernial  sac  and  the  nerve  roots  will  run  forwards 
in  the  sac  wall. 


776  OPERATIONS   ON   THE    SPINE 

F.  Myelocele.— Tliis  form  is  the  same  as  E,  except  that  there  is  no  col- 
lection of  fluid  (Fig.  934).  The  remnant  of  cord  substance  lies  in  a  groove 
or  depression  on  the  back  and  is  continuous  with  the  skin.  The  meninges 
are  continuous  with  the  subcutaneous  tissues. 

The  differential  diagnosis  of  myeloceles  E  and  F  is  easy.  They  are  in- 
operable. 

The  diagnosis  between  myelo-cystocele  D  and  meningoceles  A,  B,  and  C 
is  generally  impossible,  except  perhaps,  as  Horsley  has  suggested,  by  applying 
the  electric  current  and  observing  its  effects.  Myelo-cystoceles  are  more  fre- 
quently accompanied  by  other  deformities,  e.g.,  club-foot,  exstrophy  of  the 
bladder,  etc.,  than  are  meningoceles.  The  fact  that  the  walls  of  a  myelo- 
cystocele contain  nerve  substance,  while  those  of  meningoceles  do  not,  makes 
positive  differentiation  between  the  two  forms  of  spina  bifida  indispensable 
for  scientific  treatment.  If  we  inject  a  solution  of  iodine  (Morton's  fluid) 
into  the  sac,  we  may  be  really  throwing  it  into  the  central  canal  of  the  spinal 
cord.  The  injection  of  iodine  has  been,  until  recently,  the  favorite  treatment 
for  spina  bifida,  but  in  view  of  the  facts  related  above  one  is  compelled  to  believe 
it  unscientific. 

Operation  is  contraindicated  in  cases  of  myelocele;  in  cases  of  spina  bifida 
accompanied  by  paralyses  or  contractures  evidencing  irreparable  defects  in 
the  cord  substance;  in  cases  of  severe  hydrocephalus  or  of  abdominal  or  vesical 
fistulae — in  all  other  cases  operation  is  proper. 

One  must  remember  that  the  successful  closure  of  a  spina  bifida  may  re- 
move a  safety  valve  from  the  cerebrospinal  system,  and  that  a  persistent  excess 
secretion  of  cerebrospinal  fluid  may  lead  to  fatal  hydrocephalus. 

The  Operation. — Step  i. — Make  two  skin-flaps  from  the  base  of  the  tumor, 
of  sufficient  size  to  cover  the  wound  left  after  removal  of  the  sac.  These  flaps 
should  be  made  large  rather  than  small,  as  it  is  easy  to  trim  them  to  suit, 
before  applying  sutures. 

Step  2. — Having  exposed  the  sac  by  reflecting  the  skin -flaps,  make  an 
incision  into  it  on  one  side.  This  incision  should  be  made  transversely  and 
must  not  reach  to  the  middle  lines  of  the  body  {i.e.,  to  the  apex  of  the  tumor). 
The  reason  for  these  precautions  is  that  most  of  the  medullary  tissue,  if  present, 
is  situated  in  the  middle  line,  and  that  the  general  course  of  any  nerve  roots 
is  from  the  summit  of  the  sac  to  the  base,  i.e.,  parallel  to  the  direction  of  the 
incision. 

Step  3. — Explore  the  sac  and  observe  whether  nerves  lie  free  in  it  (Fig. 
933)  or  are  enclosed  in  its  walls  (Fig.  932).  If  the  nerves  lie  free  in  the  sac, 
trace  them  to  their  point  of  origin  in  the  medullary  substance  which  forms 
part  of  the  sac.  Separate  the  medullary  substance,  and  such  of  the  sac  as  is 
united  to  it,  from  the  rest  of  the  sac  and  reduce  it  into  the  spinal  canal. 
Remove  the  excess  of  sac.  If  the  nerves  lie  in  the  sac  wall,  empty  the  sac 
of  its  fluid  and  reduce  it  en  masse  after  removing  all  skin  from  over  it.  If 
the  case  be  discovered  to  be  one  of  meningocele,  remove  the  whole  sac  after 
suturing  its  base. 

Step  4. — Close  the  wound  by  a  series  of  deep  and  superficial  sutures. 

Babcock's  Operation. — ("Monthly   Cyclo.   and   Med.   Bull.,'"   May,   191 1.) 


BABCOCK  S    OPERATION 


777 


Fasten  a  blanket  firmly  between  the  upright  rod  legholders  on  an  ordinary 
operating  table.  Hang  the  child  over  this  by  its  groins  (Fig.  935)  fastening  the 
legs  by  bandages  to  keen  it  from  slipping.  In  front  of  the  blanket  place  a  hot- 
water  bottle  opposite  the  child's  abdomen  to  prevent  chilling.  Have  an  as- 
sistant at  the  other  side  of  the  blanket  to  manage  the  head,  watch  symptoms 
and  if  necessary  administer  an  anesthetic.  Sterilize  abraded  or  ulcerated  areas 
with  pure  carbolic  acid  followed  by  alcohol.  Paint  the  whole  area  with  tincture 
of  iodine. 


Fig.  935. — (Babcock.) 


Step  I. — Through  a  fine  needle  inject  into  the  cephalic  part  of  the  sac  3 
centigrams  novocaine  or  2  centigrams  stovaine,  dissolved  in  3-^  c.c.  sterile  10 
per  cent,  alcohol.  Inject  slowly,  withdrawing  the  piston  several  times  during 
the  injection  to  insure  thorough  mixing  of  the  analgesic  with  cerebrospinal  fluid. 
The  low  specific  gravity  of  the  mixture  prevents  it  affecting  the  higher  centres 
of  the  cord  while  the  child  is  inverted,  and  of  course  most  of  it  escapes  during 
the  operation  so  subsequent  danger  is  averted. 

Step  2. — If  the  sac  is  not  too  thin  dissect  away  all  abraded  and  ulcerated  areas 
and  disinfect  again.  By  transillumination  note  the  position  of  nerve  filaments 
and  of  portions  of  spinal  cord  so  as  to  avoid  them.  Free  the  skin  from  the  sac 
and  retract  the  former. 

Step  3. — Puncture  the  sac.  Resect  redundant  sac  if  there  is  room  between 
adherent  nerve  elements,  otherwise  let  it  collapse  into  the  spinal  cavity.  With 
a  continuous  fine  (00  to  000)  chromicized  catgut  suture  fix  the  sac  so  that  it 
cannot  unfold. 

Step  4. — Incise  the  edge  of  the  dura  where  it  blends  with  the  inner  surface 


778 


OPERATIONS    ON    THE    SPINE 


of  the  lamincX  and  strip  it  from  the  bony  canal  for  the  entire  length  of  the  defect. 
Suture  the  mobilized  dura  over  the  cord  thus  restoring  the  dural  canal. 


I.   Skin 


I'lc.   q,-i6. — (Bahcork.) 

1  1    aiM.ii.uTM^is;    ;;     l,.,,!.'    '1, 


I'IG.  93/. — {Babcock.) 

I.   Skin  everted  and  sutured;  2,  musculo-aponeurosis  flap  united;  3,  bone  flaps  united;  4,  dura   united; 

S,  reconstructed  cavity  of  spinal  arachnoid. 

Step  5. — Freely  expose  the  margins  of  the  bony  canal  and  divide  the  laminae 
with  bone  forceps  (Fig.  936).  This  forms  a  ribbon  of  bone  and  fibrous  tissue 
on  each  side  of  the  defect.  Suture  the  two  ribbons  together  and  thus  restore 
the  bony  canal  (Fig.  937). 


POTT  S   DISEASE  779 

Step  6. — From  the  erector  spinie  muscles  on  each  side  of  the  defect  form  two 
flaps  of  muscle  and  overlying  aponeurosis,  attached  above  and  below.  Suture 
these  two  flaps  in  the  middle  line.  Close  the  skin  wound  with  mattress  sutures 
so  that  there  is  eversion  and  the  thin  skin  is  so  approximated  that  leakage  and 
necrosis  is  not  likely  to  occur. 

Some  surgeons  have  recommended  that  the  osseous  defect  be  closed  by 
means  of  a  flap  of  bone  obtained  from  the  crest  of  the  ilium  and  provided  with 
a  pedicle.     This  procedure  must  rarely  be  indicated.* 

Operations  to  Immobilize  the  Spine  in  Pott's  Disease. — Apart  from  hygienic 
measures  and  the  treatment  of  abscesses,  immobilization  has  been  and  still  is 
the  desideratum  in  the  treatnjent  of  tuberculosis  of  the  bodies  of  the  vertebrae. 
As  a  substitute  for  mechanical  supports  and  braces  the  following  osteoplastic 
operations  have  been  devised  and  carried  out. 

Hibbs'  Operation. — Object:  To  produce  fusion  of  the  bones  of  the  spine 
from  a  point  two  vertebrae  above  to  a  point  two  vertebrae  below  the  diseased 
bones. 

1.  Make  a  vertical  median  incision  sufficient  to  give  ample  access  to  the 
diseased  vertebrae  and  to  two  healthy  vertebrae  above  and  also  below  the 
disease. 

2.  With  sharp  and  blunt  dissection  separate  the  periosteum  from  the 
spinous  processes  and  the  laminae  on  each  side,  carefully  separating  it  and  the 
interspinous  and  interlaminar  ligaments  from  the  upper  and  lower  edges  of 
the  spinous  processes  and  the  laminae.  Continue  the  dissection  outwards  until 
the  posterior  surface  of  the  transverse  processes  are  bared.  The  periosteum 
and  interspinous  ligaments  must  be  reflected  to  each  side  as  a  single  flap  con- 
tinuous from  the  upper  to  the  lower  end  of  the  wound.  In  the  centre  of  the 
wound  lie  the  spines  and  laminae  entirely  bare  of  periosteum,  their  upper 
and  lower  edges  being  also  bare.  No  tags  of  fibrous  tissue  must  be  present. 
During  the  whole  of  the  dissection  no  muscle  should  be  seen;  if  the  muscular 
planes  are  penetrated  the  dissection  has  been  faulty  and  bleeding  will  give 
annoyance. 

3.  With  a  chisel  or  gouge  cut  a  thin  slice  of  bone  from  the  surface  of  the 
lower  half  of  each  lamina,  the  pedicle  of  this  bone  flap  being  on  the  base  of 
the  corresponding  transverse  process.  Turn  the  bone  flap  downwards  in  such 
a  manner  that  it  bridges  the  interlaminar  space  vertically  and  its  raw 
surface  lies  flatly  in  contact  with  the  lamina  of  the  next  vertebra.  Hibbs 
thinks  the  greatest  value  of  this  step  is  the  production  of  a  bony  buttress 
preventing  the  interposition  of  fibrous  tissue  which  might  interfere  with  bone 
fusion. 

4.  With  bone-cutting  forceps  divide  the  base  of  each  spinous  process 
throughout  the  upper  three-fourths  of  its  vertical  diameter  (the  lowest 
vertebra  is  divided  throughout  its  lower  three-fourths).  Fracture  and  turn 
downwards  each  spinous  process  (the  last  one  is  turned  upwards)  so  that 
there  results  a  vertical  row  of  fragments   of    bone   overlapping  each  other. 

5.  Suture  the  periosteal  and  fascial  flaps  over  the  bones.     Close  the  skin 

*  For  a  thorough  description  of  spina  bifida  and  its  operative  treatment  the  reader  is 
referred  to  Hildebrand's  article  in  the  "Archiv  f.  klin.  Chirurgie."  Bd.  xlvi,  Heft  i. 


780  OPERATIONS    ON    THE    SPINE 

wound.  If  the  operation  has  been  properly  performed  there  will  be  very  little 
bleeding  and  no  drain  is  required.  Every  detail  of  the  work  can  be  done  with 
instruments,  so  that  it  is  unnecessary  and  therefore  objectionable,  to  put  a 
finger  in  the  wound.  Apply  dressings.  Hibbs  believes  that  the  treatment  of 
the  spinous  processes  is  the  least  important  step  in  the  operation. 

6.  Immobilize  the  spine  in  a  jacket  for  one  year. 

Remarks. — While  suitable  for  old  neglected  cases,  the  operation  is  par- 
ticularly valuable  in  early  disease.  If  psoas  abscess  is  present,  evacuate  the 
tuberculous  pus  and  close  the  puncture  a  day  or  two  before  attacking  the  spine. 

Albee's  Operation. — ("Journ.  A.  M.  A.,"  Sept.  9,  191 1). 

Step  I. — Make  a  median  dorsal  incision  over  the  tips  of  the  spinous  processes 
from  the  last  healthy  vertebra  above  to  the  first  below  the  affected  bones. 

Step  2. — Split  longitudinally  each  process  for  about  i}/^  inches  into  two 
portions  with  one-third  of  the  process  on  the  left  and  two-thirds  on  the  right. 
Separate  the  soft  structures  between  the  processes  parallel  with  the  muscles. 
Produce  a  green-stick  fracture  at  the  base  of  the  one-third  portion  of  each  of  the 
processes.     Temporarily  pack  the  long  gutter-shaped  wound. 

Step  3. — Make  an  incision  over  the  side  of  the  tibia  and  reflect  the  skin  so  as 
to  expose  the  crest  of  the  bone.  (It  is  best  not  to  have  the  skin  incision  directly 
over  the  segment  of  bone  to  be  removed.)  With  a  chisel  or  motor  saw  remove  a 
prism-shaped  piece  of  bone  with  the  periosteum  intact  on  two  of  its  surfaces 
from  the  antero-internal  aspect  of  the  tibia.  This  piece  of  bone  must  be  long 
enough  to  reach  from  the  uppermost  to  the  lowest  of  the  split  vertebrae;  it  should 
be  about  i  inch  wide  and  3-^  inch  thick. 

Step  4. — Place  the  fragment  of  bone  in  the  gutter  prepared  on  the  back, 
between  the  fragments  of  the  split  spinous  processes.  Suture  the  dense  fas- 
cia over  the  tips  of  the  spinous  processes.  Close  the  skin  wound.  Dress. 
Immobilize. 

Step  5. — Close  and  dress  the  wound  in  the  leg. 


PART  VI 

CHAPTER  LX 

NERVES 

NERVE  SUTURE;  NEURORRHAPHY 

Nerve  Suture. — When  a  nerve  is  divided  the  axis  cylinders  of  the  distal 
segment  promptly  degenerate  and  the  medullary  sheaths  break  up  and  disap- 
pear. The  nuclei  and  protoplasm  of  the  sheath  of  Schwann  proliferate  and 
form  a  new  sheath  ready  for  the  reception  of  new  axis  cylinders,  if  such  succeed 
in  reaching  the  distal  from  the  proximal  segment. 

In  the  proximal  segment  there  is  proliferation  of  the  axis  cylinders  (neurones; 
neurites).  If  the  divided  ends  of  the  nerve  are  kept  in  apposition  and  aseptic, 
they  unite  by  first  intention  and  the  axis  cylinders  from  the  central  end  pass 
into  the  sheaths  prepared  in  the  peripheral  end.  Before  the  nerve  can  regain 
its  function  the  axis  cylinders  must  penetrate  the  whole  length  of  the  nerve  to 
their  peripheral  end  organs  which  they  do  under  favorable  circumstances,  at 
the  rate  of  about  i  to  2  mm.  per  day.  In  experiments  on  animals  Van  Lair 
found  that  when  the  divided  ends  were  in  contact,  function  returned  in  from 
8  to  II  months.  When  they  were  i  cm.  apart  recovery  took  14  months;  when 
2  cm.  apart  30  months,  and  when  4  cm.  apart  there  was  no  recovery. 

If  the  ends  of  the  divided  nerve  are  too  far  apart  or  if  prompt  union  is  pre- 
vented by  infection,  etc.,  the  gap  between  the  divided  ends  becomes  filled  with 
fibrous  connective  scar  tissue;  the  divided  end  of  the  distal  segment  becomes 
covered  with  a  comparatively  thin  and  not  prominent  cap  of  scar  tissue;  the 
end  of  the  proximal  segment  forms  a  bulb  of  varying  size  (neuroma)  (Fig.  938). 
The  bulb  or  neuroma  consists  of  a  tangle  of  new  axis  cylinders,  proliferated 
Schwann  cells  and  connective  tissue;  a  structure  identical  with  the  familiar 
amputation  neuroma.  The  axis  cylinders  have  proliferated,  have  endeavored 
to  reach  the  distal  segment,  have  failed  to  pass  through  the  interposed  struc- 
tures, have  lost  their  way,  many  have  turned  back  on  themselves.  If  the  hiatus 
is  not  too  great  and  the  fibrous  tissue  filling  it  is  not  too  efficient  a  barrier,  axis 
cylinders  may  in  time  and  by  devious  routes  gain  the  peripheral  segment  and 
recovery  may  ensue. 

If  the  nerve  is  crushed  instead  of  divided  there  is  destruction  of  the  nerve 
elements  and  complete  physiological  division  with  apparent  anatomical  con- 
tinuity. Fig.  940.  Degeneration,  repair  or  failure  of  repair  go  on  identically 
as  in  the  case  of  evident  anatomical  division.     Partial  section  of  a  nerve  either 


782 


NERVES 


by  division  or  crushing  leads  to  the  same  phenomena  as  in  complete  section  but 
limited  to  the  portion  of  the  nerve  trunk  aflfected  and  in  such  lesions  notches  and 
lateral  neuromata  arc  found.     Figs.  939,  940,  941. 

In  the  above  remarks  it  is  assumed  that  the  lesions  have  been  sufficient 
to  cause  complete  anatomical  or  physiological  solution  of  continuity  with  con- 
sequent degeneration  of  the  peripheral  segment  of  the  nerve.  All  degrees  of 
injury  are  possible  even  so  slight  as  to  cause  no  peripheral  degeneration  and 
in  such  early  recovery  ensues  under  proper  treatment.  "A  very  great  number 
of  nerve  injuries  (more  than  50  per  cent.)  are  cured  spontaneously  without  any 
intervention"  (Treatment  and  Repair  of  Nerve  Lesions,  Mme.,  Athanassio- 
Benisty). 

Two  or  three  weeks  must  elapse  after  the  injury  before  there  can  be  any 
true  symptom  picture  regarding  the  nature  and  extent  of  the  lesion  and  many 
careful  examinations  may  be  necessary  to  determine  its  exact  location  and 
degree. 


Fig.  938. 


Fig.  939. 


Fig.  941. 


Different  nerves  react  differently  to  injury.  Mme.  Athanassio-Benisty 
writes:  "Clinical  examinations  will  have  to  be  made  at  frequent  intervals  in 
order  to  arrive  at  a  conclusion  with  the  least  loss  of  time. 

In  complete  paralysis  of  the  musculo-spiral  or  of  the  external  popliteal,  if 
the  clinical  signs  remain  severe  four  or  five  months  after  injury,  and  if  the  nerve 
shows  no  sign  of  regeneration,  it  may  be  assumed  that  there  is  an  indication  to 
interfere  and  to  examine  the  appearance  of  the  anatomical  lesion. 

If  the  nerve  is  found  to  be  divided  or  completely  crushed,  suture  performed 
directly  after  resection  generally  gives  the  best  results. 

With  regard  to  injuries  of  the  ulnar,  the  fifth  month  is  also  the  maximum 
period  of  time  to  be  allowed  before  exploratory  incision  should  be  made,  when 
signs  of  a  severe  lesion  are  persistent. 

This  nerve  is  slow  to  regenerate  after  suture  or  resection,  and  it  is  important 
not  to  allow  too  much  time  to  elapse  before  operating. 

The  median  and  great  sciatic  regenerate  unsatisfactorily,  slowly,  and  in  a 
\ariable  manner.  Spontaneous  regeneration  never  takes  place  in  less  than 
eight  to  ten  months  after  the  wound,  but  when  these  nerves  are  divided,  crushed, 
or  severely  injured,  their  regeneration  is  particularly  protracted.  Thus,  when 
clinical  examination  reveals  persistence  of  the  signs  of  a  severeJesion,  the  fourth 
month  should  not  be  allowed  to  elapse  before  interfering." 


NERVE    INJURIES 


783 


Remote  results  of  operation  for  wounds  of  the  sciatic  and  it's  branches.  (Auvray,  Bull,  et 
Mem.  Soc.  de  Chir.  de  Paris,  xlvi,  p.  1121,  1920).  From  19  out  of  24  personal  cases,  it  was 
possible  to  obtain  information. 

4  cases  operated  on  for  pain  (liberation  of  nerve,  removal  foreign  bodies)  2  completely 
recovered.     2  improved. 

14  cases  operated  on  for  paralysis.  In  9  the  operation  was  'liberation'  of  the  nerve  with 
only  2  cures  and  seven  failures.  In  5  cases  there  was  end-to-end  suture;  of  these  there  was  i 
satisfactory  result  and  4  failures. 

I  case  operated  on  for  'reflex  paralysis'  with  improvement.  The  same  surgeon  had  good 
results  in  two-thirds  of  his  cases  of  operations  on  the  radial  (musculo-spiral)  nerve. 


/7cx.  d/'g.  sub.  m. 
"  prof. ' 


u/mjr/j  m^ 


Fig.  942. — I.  Track  for  flexor  carpi  ulnaris.  2.  Tract  for  flexor  profundus  digitorum. 
3.  Tract  for  hypothenar  eminence,  interossei,  third  and  fourth  lumbricals,  adductor  poUicis 
and  deep  head  of  flexor  brevis  poUicis.     4.  Sensor}'  tract.     {Vulpius  and  Stoffel.) 

Vulpius,  Stoffel  and  others  have  observed  that  bundles  of  nerve  fibres  des- 
tined for  distribution  to  certain  muscles  or  areas,  occupy  definite  positions  in 
the  main  trunk  of  the  nerve.  Pierre  Marie  with  Meige  and  Gosset  by  means 
of  electrical  stimulation  in  the  operation  wound  have  proved  the  existence  of 
this  systematic  intra-truncular  distribution  and  determined  the  topography  of 


784 


NERVES 


certain  nerves.  In  uniting  divided  nerves  by  suture  the  great  importance  of 
avoiding  all  torsion  must  be  evident,  otherwise  a  bundle  of  nerve  fibres  normally 
belonging  to  one  muscle  may  be  sent  to  another  (Fig.  942). 

Restoration  of  function  after  suture  for  complete  division  is  subject  to  much 
variation,  (a)  Muscle  tone  returns  early;  later  muscular  sensibility;  (b)  Cu- 
taneous sensibility.  Protopathic  begins  to  return  in  from  6  weeks  to  6  months 
and  is  complete  in  from  6  to  12  months.  Epicritic  sensibility  begins  to  appear 
in  about  6  months  but  is  not  complete  for  a  very  long  time,  (c)  Motion.  The 
return  of  motion  depends  to  some  extent  on  the  distance  of  the  nerve  lesion 
from  the  muscles  supplied.  The  muscles  nearest  the  site  of  nerve  suture  regain 
power  first.  Motion  may  be  expected  to  show  itself  in  from  6  to  9  months 
but  may  not  be  at  its  maximum  for  2  to  3  years,  (d)  Trophic  power  returns 
pari  passu  with  general  nerve  recovery,     (e)  Tinel  considers  formication  the 


Fig.  943- 


-Paralysis  median  and  ulnar  nerves.     Shaded  areas  show  loss  to  pin-prick  and 
cotton-wool.     {Manual  Neuro-Surg.,  U.  S.  A.) 


most  important  sign  of  nerve  regeneration.  If  pressure  is  made  over  the  nerve 
trunk  the  patient  experiences  a  tingling  sensation  in  the  area  of  its  cutaneous 
distribution.  Formication  begins  in  4  to  6  weeks  and  as  the  new  fibrils  grow- 
down  the  degenerated  nerve,  their  progress  can  be  traced  by  the  advancing 
zone  in  which  the  tingling  is  observed. 

It  has  long  been  known  but  not  properly  appreciated,  that  prophylactic 
treatment  of  paralytic  deformities  is  of  very  great  importance.  Stretching  of 
paralyzed  muscles  must  be  prevented  by  proper  posture,  splints  or  apparatus. 
Nutrition  of  the  muscles  must  be  favored  by  massage,  etc.  In  fact  deformities 
must  be  prevented  and  the  muscles  kept  in  such  condition  that  they  can  act 
as  soon  as  nerve  activating  force  can  be  supplied. 

Primary  Neurorrhaphy. — When  a  nerve  of  any  importance  has  been  divided 
it  ought  to  be  sutured  at  once.  This  presupposes  the  possibility  of  asepsis. 
In  mobile  war,  the  extent  of  the  trauma,  the  long  delay  before  operation  can 
be  undertaken,  the  rush  of  life-saving  work  and  lack  of  room  in  the  evacuation 
hospitals  all  tend  to  make  primary  suture  a  rarity,  but  during  periods  of  lesser 


NERVE    SUTURE  785 

activity  as  in  trench  fighting  the  primary  suture  is  often  feasible  and  becomes 
a  great  conservative  agency.  In  civil  life  primary  neurorrhaphy  should  be 
the  rule.  If  the  wound  in  the  nerve  is  much  contused  it  must  be  trimmed 
with  a  sharp  knife  (the  blade  of  a  safety  razor)  as  the  contused  tissue  will  die 
and  form  a  barrier  against  regeneration.  In  suturing  use  very  fine  silk  or  linen, 
preferably  waxed,  threaded  on  fine  cambric  needles.  Fine  plain  catgut  may 
be  employed. 

Direct  Sutiire.^ — Through  the  sheath  of  the  nerve  introduce  three  or  four 
symmetrical  stitches  and  gently  approximate  the  cut  ends  of  the  nerve.  It  is 
important  to  completely  close  the  epineurium  to  prevent  escape  of  growing 
nerve  fibrils.  Be  careful  not  to  rotate  the  nerve  when  the  sutures  are  being 
tied,  lest  the  intra-truncular  arrangement  of  nerve  bundles  be  disturbed.  One 
stay  suture  through  the  whole  thickness  of  the  nerve  may  be  of  value.  Never 
handle  the  nerve  ends  with  forceps.  Do  not  have  any  tension  on  the  sutures, 
this  is  fatal  to  success.  If  the  nerve  is  only  partially  divided  suture  of  the 
divided  portion  is  easy  and  should  be  done. 

Indirect  Suture. — Fibrous  tissue  around  the  divided  nerve  is  united  by 
sutures  and  helps  to  hold  the  ends  in  position.  If  it  is  difficult  to  bring  the 
divided  ends  of  the  nerve  together  flexion  of  the  limb  may  overcome  the  difii- 
culty  and  must  be  kept  up  until  union  is  advanced.  (See  remarks  by  Sir 
Robert  Jones,  page  787.)  Implantation  of  a  segment  of  nerve  to  bridge  a  gap 
may  be  necessary. 

Secondary  Neurorrhaphy. — A  nerve  has  suffered  anatomical  or  physiological 
division  partial  or  complete.  Sufficient  time  has  passed  to  permit  the  assump- 
tion that  either  no  restoration  of  continuity  has  been  attained  or  that  all  the 
possible  recovery  of  function  has  already  returned  and  is  insufiicient.  An  ex- 
ploratory operation  is  necessary. 

Step  I. — If  possible  avoid  the  use  of  a  tourniquet.  Expose  the  nerve  above 
and  follow  it  down  to  the  site  of  injury.  If  necessary  expose  it  also  below  and 
follow  it  up.  It  is  usually  wrong  to  expose  the  mass  of  scar  tissue  directly  and 
endeavor  to  find  the  nerve  in  it. 

I.  The  want  of  conductivity  is  apparently  due  to  pressure  by  a  fragment 
of  bone,  or  a  mass  of  scar  tissue.  Free  the  nerve  (neurolysis)  and  take  precau- 
tions to  avoid  recurrence. 

II.  It  is  suspected  that  a  mass  of  scar  tissue  inside  the  nerve  is  at  fault. 
Split  the  nerve  longitudinally  and  remove  the  noxious  material.  When  freeing 
the  nerve  be  careful  not  to  divide  branches. 

III.  There  is  a  very  small  amount  of  interstitial  scar  tissue.  Injection  of 
salt  solution  into  the  nerve  may  open  up  new  channels  for  nerve  growth. 

IV.  There  is  a  distinct  neuroma  with  apparent  anatomical  continuity  (Fig. 
940).  SpHt  the  neuroma  and  note  that  the  axis  cylinders  fail  to  pass  through. 
Treat  exactly  as  if  there  was  evident  anatomical  division. 

V.  There  is  evident  anatomical  division,  the  two  ends  of  the  nerve  being 
separated  by  a  greater  or  less  amount  of  scar  tissue. 

Dissect  the  scar  from  its  surroundings  but  not  yet  from  its  nerve  attachment. 
Grasping  the  scar  tissue  with  forceps  make  gentle  traction  through  it  on  the  nerve 
so  as  to  free  it  better  and  obtain  some  lengthening.     With  a  sharp  knife  partially 

60 


786  NERVES 

cut  through  the  scar  tissue  transversely.  Leaving  some  of  the  scar  tissue  intact 
provides  a  useful  handle  and  guide  to  aid  in  accurate  suturing.  Cut  off  thin, 
transverse  slices  from  the  upper  and  lower  segments  of  the  divided  scar  until 
so  much  of  the  neuroma  has  been  removed  that  healthy  nerve  fibrils  are  exposed 
in  the  upper  segment  and  good  nerve  channels  in  the  lower.  Suture  with  fine 
silk,  linen  or  plain  catgut,  using  fine  non-cutting  needles  and  including  as  Uttle 
of  the  nerve  in  the  suture  as  possible.     Avoid  axial  rotation  of  the  nerve. 

An  exhaustive  experimental  investigation  of  material  for  nerve  suture  (Sargent  and  Green- 
field, Brit.  Med.  Jour.,  Sept.  27,  1919)  justifies  the  following  conclusions: 

(r)  Plain  thread  or  silk  sutures  cause  no  irritation,  but  are  relatively  unabsorbable. 

(2)  'Plain   sterilized'  or  'plain  iodized  gut'  are   rapidly  ab- 
sorbed, but  have  low  tensile  strength  and  are  slightly  irritating. 

(3)  'Japanese  silkworm   gut'  has  great  tensile  strength   and 
in    rate  of  absorbability  and   reaction  which  it  causes,  holds  a 

Tension  A,  i,  >:"'  .  place  midway  between  groups  i  and  2. 

Suture  \.L'~J'* 7   Union  (4)  Chemical    antiseptics    should   be   avoided    in     all    suture 

material. 

(5)  The  disadvantages  of  any  suture  material  are  exaggerated 

when  passed  through  the  whole  thickness  of  a  nerve  in  the  form 

,  .  .,     c-  .     of  a   tension   suture,   as   this   tends    to    produce    an    intraneural 

I-IG.  944. —  {AUcr  i) argent  ,  ,  ,    1  ,        r        •  T-    1 

and  GreenfiddA  neuroma  above  and  below,  thus  formmg  a  hmdrance  to  regeneration 

(Fig.  944). 

Similarly  excise  the  rest  of  the  scar  tissue  and  complete  the  suturing.  Exact 
hemostasis  is  important.  Bleeding  from  the  nerve  may  be  controlled  by  gentle 
pressure  with  gauze  wrung  out  of  warm  water  or  with  a  small  fragment  of 
muscle. 

VI.  There  is  a  gap  between  the  two  ends  of  the  nerve,  which  cannot  be 
closed  sufficiently  to  permit  of  direct  end-to-end  suture.  Transplantation  may 
be  used.  The  'cable'  transplant  is  the  best,  as  by  this  means  a  slender  unim- 
portant nerve  may  be  employed  as  the  implant. 

Expose  and  excise,  with  gentleness,  a  long  segment  of  such  a  nerve  as  the 
Lesser  Internal  Cutaneous  or  the  Superficial  Radial  in  the  arm  or  the  External 
Cutaneous  or  the  Short  Saphenous  in  the  leg. 

Expose  and  prepare  the  ends  of  the  nerve  it  is  desired  to  unite. 

With  a  sharp  knife  cut  the  implant  into  segments  of  length  sufficient  to  fill 
the  gap.  With  a  fine  suture  perforating  the  segments  near  their  ends  unite 
them  into  a  cable.     The  suture  must  not  compress  the  nerves. 

Suture  the  ends  of  the  cable  to  the  proximal  and  distal  stumps  of  the  nerve 
to  be  repaired. 

VII.  The  nerve  is  only  partly  divided,  there  is  a  unilateral  notch  and  neu- 
roma. Excise  the  neuroma  and  scar  tissue  exactly  as  described  above,  but  most 
jealously  preserve  the  intact  portion  of  the  nerve. 

The  advisableness  of  surrounding  the  line  of  suture  with  some  material  such 
as  Cargile  membrane,  fat,  fascia,  formalinized  artery,  etc.,  in  the  hope  of  avoid- 
ing adhesions,  is  a  matter  of  much  discussion.  On  the  whole  the  best  method 
for  avoiding  adhesions,  is  to  place  the  repaired  nerve  in  the  sulcus  between  two 
muscles  and  to  be  very  exact  in  securing  hemostasis. 

No  apology  is  required  for  quoting  at  length,  opinions  expressed  by  Sir 


NERVE    REPAIR  787 

Robert  Jones  in  his  address  before  the  American  College  of  Surgeons  (Brit. 
Med.  Jour.,  Nov.  8,  igiq). 

"Experience  taught  us  that  it  was  better  to  explore  earlier  and  more  fre- 
quently than  we  did  at  the  beginning  of  the  war." 

"It  is  found  that  if  a  nerve  is  simply  concussed  or  compressed,  and  has 
undergone  Wallerian  degeneration,  it  will  early  show  signs  of  recovery.  In 
cases  which  do  not  spontaneously  recover  in  a  month  or  two,  it  is  usually  a  mis- 
take to  await  regeneration  of  the  nerve,  and  an  exploratory  operation  should  be 
undertaken.  Inspection  of  the  exposed  nerve  at  the  time  of  operation  and  its 
faradic  excitability  should  be  regarded  as  a  part  of  diagnosis.  It  is  essential 
in  such  cases  that  the  surgeon  should  be  experienced  in  nerve  surgery,  and  be 
prepared  to  close  the  wound  without  interfering  with  the  nerve  if  it  has  an  in- 
tact sheath,  and  gives  a  faradic  response  when  tested  with  a  weak  current.  It 
is  probable  that  no  interval  between  w'ound  and  operation  is  too  long  to  preclude 
possible  recovery  after  suture.  The  state  of  the  muscles,  tendons,  and  joints 
is  the  important  factor. 

"It  has  been  found  in  practice  that  end-to-end  suture  can  be  attained  in  the 
great  majority  of  cases  by  posturing  the  joints  and  by  transposing  nerves.  An 
inch  and  a  half  can  be  gained  by  transposing  the  musculo-spiral  to  the  inner 
side  of  the  humerus,  and  several  inches  by  transposing  the  ulnar  to  the  front  of 
the  elbow\  In  the  rare  instances  where  the  nerve  could  not  be  brought 
together  we  found  this  could  be  accomplished  by  a  two-stage  operation.  Silk 
was  tied  around  the  bulbs,  and  they  were  brought  together  as  nearly  as  possible, 
extra  length  being  secured  by  posturing  the  limb.  The  wound  was  then  closed 
and  gradual  traction  applied  to  the  nerve  through  the  limb  for  some  weeks. 
At  the  second  operation  it  was  found  that  the  ends  could  usually  be  brought 
together.  It  is  needless  to  emphasize  the  importance  of  approaching  the  nerve 
through  normal  tissue  above  and  below  the  lesion  were  it  not  that  even  yet 
surgeons  may  be  found  making  the  exploration  through  scar  tissue.  Nothing 
is  to  be  gained  from  surrounding  the  suture  line  with  vein  or  Cargile  membrane 
or  fat  introduced  from  without.  If  the  nerve  has  to  be  protected  from  scar 
tissue,  a  living  muscular  flap  is  indicated,  but,  whenever  possible,  the  scar  tissue 
should  be  freely  excised.  The  Medical  Research  Committee,  whose  report  is 
not  yet  published,  has  carefully  investigated  a  large  number  of  cases  operated 
upon.  In  the  case  of  nerve  grafting  they  have  not  met  with  one  case  of  com- 
plete recovery  and  but  very  few  partial  recoveries.  Most  cases  have  ended  in 
failure.  Bridging  by  catgut,  vein,  alcoholized  nerve,  and  other  foreign  material 
has  consistently  failed.  The  turning  down  of  flaps  of  nerve,  and  nerve  crossing 
or  anastomosis — that  is,  implanting  the  distal  end  of  the  divided  nerve  into 
a  healthy  one — invariably  fails.  The  conclusion  come  to  is  that  end-to-end 
suture  by  a  one,  or,  if  necessary,  a  two-stage  operation,  is  the  method  to  be 
adopted  in  every  case. 

"In  cases  of  irreparable  damage  to  the  musculo-spiral  or  posterior  interos- 
seous, tendon  transplantation  properly  performed  has  proved  an  unqualified 
success.  It  must  be  associated  with  a  good  technique,  and  be  followed  by 
careful  re-education.  The  operation  I  suggested  in  pre-war  days  with  certain 
modifications  I  still  recommend,  but  I  advocate  a  more  frequent  use  of  the 


788  NERVES 

pronator  radii  teres.  The  flexor  carpi  radialis  and  the  flexor  carpi  ulnaris  can 
be  transplanted  into  the  paralvzed  extensors  of  the  thumb  and  finp;ers,  and  the 
pronator  radii  teres  may  be  affixed  to  the  radial  extensors.  In  transj)lanting 
tendons  it  is  important  to  pay  careful  attention  to  the  correct  tension,  and  the 
hand  and  fingers  should  be  kept  well  dorsiflexed  when  the  attachments  are 
being  made,  and  the  transplanted  tendon  must  run  a  straight  course  from  its 
origin  to  its  new  insertion.  Attention  to  these  points  will  make  the  difference 
between  success  and  failure.  If  the  operation  is  a  real  success,  the  fingers  and 
thumb  can  be  easily  fully  extended.  Tendon  transplantation  with  the  object 
of  merely  dorsiflexing  the  wrist  should  be  discouraged,  and  tendon  fixation  with 
the  object  of  permanently  fixing  the  wrist  in  dorsiflexion  should  be  reserved  for 
those  cases  where  transplantation  has  been  a  failure  and  where  the  extensor 
muscles  and  tendons  have  been  destroyed." 

"The  prognosis  as  regards  functional  utility  after  nerve  suture  depends  very 
largely  upon  which  particular  nerve  has  been  injured.  Thus  the  musculo-spiral 
usually  makes  a  good  recovery,  whilst  the  ulnar,  as  regards  the  intrinsic  muscles 
of  the  hand,  does  badly.  Another  factor  of  importance  in  prognosis  is  the  occu- 
pation of  the  patient.  A  man  with  an  ulnar  nerve  lesion  will  usually  recover 
both  sensation  and  muscular  control  quite  well  enough  for  most  trades,  but 
he  will  not  recover  control  of  the  finer  movements  of  the  hand — such  as  are 
needed  for  piano  playing. 

"After  the  musculo-spiral,  in  order  of  good  recoveries,  we  must  place  the 
sciatic.  The  results  of  suture  here  are  surprisingly  good.  A  large  number  of 
our  cases  were  examined  two  or  three  years  after  suture.  Some  of  these  men 
could  jump,  climb  ladders,  and  run,  and  many  have  returned  to  their  pre-war 
employment. 

"The  brachial  plexus  often  makes  a  good  recovery,  especially  the  upper 
part.  Plexus  lesions  should  be  watched  for  a  long  time,  six  to  nine  months  or 
more,  and  not  operated  on  for  exploratory  purposes  as  are  the  nerves  themselves, 
because  they  frequently  make  excellent  progress,  and  a  generalized  paresis  may 
later  be  limited  to  one  cord,  or  nerve. 

"Median  injuries  do  fairly  well,  the  thumb  intrinsics  even  recovering  in 
some  cases,  whilst  it  is  usual  for  the  wrist  flexors  and  considerable  sensation 
to  recover.  Sensation,  however,  is  usually  lost,  or  very  slowly  or  rarely  recov- 
ered from,  over  the  terminal  phalanx  of  the  index-fingers. 

"The  ulnar  recoveries  are  good  as  regards  wrist  and  finger  flexors,  and  even 
its  sensory  disturbance  clears  up  well.  As  has  been  stated,  good  recovery  of 
the  interossei  is  very  rare.  They  may  and  do  recover  their  faradic  excitability 
more  often  than  voluntary  power. 

"Combined  lesions  of  the  median  and  ulnar,  particularly  if  complicated  by 
ligation  of  the  artery,  do  very  badly.  There  is  usually  the  stiff,  rigid,  board- 
like hand  with  joint  changes  to  still  further  hinder  the  chance  of  good  function. 
This  is,  indeed,  the  important  obstacle. 

"The  after-treatment  of  cases  of  peripheral  nerve  injury  has  not  undergone 
much  change.  The  relaxation  of  muscles  is  essential,  and  it  is  also  necessary 
that  the  relaxed  position  of  the  nerve  should  not  be  too  early  dispensed  with, 
otherwise  the  recently  regenerated  axis  cylinders  will  be  ruptured.     Interrupted 


NERVE    IMPLANTATIONS  789 

galvanic  stimulation,  massage,  heat  and  re-education  are  indispensable  de- 
siderata." 

Direct  Implantation  of  a  Nerve  into  Muscle. — Attempts  to  restore  function 
to  a  paralyzed  muscle  have  usually  been  made  by  anastomosing  a  healthy  motor 
nerve  to  the  nerve  trunk  which  supplied  the  muscle.  Heineke  (Zent.  fiir  Chir., 
1914,  No.  11)  conceived  the  idea  that  by  implanting  the  sound  nerve  into  the 
muscle,  the  axis  cylinders  might  either  distribute  themselves  to  the  individual 
muscle  fibres  by  growing  into  the  preexisting  nerve  paths  or  might  reach  the 
muscle  fibres  directly  and  form  new  nerve  endings. 

Heineke  and  his  assistants  produced  paralysis  of  certain  muscles  in  rabbits 
by  exposing  the  two  branches  of  the  sciatic  nerve  (tibial  and  peroneal)  and  ex- 
cising 1-2  cm.  of  the  tibial  nerve.  The  peroneal  nerve  was  then  exposed  down- 
wards and  divided  below  the  head  of  the  fibula.  The  central  end  of  the 
peroneal  nerve  was  now  pulled  through  a  tunnel  bored  in  the  gastrocnemius 
and  fixed  there.  After  14  days  the  gastrocnemius  responded  slightly  to  faradic 
and  galvanic  stimulation  of  the  peroneal  nerve  in  the  thigh.  After  four  weeks 
the  reaction  was  powerful  while  "after  eight  weeks  the  power  and  extent  of  the 
contractions  could  not  be  distinguished  from  the  normal  and  were  not  confined 
to  the  muscle  in  which  the  nerve  was  implanted  but  the  neighboring  muscles 
of  the  flexor  group  took  part  in  the  contractions.  The  muscles  which  were  at 
first  atrophied  and  yellow  regained  their  normal  color  and  consistence."  A 
muscle  enervated  for  21  days  can  recover  after  direct  implantation  of  a  healthy 
nerve. 

An  extraordinary  case  of  secondary  nerve  suture  of  the  facial  nerve  is  re- 
ported by  Emmet  Rixford.  Eight  weeks  after  an  injury  the  facial  nerve 
was  identified  as  it  left  the  stylomastoid  foramen  and  was  found  to  be  divided 
I  cm.  below  this  point.  The  distal  segment  was  found  with  great  diflaculty 
by  first  exposing  the  two  principal  branches  in  the  parotid  and  tracing  them 
back.  The  gap  between  the  segments  was  about  i  cm.  The  proximal  segment 
after  vivification  was  so  short  that  stitches  could  not  be  introduced.  Rixford 
cut  away  enough  of  the  mastoid  process  and  the  external  wall  of  the  aqueduct 
of  Fallopius  so  that  the  nerve  could  be  mobilized  and  the  two  segments  united 
by  sutures.  The  result  was  entirely  good.  In  repose  the  two  sides  of  the  face 
looked  alike  and  the  patient  could  close  the  eye  on  the  afi'ected  side  independ- 
ently of  the  other  with  an  expressive  wink.     ("Trans.  Am.  Surg.  Assoc, "  xxii.) 

Suture  of  Recurrent  Laryngeal  Nerve. — Shelton  Horsley  ("Annals  of  Surg.,''  li, 
524)  reports  a  case  in  which  the  left  recurrent  laryngeal  nerve  w^as  divided  by  a 
bullet  at  a  point  just  before  the  nerve  entered  the  larynx.  The  voice  was  hoarse 
and  weak.  Respiration  was  impeded.  The  left  vocal  cord  was  paralyzed  and 
the  larynx  above  the  glottis  was  congested.  Horsley  operated  as  follows: 
jMake  an  incision  along  the  anterior  border  of  the  left  sterno-mastoid.  The 
middle  of  this  cut  is  opposite  the  inferior  limit  of  the  larynx.  Retract  the  sterno- 
mastoid  and  with  it  the  carotid  and  internal  jugular  outwards.  Expose  the 
left  lobe  of  the  thvroid  and  retract  it  to  the  right  along  with  the  trachea  and 
larynx.  Look  for  the  nerve  in  the  groove  between  the  trachea  and  oesopha- 
gus. In  Horsley's  case  the  wounded  part  of  the  nerve  was  surrounded  by 
a  mass  of  scar  tissue.     About  8  mm.  of  involved  nerve  was  excised  and  the 


7 go  NERVES 

divided  ends  united  by  a  fine  catgut  suture.  Six  days  after  operation  there 
was  no  improvement  in  the  symptoms.  Three  months  later  the  movements 
of  the  glottis  were  almost  normal  though  the  left  vocal  cord  seemed  a  little 
weak.  The  voice  was  no  longer  hoarse  but  had  not  regained  its  full  volume. 
Shepherd  has  successfully  sutured  the  recurrent  laryngeal  nerve  after  it  had 
been  accidentally  divided  during  a  strumectomy. 

NERVE  ANASTOMOSIS 

I.  Nerve  Anastomosis  for  Facial  Paralysis. — The  first  operation  of  this 
kind  was  performed  by  Ballance  and  Purves  in  1895.  Faure  operated  in  1898, 
and  in  1900  Robert  Kennedy  in  a  case  of  severe  facial  spasm  divided  the  facial 
nerve,  uniting  the  proximal  extremity  of  its  distal  portion  to  the  partially 
divided  spinal  accessory  nerve.     The  result  was  perfect. 

Harvey  Gushing  ("Annals  of  Surgery,"  May,  1903)  reports  a  case  in  which 
the  facial  nerve  was  destroyed  near  the  stylo-mastoid  foramen.  After  the 
original  wound  (pistol  wound)  was  thoroughly  healed,  the  following  operation 
was  performed: 

1.  Incision  along  anterior  border  sterno-mastoid. 

2.  Exposure  spinal  accessory  nerve  at  point  of  entry,  into  deep  surface  of 
sterno-mastoid,  about  two  inches  below  the  tip  of  the  mastoid. 

Exposure  distal  segment  of  facial  nerve  by  incising  the  posterior  border  of 
the  parotid  gland  in  a  line  parallel  to  and  directly  under  the  original  skin  in- 
cision. If  this  cut  be  made  carefully,  one  of  the  main  branches  of  the  nerve 
is  certain  to  be  encountered  and  can  be  followed  back  by  blunt  dissection 
without  (Fig.  945)  isolating  the  nerve  itself. 

3.  Square  division  of  facial  nerve  close  to  the  scar  tissue  existing  at  point 
of  original  injury. 

4.  Division  spinal  accessory  nerve  at  point  of  entry  into  the  muscle. 

5.  Approximation  of  the  two  nerves,  without  tension,  over  the  posterior 
belly  of  the  digastric  muscle.     Suture. 

6.  Closure  of  wound. 

Improvement  was  noted  after  an  extraordinarily  short  time.  The  ultimate 
result  was  most  gratifying. 

Murphy  insists  on  the  importance  of  imbedding  the  point  of  nerve  union 
inside  a  muscle  belly  {e.g.,  sterno-hyoid).  In  one  case  he  saw  the  point  of  union 
imbedded  and  compressed  into  uselessness  by  scar  tissue.  After  freeing 
the  nerve  from  scar  tissue  and  imbedding  it  in  muscle  a  good  result  was  obtained. 

Instead  of  using  the  spinal  accessory,  the  hypoglossal  nerve  has  been  utilized 
to  supply  nerve  stimuli  to  the  facial.  This  was  first  done  by  Ballance  and 
Stewart,  later  by  Frazier.  The  glossopharyngeal  nerve  has  also  been  similarly 
used.     The  various  operations  for  facial  palsy  may  be  systematized  as  follows: 

Anatomy. — The  facial  nerve  emerges  through  the  stylo-mastoid  foramen 
where  it  is  deeply  seated;  from  here  it  runs  "downwards,  outwards  and  a 
little  forwards  to  turn  or  wind  round  the  styloid  process,  after  this  its  course 
is  almost  horizontally  forwards  until  it  crosses  the  posterior  auricular  artery 
and   immediately  plunges   into   the   parotid  gland.     The   horizontal   portion 


NERVE   ANASTOMOSIS 


791 


of  the  nerve  is  situated  at  the  level  of  the  tip  of  the  lobule  of  the  ear,  i.e.,  about 
^i  inch  below  the  lower  border  of  the  zygomatic  arch." 

The  Spinal  Accessory  Nerve.~The  external,  spinal  or  surgical  portion  of 
this  nerve  emerges  from  the  skull  through  the  jugular  foramen;  from  here  it 


Fig.  945. — Nerve  anastomosis.     {Cushing,  Annals  of  Surg.) 


passes  downwards,  outwards  and  a  little  backwards  in  front  of  (rarely  behind) 
the  internal  jugular  vein  between  that  vein  and  the  occipital  artery  which 
crosses  it  perpendicularly.  The  nerve  now  lies  exactly  between  the  transverse 
process  of  the  atlas  and  the  posterior  border  of  the  digastric.     Below  this  point 


792  NERVES 

the  nerve  passes  behind  the  posterior  border  of  the  parotid  to  enter  the  deep 
surface  of  the  sterno-mastoid  2  inches  below  the  apex  of  the  mastoid  process. 

The  Hypoglossal  Nerve. — The  hypoglossal  nerve  leaves  the  skull  through 
the  anterior  condylar  foramen  and  lies  on  the  inner  side  of  the  deep  cervical 
vessels.  As  it  descends,  the  nerve  comes  forward  between  the  internal  carotid 
artery  and  jugular  veins  to  the  lower  border  of  the  digastric  muscle  where  it 
curves  forwards  round  the  origin  of  the  occipital  artery,  the  sterno-mastoid 
branch  of  which  turns  downwards  over  the  nerve.  From  this  point  the  nerve 
runs  forwards  above  the  hyoid  bone,  passes  under  the  tendon  of  the  digastric, 
the  lower  end  of  the  stylo-hyoid  and  the  mylo-hyoid  muscles,  and  crosses  the 
external  carotid  and  lingual  arteries. 

Spino-facial  Anastomosis. — Step  i. — Incision  along  the  anterior  border  of 
the  sterno-mastoid,  beginning  above  in  the  groove  between  the  external  ear  and 
the  mastoid  at  the  level  of  the  tragus  and  ending  at  a  point  about  5  inches  lower. 

Step  2. — Retract  the  ear  forwards.  Divide  the  fibrous  tissues  covering  the 
mastoid  so  as  to  gain  access  to  its  anterior  border.  Expose  the  anterior  border 
of  the  sterno-mastoid. 

Step  3. — With  blunt  dissection  penetrate  between  the  parotid,  the  anterior 
border  of  the  mastoid.  Move  the  dissecting  instrument  horizontally  and  not 
vertically,  to  avoid  injuring  the  nerve.  The  nerve  should  be  found  at  a  depth 
of  a  little  less  than  3'^  inch  from  the  surface  of  the  mastoid  at  the  junction  of 
its  lower  and  middle  thirds  (Marion).  Isolate  the  nerve  and  divide  it  as  far 
back  as  possible. 

Step  3. — Open  the  sheath  of  the  sterno-mastoid  longitudinally.  Demonstrate 
the  transverse  process  of  the  atlas  about  ^^  inch  below  the  mastoid,  and 
expose  it  clearly  to  sight  by  bluntly  dividing  the  fibrous  tissues  covering  it. 
Demonstrate  the  posterior  belly  of  the  digastric  in  front  of  the  atlas.  The  spinal 
accessory  nerve  lies  between  the  transverse  process  of  the  atlas  behind  and  the 
digastric  in  front.     Isolate  the  nerve. 

Step  4. — Divide  the  nerve  as  its  entrance  into  the  sterno-mastoid,  and  make 
an  end-to-end  anastomosis  between  its  proximal  segment  and  the  distal  seg- 
ment of  the  facial. 

Step  5. — Bury  the  line  of  nerve  suture  in  the  belly  of  the  digastric  muscle 
after  incising  the  muscle  for  this  purpose. 

Step  6. — Close  the  wound  with  buried  and  superficial  sutures. 

Hypoglosso-facial  Anastomosis. — Step  i. — From  a  point  on  the  level  of  the 
tragus,  in  the  groove  between  the  external  ear  and  the  mastoid,  make  an  incision 
downwards  along  the  anterior  border  of  the  sterno-mastoid  to  a  point  a  trifle 
below  the  angle  of  the  jaw;  from  this  low  point  cut  forwards  horizontally  on  the 
level  of  the  hyoid  bone,  for  about  i  inch. 

Step  2. — Expose  and  divide  the  facial  nerve  as  in  the  spino-facial  anasto- 
mosis. 

Step  3. — In  the  lower  part  of  the  wound  open  the  sheath  of  the  sterno- 
mastoid  anteriorly,  retract  the  muscle  backwards,  divide  the  deep  layer  of  the 
sheath  of  the  mastoid  at  the  level  of  the  greater  horn  of  the  hyoid.  The  hypo- 
glossal nerve  is  to  be  sought  either  posteriorly  where  it  crosses  the  external 


FACIAL    FAl.SY  793 

carotid  (Fig.  946)  or  anteriorly  between  the  greater  horn  of  the  hyoid  and  the 
posterior  belly  of  the  digastric. 

Step  4. — Free  the  nerve  very  gently  from  its  surroundings.  Divide  the  nerve 
so  far  forwards  that  enough  isolated  nerve  trunk  is  left  to  be  turned  upwards  and 
forwards  and  united  without  tension  to  the  distal  segment  of  the  divided 
facial  nerve.     Complete  the  anastomosis. 

Steps  5  and  6. — As  in  spino-facial  anastomosis. 


Hypo- 
glossal n. 


Fig.  946. — Exposure  of  hypoglossal  nerve.     {Marion.) 

Indications  for  Operation  for  Facial  Palsy. — i.  Where  it  is  known  that 
the  facial  nerve  is  completely  divided,  immediately  unite  its  divided  ends 
if  possible;  if  this  is  impossible  perform  spino-facial  or  hypoglosso-facial  anas- 
tomosis as  soon  as  possible. 

2.  When  there  is  reasonable  doubt  as  to  the  permanency  and  completeness 
of  the  lesion,  delay  is  justifiable.  If  there  is  no  sign  of  recovery  in  six  months, 
operate  (Frazier). 

3.  In  old  cases  test  the  facial  muscles,  if  they  are  completely  atrophied  and 
no  longer  respond  to  the  faradic  current,  probably  operation  will  do  no  good. 
If  the  muscles  respond  to  faradic  stimulation  operation  is  proper. 

4.  Facial  palsy  from  "  cold."  This  is  probably  an  infective  neuritis  (Spiller). 
The  prognosis  is  usually  good  without  operation.  If,  after  four  to  six  months, 
the  facial  muscles  are  still  almost  completely  paralyzed  and  reaction  of  degenera- 
tion is  pronounced,  Spil  er  would  recommend  anastomosis.  The  same  rules 
apply  to  facial  paralysis  from  middle  ear  disease. 

C.  E.  Dennis  (Brit.  Med.  Jour.,  Sept.  21,  1918)  recommends  highly  a 
splint  devised  by  Miss  Jennings.     If  recovery  from  injury  to  the  facial  nerve 


794  NERVES 

is  going  to  take  place  it  is  as  important  to  prevent  overstretching  of  the  para- 
lyzed facial  muscles,  as  of  the  foot  muscles  in  anterior  poliomyelitis.  The 
splint  consists  of  malleable  German  silver  wire  bent  so  as  to  hook  into  the  corner 
of  the  mouth  and  over  the  ear  of  the  affected  side  like  the  ear-piece  of  spectacle 
frames  'Fie.  947  >. 

Choice  of  Operation. —  i.  In  palsy  from  division  of  the  facial  nerve  im- 
mediate reunion  is  always  desirable,  but  not  often  possible. 

2.  Spino-facial  anastomosis  is  somewhat  more  easily  performed  than  is  the 
hN^poglosso-facial  operation,  and  the  muscles  paralyzed  by  the  nerve  section 
are  less  important.  The  spinal-accessory  nerve,  however, 
is  dominated  by  the  centres  for  associated  movements  of 
the  shoulder,  hence  after  operation  there  are  liable  to  be 
movements  of  the  facial  muscles  every  time  the  patient 
raises  his  shoulder.  Mr.  Ballance  has  given  up  spino- 
facial  anastomosis  on  account  of  the  difficulty  of  securing 
dissociation. 

3.  Hypoglosso-facial    anastomosis   is   not   much   more 
difficult  than  spino-facial,  the  muscles  supplied  are  not  of 
Fig.  94  7- — {Miss     prime    importance.      The    hj^Doglossal   cortical   centre  is 
mng s  spin  .       functionally  more  allied  to  the  facial  centre  than  is  that  of 

the  spinal  accessory. 
Spiller  writes : "  In  employing  the  h}'poglossal  as  the  nerve  for  anastomosis  with 
the  facial  it  is  possible  that  emotional  movements  may  be  restored,  and  such 
seems  to  have  been  the  result  in  a  case  observed  by  Koster  and  Bernhardt,  in 
which  the  corner  of  the  mouth  on  the  affected  side  was  moved  during  laughter." 
Treatment  of  Facial  Paralysis  by  Muscle  Transplantation. — A.  Jianu 
("Deutsche  Zeitsch.  fiir  Chir.,"  cii,  p.  577.  Ref.  "Journal  de  Chir.,"  Feb.,  1910) 
has  operated  by  taking  a  flap  from  the  sterno-mastoid  muscle  (pedicle  above) 
and  suturing  it  to  the  angle  of  the  mouth.  The  result  was  satisfactory.  Jon- 
nesco,  following  Jianu's  principle,  exposed  the  masseter  by  a  curved  incision 
following  the  edge  of  the  inferior  maxilla  (both  the  ascending  and  horizontal 
rami);  split  the  masseter  in  the  direction  of  its  fibres;  separated  the  anterior 
portion  of  the  muscle  from  its  insertion  into  the  jaw,  and  so  formed  a  muscular 
flap  attached  to  the  zygoma.  This  flap  he  sutured  to  the  angle  of  the  mouth. 
The  result  was  correction  of  the  deviation  of  the  mouth;  prevention  of  the 
escape  of  saliva;  ability  voluntarily  to  move  the  angle  of  the  mouth. 

The  operation  does  not  pretend  to  remedy  the  paralysis  of  the  orbicularis 
muscle  and  must  be  of  very  limited  value.  Cuneo  remarks  that  Jianu's  opera- 
tion should  be  reserved,  in  cases  of  total  facial  paralysis,  to  those  in  which  nerve 
anastomosis  has  failed,  and  that  when  performed  it  should  be  supplemented 
by  some  operation  on  the  eyelids,  such  as  angular  tarsorrhaphy. 

Lexer  (Eden,  Beitr.  z.  klin.  Chir.,  Lxxiii,  123)  has  used  a  slip  of  masseter 
to  support  the  mouth.  His  incision  penetrates  the  skin  and  subcutaneous 
tissues  in  the  naso-labial  fold.  From  this  cut  he  burrows  back  and  down 
until  the  parotid  is  reached.  The  parotid  is  now  retracted  bluntly  upwards 
and  forwards  to  expose  the  insertion  of  the  masseter  from  the  anterior  margin 
of  which  a  flap  i  cm.  wide,  with  pedicle  above,  is  detached  and  sutured  to  the 


OBSTETRIC    PALSY  795 

tissues  near  the  angle  of  the  mouth.  If  there  is  paralysis  of  the  eyelids  a  similar 
Hap  may  be  obtained  from  the  temporal  muscle  and  sutured  to  the  external 
angle  of  the  eye.  The  primary  incision  is  vertical  and  made  inside  the  temporal 
hair  line;  a  small  secondary  incision  close  to  the  eye  is  necessary  to  permit 
suturing. 

George  Fenwick  (Brit.  Med.  Jour.,  Nov.  29,  1919)  operates  as  follows: 

Preliminary  to  anesthesia  inspect  and  compare  the  two  sides  of  the  face 
and  mark  on  the  skin  (a)  the  lower  half  of  the  naso-labial  furrow,  (b)  The 
position  of  the  dimple  in  the  center  of  the  cheek  which  becomes  evident  when 
laughing,  (c)  The  direction  of  one  of  the  lines  of  crowsfoot  below  the  external 
canthus. 

Step  I. — Make  an  incision  in  the  hair  line  from  the  Zygoma  upwards  and 
backwards  to  the  top  of  the  temporal  fossa.  The  incision  is  parallel  to  the 
fibres  of  the  temporal  muscle.     Undermine  the  skin  to  expose  the  fascia. 

Step  2. — By  parallel  incisions  along  the  direction  of  the  fibres  form  a  flap, 
with  pedicle  below,  consisting  of  the  whole  thickness  of  the  temporal  muscle 
and  its  fascial  covering.  This  flap  should  be  as  thick  as  a  man's  thumb.  Im- 
mediately anterior  to  this  make  a  similar  but  narrower  flap.  Detach  both 
flaps  from  the  underlying  bone. 

Step  3. — ]\Iake  a  small  incision  along  the  crowsfoot  mark  below  the  external 
canthus.  ]Make  a  subcutaneous  tunnel  from  here  to  the  temporal  wound. 
Pull  the  smaller  muscle  flap  through  the  tunnel  and  suture  its  free  end  to  the 
orbicularis  palpebrarum.     Of  course  the  muscle  flap  should  be  fairly  taut. 

Similarly  incise  the  skin  in  the  lower  part  of  the  naso-labial  groove  and  make 
a  tunnel  under  the  skin  from  the  temporal  wound  to  the  angle  of  the  mouth. 
Pull  the  larger  muscular  flap  through  the  tunnel  and  suture  its  free  end  to  the 
superficial  fascia  in  the  cheek  wound  and  to  the  orbicularis  oris  below  and 
slightly  mesial  to  the  angle  of  the  mouth. 

Step  4. — Suture  the  wound  in  the  temporal  muscle.     Close  the  skin  wounds. 

After  Treatment. — Begin  massage  and  Faradism  early.  Have  the  patient 
practice,  before  a  mirror,  using  the  temporal  slips  of  muscle  in  their  new  function. 

II.  DUCHENNE-ERB  PARALYSIS— OBSTETRICAL  P-\LSY 

Paralyses  of  certain  groups  of  muscles  in  the  upper  extremity  may  be 
recognized  soon  after  birth.  The  origin  of  these  paralyses  is  disputed.  Until 
recently  they  were  ascribed  exclusively  to  tearing,  stretching  or  compression 
of  the  brachial  plexus  during  birth  (Duchenne)  or  to  trauma  received  later  in 
life.  The  part  of  the  plexus  affected  is  believed  to  be  at  that  point  where  the 
anterior  primary  divisions  of  the  fifth  and  sixth  cervical  nerve  roots  unite. 
The  motor  fibres  in  these  two  nerve  roots  supply  the  deltoid;  supraspinatus  and 
infraspinatus;  biceps;  brachialis  anticus;  supinator  longus  and  brevis,  and 
the  teres  minor.  Thus  in  a  typical  case  of  Duchenne-Erb  paralysis  the  arm 
cannot  be  abducted  at  the  shoulder,  flexion  of  the  elbow  is  impossible,  the 
forearm  is  in  a  position  of  pronation,  the  whole  arm  is  rotated  outwards  to  such 
an  extent  that  the  palm  of  the  hand  may  be  directed  outwards. 

Wilfred  Harris  and  V.  W.  Low  ("'Brit.  Med.  Journ.,"  Oct.  24,  1903)  believe 
that  Markoe's  case  ("Annals  of  Surg.,"  1885,  ii,  [85)  of  division  of  the  fifth 


796  NERVES 

cervical  root  proves  that  the  deltoid,  spiiiati,  biceps,  and  brachialis  anticus 
derive  their  whole  motor  supply  from  this  source,  while  the  supinator  longus  is, 
at  least  in  part,  indebted  to  it  for  its  motor  impulses. 

Turner  Thomas  ("Annals  of  Surg.,"  Feb.,  1914)  disputes  these  views  vig- 
orously. "The  fact  that  in  most  cases  there  is  practically  no  disturbance  of  sen- 
sation in  the  affected  limb,  although  the  roots  of  the  brachial  plexus  are  all 
mixed  nerves,  has  not  been  satisfactorily  explained."  He  believes  that  the 
great  majority  of  cases  of  obstetrical  paralysis  of  the  upper  limb  are  due  to 
pressure  on  the  front  of  the  shoulder  during  birth,  causing  a  bending  down  of 
the  acromion  process  and  specially  a  posterior  subluxation  of  the  head  of  the 
humerus.  The  bending  of  the  acromion  interferes  with  reduction.  The  fact 
that  when  this  subluxation  cannot  be  recognized  after  birth,  spontaneous 
reduction  being  assumed  to  have  occurred,  complete  recov^ery  ensues  under 
any  or  no  treatment,  also  the  fact  that  late  correction  of  the  persistent  sub- 
luxation leads  to  improvement,  support  his  views. 

The  presence  of  extensive  adhesions  about  the  plexus,  as  demonstrated 
at  operation,  renders  doubtful  the  presence  of  ruptured  nerve  roots  occasionally 
described,  because  of  the  great  difficulty  in  dissecting  accurately  these  delicate 
and  interweaving  structures  under  the  unfavorable  local  conditions.  Turner 
Thomas  believes  the  adhesions  are  due  to  a  spread  upwards,  no  great  distance, 
of  the  reparative  inflammation  at  the  injured  shoulder  joint.  Lange,  at  opera- 
tion, in  one  case  found  the  cause  of  the  paralysis  to  be  the  imbedding  of  the 
branches  of  the  plexus  in  thick  connective  tissue  in  the  axilla,  and  found  also  a 
diminution  and  deformation  of  the  head  of  the  humerus. 

Immediately  after  birth  reduction  of  the  subluxation  will  probably  be 
easy;  after  some  months  it  is  difficult  because  of  anatomic  changes.  Thomas 
states,  "  the  first  indication  at  any  stage  is  to  reduce,  the  next  to  obtain  the  best 
possible  motion  at  the  shoulder  joint."  If  the  surgeon  believes  injury  to  the 
brachial  plexus  is  primarily  at  fault  (the  author  is  strongly  inclined  to  consider 
that  Turner  Thomas  is  correct  in  denying  this),  then  when  a  case  presenting 
the  symptoms  enumerated  shows  no  improvement  after  two  or  more  months 
of  treatment  by  electricity,  massage,  etc.,  but,  on  the  contrary,  the  electrical 
reactions  of  degeneration  begin  to  appear,  then  operative  treatment  becomes 
proper.  There  are  two  methods  by  which  improvement  may  be  attained — 
one  by  nerve  anastomosis,  the  other  by  muscle  transplantation  or  transference. 

(A)  Direct  Method. — Robert  Kennedy's  Operation. — ("Brit.  Med.  Jour.," 
Feb.  7,  1903).  Place  the  patient  on  his  back,  with  a  pan  under  the  shoulders 
to  permit  of  the  head  being  well  thrown  back.  Incline  the  head  and  face  to  the 
opposite  side. 

Step  I. — From  the  junction  of  the  middle  and  lower  thirds  of  the  outer 
margin  of  the  sterno-mastoid  make  an  incision  outwards  and  downwards  to 
the  junction  of  the  outer  and  middle  thirds  of  the  clavicle.  Divide  the  deep 
fascia  between  the  sterno-mastoid  and  trapezius.  Expose  the  omo-hyoid  below 
the  lower  edge  of  the  wound.  Above  the  omo-hyoid  expose  the  scalenus  anti- 
cus muscle  and  demonstrate  the  nerve-trunks  emerging  from  under  it.  Trace 
the  two  upper  nerve-trunks  outwards  to  their  junction. 

Step  2. — Having  found  the  junction  of  the  fifth  and  sixth  nerves,  recog- 


ollSTK  IRIC    PALSY 


797 


nize  the  various  branches  and  free   Uiem  from  adhesions   (Fig.  948).     Free 
the  main  trunks  from  the  adhesions  which  seem  to  be  always  present. 

/f/YOA/30/OS. 

SUDCLAi'/aS. 

SUPRASCAPULAR. 
/Supru-spinatus.  \ 
I  /nfra-spl/tatus.f 

•mSCULO-CUrANEOUS. 

/Cora  CO  -Br»chiulis\ 
\,  [Biceps, Brae//.. AntJ 

,M£D/AN. 
■''CmCl/MFl£K. 

•'  /  Deltoid.    \ 
\rt:res-7nino>.J 

mUSCULO-SPmL. 

(IS;ipinator  louffusX 
et  ire  vis .  \ 

Brack. Arit.,Triceps\ 
Anconeus.  I 

[^tensors  or  Ha,id.] 


im 


POST.THORACIC. 

(Serratas   r/iuffnusji 

ANT.THORACIV-:' 
SUBSCAPULAR:-- 

iSuhscapularis .  | 
\latissi»t.us  dorsi .\ 
\  Teres  m.ajor.      ' 


Fig.  948. — Duchenne-Erb  paralysis. 

The  accompanying  illustrations  (Fig.  949,  950)  taken  from  A.  S.  Taylor's 
article  on  "Brachial  Birth  Palsy"  ("  Journ.  A.  M.  A.,"  Jan.  12,  1907)  illustrate 
well  the  anatomy  of  the  brachial  plexus. 


Fig.  949. — {Taylor.) 
A.  Scalenus  anticus.     B.   Phrenic  n.     C.  Int.  jugular.     D.  Transversalis  colli  a.     E.  Seventh  root. 
P.   Omo-hyoid.     G.   Fifth  root.     H.   Scalenus  medius.     I.   Sixth  root.     K.   Suprascapular  n.     L.    Ext. 
ant.  thoracic  n.      M.  Clavicle.      N.  Nerve  to  subclavius. 


Step  3. — Note  the  condition  of  the  isolated  nerve.     Kennedy  has  always 
found  it  to  be  in  a  hopelessly  cicatricial  condition.     If  the  whole  nerve  seems 


798 


NERVES 


to  be  composed  of  scar  tissue,  divide  the  fifth  and  sixth  above  the  diseased 
area.  The  cut  surface  ought  to  show  a  healthy  appearance;  if  not,  slice  off 
more  of  the  nerve  until  healthy  tissue  is  reached.  Pull  the  diseased  area  in- 
wards and  put  on  the  stretch  the  three  peripheral  divisions  of  the  nerve,  viz.,  the 
supra-scapular  nerve,  the  branch  to  the  outer  and  that  to  the  posterior  cord  of 
the  plexus.  Divide  these  three  branches  at  points  beyond  the  disease,  the 
section  being  made  through  healthy  nerve. 


'ieliaxtKilt'-''" 

■ 

J 

"^-WF 

^^JOm^^Bi'/r^ui^.-.. 

■ 

K 

^ijl^ 

^2s//^ai 

L 

4 

|flHP^|P''v   ' 

M 

-aL 

N 

^^^^■^^^ 

0 

scf^      '''jSB^^ 

P 

'i*'  ~7^^^.        "oES^^^^^k. 

^0 

mw^',  'ja.  '-•  -■■■ 

H 
1 

**«^^C?^*'?^'^'^ 

Fig.  gso-— {Taylor.) 
A.  Phrenic  n.     B.  Scalenus  ant.     C.  Int.  jugular.     D,0.  Transversalis  colli  a.     E.  Omo-hyoid.     F.R 
Suprascapular  a.     G.  Eighth  cervical  and  dorsal  root.     H.  Muscular  branch.    I.  Subclavian  v.  J.  Fift 
root.    K.  Sixth  root.    L.  Scalenus  medius.     M.  Nerve  to  subclavius.     N.  Suprascapular  n.    S.  Claviclelan 
subclavius.    T.  Pect.  major.    U.  Ant.  thoracic  n. 


Step  4. — Suture  the  three  peripheral  stumps  to  the  two  proximal  stumps 
of  nerve  by  means  of  fine  chromicized  catgut  threads.  Before  approximating 
the  divided  nerve  ends  and  tying  the  sutures,  push  the  shoulder  upwards  and 
incline  the  head  to  the  side  being  operated  upon.  This  relieves  tension,  and 
permits  of  approximation.  Cover  the  line  of  nerve  suture  with  muscle,  fascia 
or  some  material  like  Cargile's  membrane. 

Step  5. — Close  the  external  wound.  Apply  dressings.  With  plaster-of- 
Paris  or  a  suitable  apparatus,  keep  the  shoulder  elevated  and  the  head  inclined 
to  the  side  on  which  operation  has  been  performed,  and,  above  all,  prevent 
motion  of  the  head  on  the  shoulders.  When  the  lesion  is  more  extensive, 
especially  when  it  lies  beneath  the  clavicle,  continue  the  skin  incision  down- 
wards between  the  pectoralis  major  and  deltoid.     Separate  these    muscles. 


HIRTH    PALSY  799 

Divide  the  clavicle  in  the  same  line,  also  the  sub-clavius  and  omo-hyoid  mus- 
cles and  supra-scapular  vessels.  Pull  the  outer  fragment  of  the  clavicle  and 
the  shoulder  outwards  exposing  the  entire  plexus  to  the  upper  margin  of  the 
pectoralis  minor,  which  may  also  be  divided  if  necessary.  When  the  nerve 
suture  is  completed  reunite  the  divided  muscles  and  bone. 

After  two  weeks  the  fixed  dressings  may  be  discarded.  Kennedy  does 
not  advise  any  special  after-treatment,  believing  that  the  nervous  impulses, 
which  can  now  reach  the  muscles,  will  lead  to  their  satisfactory  development. 
Most  surgeons  will  undoubtedly  endeavor  to  assist  recovery  by  the  use  of 
electrical  stimulation  and  massage. 

Harris  and  Low  think  that  Kennedy  relies  too  much  on  the  physical  appear- 
ance of  the  nerves  when  exposed,  and  as  a  consequence  may  be  led  to  excise  too 
much.  Thus,  if  the  deltoid,  spinati,  biceps,  and  brachialis  anticus  muscles 
(and  perhaps  also  the  supinator  longus)  are  paralyzed,  and  if  Markoe's  obser- 
vation be  remembered,  then  after  exposing  the  nerves  it  would  be  wise  sepa- 
rately to  stimulate  faradically  the  fifth  and  sixth  nerves.  If  stimulation  of 
the  fifth  fails  to  gain  response  while  stimulation  of  the  sixth  does,  then  these 
observers  advise  that  the  fifth  nerve  be  followed  upwards,  be  divided  well 
above  the  junction,  and  the  proximal  end  of  its  peripheral  portion  be  anasto- 
mosed to  a  split  in  the  side  of  the  sixth  nerve.  Part  of  this  advice  does  not 
appeal  to  the  author,  as  there  seems  to  be  little  advantage  to  be  gained  by 
it,  in  that  the  portion  of  the  fifth  nerve  grafted  on  to  the  sixth  has  been  proved 
to  be  incapable  of  conduction. 

Undoubtedly  Harris  and  Low  are  right  in  advising  the  use  of  electrical 
tests  before  excising  portions  of  the  nerve,  as  by  this  means  nerve  tissue  may 
be  saved  which  would  otherwise  be  destroyed.  The  benefit  of  analytical 
observation  during  operation  is  shown  by  a  case  in  which  Harris  and  Low 
made  use  of  cross-union.  The  case  was  one  of  atypical  Duchenne-Erb 
palsy: 

A  girl,  aged  two  years,  had  suffered  a  few  months  before  from  ''infantile 
paralysis  or  acute  anterior  poliomyelitis  of  the  right  shoulder,"  leaving  behind 
paralysis  and  wasting,  with  reaction  of  degeneration  in  the  deltoid,  supra- 
spinatus,  and  infraspinatus  muscles.  The  biceps,  brachialis  anticus,  and 
supinator  longus  were  only  slightly  affected.  From  dissections  and  experi- 
ments on  monkeys  Harris  and  Low  concluded  that  the  "circumflex"  bundle 
of  nerve  filaments  occupies  the  upper  half  of  the  fifth  root.  In  the  case  under 
discussion  they  made  a  longitudinal  split  in  the  fifth  root,  found  that  the  faradic 
stimulation  of  the  upper  segment  of  the  nerve  gave  the  very  slightest  contrac- 
tion of  the  biceps  with  definite  weak  contractions  of  the  deltoid  and  triceps, 
while  stimulation  of  the  lower  half  gave  powerful  contractions  of  the  biceps, 
causing  strong  flexion  of  the  forearm,  with  no  contractions  at  all  in  the  deltoid. 
This  being  so,  the  "upper  half  of  the  nerve  was  formed  into  a  flap  having  its 
base  below  (at  the  junction  of  the  fifth  and  sixth  roots)  and  the  free  end  of 
the  flap  was  anastomosed  to  a  split  made  in  the  side  of  the  sixth  root." 

Operations  such  as  this  one  of  Harris  and  Low  have  not  yet  stood  the 
test  of  time,  but  their  possibility  and  plausibility  make  them  deserving  of  atten- 
tion.    In  one  of  his  cases  Kennedy  had  a  most  gratifying  result. 


8oO  NERVES 

(B)  Indirect  Method.  -Tubby's  Operation. — ("Brit.  Med.  Jour.,"  Oct.  17, 
1903.)  In  some  cases  satisfactorily  treated  by  Tubby  no  attempt  was  made  to 
repair  the  damaged  nerves,  but  disability  was  relieved  by  means  of  muscle 
transplantation  or  grafting.     The  operation  is  performed  in  two  sittings: 

(a)  Restoration  of  Elbow  Flexion. — Step  i. — Make  an  incision  four  to  six 
inches  long,  from  the  middle  of  the  back  of  the  upper  arm  downwards  and 
forwards  towards  the  front  of  the  elbow,  and  following  the  course  of  the  mus- 
culo-spiral  groove. 

Step  2. — Expose  and  draw  aside  the  musculo-spiral  nerve.  Demonstrate 
the  outer  part  of  the  triceps  muscle  which  arises  above  and  to  the  outer  side 
of  the  musculo-spiral  groove.  Detach  a  wide  strip  of  the  outer  part  of  the  tri- 
ceps from  its  tendon,  and  separate  it  upwards  for  three  to  four  inches,  leaving 
this  strip  or  flap  attached  to  the  rest  of  the  triceps  by  its  upper  extremity. 

Step  3. — Through  the  same  incision  expose  the  lower  end  of  the  biceps.  At 
a  point  about  two  inches  above  the  elbow  make  a  tunnel  through  the  muscle, 
from  behind  forwards.  Flex  the  elbow  to  relieve  tension.  Pull  the  free  end  of 
the  triceps  flap  through  the  tunnel  in  the  biceps  and  fix  it  there  with  sutures. 

Step  4. — Close  the  wound.  Dress.  Immobilize  the  elbow  in  a  position 
of  flexion.     Do  not  permit  any  attempts  at  motion  for  one  month. 

ib)  Restoration  of  Shoulder  Abduction. — Step  1. — From  a  point  one  inch 
below  the  middle  of  the  clavicle  make  an  incision  outwards  to  the  tip  of  the 
acromion  and  then  downwards  for  three  inches.  From  the  tip  of  the  acromion 
make  an  incision  upwards  for  two  to  three  inches.     Reflect  the  flaps  outlined. 

Step  2. — Demonstrate  the  clavicular  portion  of  the  pectoralis  major;  sepa- 
rate it  from  its  attachment  to  the  rest  of  the  muscle;  divide  its  insertion  into 
the  humerus,  thus  forming  a  muscular  flap  attached  to  the  clavicle.  Demon- 
strate and  divide  the  insertion  of  the  trapezius  into  the  clavicle;  separate  the 
corresponding  part  of  the  muscle  from  the  rest  of  the  trapezius  by  splitting  in 
the  direction  of  the  fibres.     Thus  a  second  muscular  flap  is  obtained. 

Step  3. — Bring  the  free  end  of  the  flap  obtained  from  the  pectoralis  major 
upwards  over  the  acromion  process  and  fix  it  into  the  deltoid.  With  sutures 
fix  a  few  fibres  of  the  pectoral  flap  to  the  tip  of  the  acromion  so  as  to  avoid 
slipping.  If  the  flap  is  not  long  enough  to  reach  and  be  united  to  the  deltoid 
satisfactorily,  make  a  vertical  incision  through  the  muscle  to  the  bone,  reflect 
upwards  a  flap  of  periosteum  (as  thick  and  large  as  possible),  and  unite  this 
to  the  end  of  the  pectoral  flap.  Suture  the  end  of  the  flap  obtained  from  the 
trapezius  to  the  side  of  the  pectoral  flap.  The  result  is  a  new  muscle  com- 
posed of  contributions  from  the  pectoralis  major  and  the  trapezius,  inserted 
into  the  humerus  in  imitation  of  the  deltoid. 

Step  4. — Close  the  wound.  Dress.  Immobilize  in  a  position  of  abduction. 
Do  not  put  the  newly  grafted  muscle  on  stretch  for  at  least  a  month.  After 
one  month  begin  exercises  with  caution.  Tubby  has  had  some  excellent  results 
from  this  operation. 

In  certain  cases  of  deltoid  paralysis,  other  than  Duchenne's,  muscle  trans- 
plantation may  be  valuable. 

Hildebrand's  Operation. — Instead  of  changing  the  site  of  insertion  Hilde- 
brand  has  changed  the  site  of  origin  of  the  pectoralis  major. 


HILDEBRAND  S    OPERATION 


80 1 


Experiments  have  shown  that  a  muscle  which  has  been  almost  entirely  cut  off 
from  the  circulation  may  be  united  with  the  body  again  and  retain  its  function 
provided  that  its  connection  with  the  central  nervous  system  is  retained  and 
that  the  blood  supply  of  these  nerve  connections  is  intact.  It  is  true  that  the 
majority  of  the  muscle  fibres  degenerate  as  a  result  of  the  sudden  limitation 
of  the  circulation,  but  the  power  of  regeneration  is  completely  preserved. 
These  experiments  teach  that  preservation  of  the  nerve  supply  is  much  more 
important  than  preservation  of  the  vascular  connections  of  a  muscle  used  in 
transplantation.  Hildebrand  used  the  above  knowledge  in  the  following  case: 
A  child,  age  four,  suddenly  became  paralyzed  in  left  shoulder  fifteen  months 
before. 

Examination  showed  complete  loss  of  function  of  the  following  muscles: 
Sterno-mastoid  and  trapezius  (n.  accessorius),  deltoid  and  teres  minor  (n. 
axillaris),  serratus  anticus  major  (n.  thoracicus  longus),  infraspinatus  (n. 
suprascapularis).  Flail  joint.  Arm  hung  loose,  was  rotated  inwards  and 
adducted. 


waciG 

nerves 

'ecto  rails 
minor 


Fig.  951. — Transplantation  of  pectoralis  major.     {Adapted  from  Zuckerkandl.) 

Operation. — Step  i. — Make  an  incision  through  the  skin  from  the  sternal 
end  of  the  fourth  rib  upwards  to  the  sterno-clavicular  joint,  from  here  outwards 
immediately  above  the  clavicle  to  the  acromion  and  thence  downwards  over 
the  bulge  of  the  shoulder  to  a  point  near  the  insertion  of  the  deltoid.  Reflect 
downwards  the  skin  flap  thus  outlined,  so  as  to  expose  the  pectoralis  major 
and  the  deltoid  very  freely. 

Step  2. — Divide  the  sterno-clavicular  origin  of  the  pectoralis  major  through 
its  tendinous  portion,  i.e.,  close  to  the  bone.  Separate  the  muscle  completely 
from  the  chest-wall.  With  utmost  care  preserve  the  anterior  thoracic  nerves 
and  the  accompanying  vessels  which  come  from  under  the  clavicle  above  and 
enter  the  deep  surface  of  the  muscle  (Fig.  951).  The  muscle  is  now  merely 
attached  to  the  body  by  its  insertion  into  the  humerus  and  by  its  vessels  and 
nerves. 

51 


802 


NERVES 


Step  3. — Turn  the  flaps  upwards  and  outwards  so  as  to  cover  part  of  the 
deltoid  and  suture  the  divided  origin  of  the  muscle  to  the  outer  third  of  the 
clavicle  and  to  the  acromion  after  preparing  these  bones  by  cutting  a  groove 
in  them.  The  muscle  now  extends  from  the  clavicle  (outer  one-third)  and 
acromion  over  the  apex  of  the  shoulder  to  the  crest  of  the  greater  tubercle  of  the 
humerus,  i.e.,  it  is  in  position  to  elevate  the  arm. 

Step  4. — Close  the  skin  wound.  Apply  dressings.  Fix  the  arm  in  the 
horizontal  posture  (abduction)  so  as  to  relax  the  implanted  muscle.  At 
the  end  of  six  weeks  the  patient  was  able  to  bring  the  arm  forwards  nearly  to  the 
horizontal,  and  was  able  to  touch  her  nose  and  the  back  of  her  neck.  ("Archiv 
fiir  klin.  Chir.,"  Ixxviii,  75.) 


Fig.  952. — Nerve  anastomosis.     {Murphy,  Surg.  Gyn.  Obsl.) 


Hoffa's  Operations.^ — HofiFa  has  devised  measures  similar  to  those  of  Tubby. 
His  report  ("Archiv  fiir  klin.  Chir.,"  Ixxxi,  473)  is  as  follows: 

1.  A.  M.  9.  Right  paralytic  flail  shoulder.     Complete  paralysis,  deltoid. 
0/>era/fo«.— Separation  of  the  trapezius  from  the  clavicle,  acromion  and 

scapula.  Union  of  the  divided  trapezius  to  the  deltoid,  the  arm  being  com- 
pletely abducted.  Result  good.  The  patient  can  raise  the  arm  almost  to 
the  horizontal,  and  the  function  is  only  slightly  limited. 

2.  F.    K.    23^.     Obstetrical    paralysis,    right    arm.     Arm    hangs    loosely 
downwards;  internal  rotation  so  marked  that  the  elbow  points  forwards. 

Operation. — Division  of  the  insertion  of  the  very  tense  pectoralis  major. 


NERVE    STRETCHING  803 

Resection  of  a  part  of  the  head  of  the  humerus.  Transplantation  of  the  tra- 
pezius into  the  deltoid.  Result  good.  The  internal  rotation  corrected;  the 
arm  can  be  raised  nearly  to  the  horizontal  so  that  the  hand  is  easily  put  to  the 
mouth. 

III.  Nerve  anastomosis  for  anterior  poliomyelitis.  Since  it  has  been  shown 
that  a  paralyzed  nerve  which  is  functionally  separated  from  its  motor  centre 
is  still  able  to  carry  impulses  if  anastomosed  with  a  functionally  intact  neigh- 
boring nerve,  endeavors  have  been  made  by  several  surgeons  to  supply  nerve 
stimuli  to  the  muscles  paralyzed  as  a  result  of  anterior  poliomyelitis,  by  means 
of  nerve  anastomosis.  As  very  great  and  often  unexpected  recovery  may  take 
place  after  paralysis  from  anterior  poliomyelitis  it  is  usually  considered  wise 
to  wait  6  months  or  more  before  deciding  on  operative  interference. 

Fig.  952  (Murphy)  shows  a  type  of  operation  which  does  not  meet  with  the 
approval  of  men  who  gained  much  experience  in  the  great  war. 

IV.  Dislocation  of  Ulnar  Nerve  at  Elbow. — Momburg  ("Archiv  f.  klin. 
Chir.,"  Ixx,  215)  has  shown  that  the  ulnar  nerve  is  frequently  thrown  out  of 
its  groove  on  the  inner  epicondyle,  especially  during  elbow  flexion;  that  this 
is  entirely  unimportant  unless  the  nerve  is  irritated;  that  when  there  are  irrita- 
tion and  pain,  the  only  cure  is  by  operation.  Several  operations  have  given 
good  results.  Croft  sutured  the  nerve  to  the  triceps  tendon  and  the  fibrous 
tissue  covering  the  bone.  McCormac  isolated  the  nerve  and  fixed  it  by  loops 
of  kangaroo  tendon  to  the  triceps  tendon.  Several  surgeons  have  formed  flaps 
of  fascia  or  even  of  bone  and  periosteum  (from  the  epicondyle)  and  with  these 
covered  the  nerve  in  its  groove.  Momburg  splits  the  triceps  tendon  and  part 
of  the  muscle  longitudinally;  at  the  upper  end  of  the  split  he  divides  the  muscles 
to  the  ulnar  side  of  the  split,  pulls  the  flap  thus  formed  around  the  nerve,  and 
sutures  the  muscle  in  its  normal  position.  The  nerve  now  passes  through  the 
triceps  and  cannot  be  dislocated. 

ALTERATIVE  OPERATIONS  ON  NERVES 

The  most  important  methods  employed  to  modify  the  structure  or  condi- 
tion of  nerves  are  nerve-stretching  and  the  disassociation  of  fibres.  In  the 
latter  operation,  after  the  nerve  is  exposed,  its  fibres  are  separated  one  from  the 
other  by  blunt  dissection;  the  indications  and  results  are  supposed  to  be  similar 
to  those  of  nerve-stretching,  but  the  operation  does  not  appeal  to  most  surgeons. 
Dissociation  may  be  better  obtained  by  injecting  into  the  nerve  normal  salt 
solution.  Nerve-stretching  has  been  used  in  many  affections.  Its  employment 
seems  most  valuable  in  neuritis  {e.g.,  sciatica),  perforating  ulcer  of  the  foot,  vari- 
cose ulcer  (the  ulcer  being  dystrophic,  i.e.,  due  to  a  lack  of  nerve  stimuli  to  the 
area  affected),  angio-neurotic  changes  in  the  lower  extremity,  muscular  spasm, 
e.g.,  in  facial  region.  Various  explanations  of  the  modus  operandi  of  nerve- 
stretching  have  been  given,  the  most  reasonable  being  the  breaking  down  of 
adhesions  and  the  production  of  local  hj^^eremia. 

Sciatic  Nerve. — The  most  suitable  cases  for  nerve-stretching  are  those  of 
sciatica  due  to  exposure  to  cold  and  wet  and  in  which  the  pain  is  limited  to  the 
distribution  of  the  nerve. 

The  Operation. — ^Lay  the  patient  in  the  prone  position.     Note  by  palpation 


8o4  NERVES 

the  tuber  ischii  and  the  great  trochanter,  midway  between  these  points  make 
a  4-inch  longitudinal  incision  downwards  from  a  point  just  above  the  gluteal 
fold.  The  centre  of  the  cut  corresponds  to  the  lower  edge  of  the  gluteus  maxi- 
mus  which  is  at  a  level  lower  than  the  fold  of  the  buttock.  Divide  the  fascia. 
Demonstrate  the  edge  of  the  gluteus  maximus  running  downwards  and  out- 
wards, and  retract  it  upwards.  Feel  for  and  retract  inwards  the  hamstring 
muscles  after  relaxing  them  by  bending  the  knee. 

The  nerve  is  now  exposed.  Hook  the  nerve  up  with  the  fmger  and  apply 
traction  both  upwards  and  downwards.  The  traction  must  be  steady  and 
strong.  Enough  power  to  lift  the  limb  may  commonly  be  exerted  without 
danger,  as  the  sciatic  nerve  can  withstand  a  strain  of  about  80  pounds.  Re- 
place the  nerve  in  its  bed.     Close  the  wound. 

Internal  Popliteal  Nerve  (Tibial  Nerve). — Step  1. — From  the  centre  of  the 
popliteal  space  make  a  33'2  inch  incision  downwards  over  the  interval  between 
the  two  heads  of  the  gastrocnemius.  Retract  the  short  saphenous  vein  and 
nerve.     Divide  the  deep  fascia. 

Step  2. — Separate  the  two  heads  of  the  gastrocnemius.  Flex  the  knee  to 
relieve  tension.  Follow  the  short  saphenous  vein  into  the  popliteal  space;  it 
goes  directly  to  the  popliteal  vessels,  superficial  to  which  the  nerve  lies. 

Step  3. — Hook  up  the  nerve  with  the  finger.  Stretch  it  by  pulling  upwards 
and  downwards. 

External  Popliteal  Nerve  (Peroneal). — Treves  thus  describes  the  exposure  of 
this  nerve: 

"Anatomy. — The  external  popliteal  or  peroneal  nerve  follows  the  outer 
side  of  the  popliteal  space,  lying  close  to  the  biceps.  Passing  over  the  outer 
head  of  the  gastrocnemius,  between  it  and  the  biceps,  the  nerve  reaches  the  neck 
of  the  fibula,  and  crosses  that  bone  beneath  the  fibres  of  the  peroneus  longus 
muscle.  The  nerve  may  be  easily  felt,  when  the  knee  is  a  little  flexed,  as  a 
loose  rounded  cord,  lying  just  behind  the  biceps,  as  it  nears  the  head  of  the 
fibula. 

"Operation. — The  patient  lies  upon  the  sound  side,  with  a  sufficient  tending 
to  the  prone  position  to  well  expose  the  outer  aspect  of  the  knee.  The  knee- 
joint  is  extended.  An  incision,  one  inch  and  a  half  in  length,  is  made  parallel 
with  and  immediately  posterior  to  the  tendon  of  the  biceps.  The  cut  should 
be  so  placed  that  its  upper  half  is  in  relation  with  the  tendon  while  its  lower 
half  is  over  the  fibula.  The  skin  and  deep  fascia  having  been  divided,  the  biceps 
tendon  is  exposed.  The  knee  should  now  be  a  little  flexed  and  the  nerve 
sought,  close  to  the  point  at  which  the  tendon  reaches  the  head  of  the  fibula. 
A  narrow  and  unduly  prominent  ilio-tibial  band  has  been  mistaken  for  the 
biceps  tendon." 

Facial  Nerve. — The  facial  nerve  has  been  successfully  stretched  in  the  treat- 
ment of  spasmodic  tic.  This  operation  is  highly  recommended  by  Kocher. 
Exposure  of  the  facial  nerve  is  sufficiently  described  in  the  chapter  on  nerve 
anastomosis. 

Exposure  of  Musculo-spiral  (Radial)  Nerve. — This  nerve  requires  ex- 
posure and  treatment,  in  most  instances,  because  of  injury  or  compression  due 
to  fracture  of  the  humerus. 


MUSCULO-SPIRAL    NERVE 


805 


Fig.  953. — -{Schwartz  and  Ktiss.) 


Exposure  of  Nerve  in  Lower  Part  of  Upper  Arm. — Step  i. — Make  an 
oblique  incision  about  3  inches  long  in  the  groove  between  the  supinator  longus 
and  brachialis  anticus  muscles.  The  whole  of  this  incision  is  in  the  lower 
third  of  the  arm.  Divide  the  deep  fascia.  Separate  the  two  muscles  ("sup. 
longus;  brachialis  ant.)  and  expose  the  nerve  which  lies  between  them. 

Step  2.— Follow  the  nerve  upwards  to  the  site  of  injury  being  careful  not 
to  injure  the  companion  artery.     In  a  case  operated  on  by  the  author  the  nerve 
was  stretched  as  a  thin  fibrous  band 
over  a  sharp  angle  of  bone  for  a 
distance  of  about  3'^  inch.     All  ob- 
jectionable pieces  of  bone  were  cut 
away;    the    nerve    which    was    ad- 
herent  to   the  bone  was  freed;   a 
layer  of  brachialis  anticus  muscle 
was    stitched   between    the    nerve 
and  the  bone  and  the  wound  closed. 
The  result  was  perfect  after  some 
months  of  appropriate  treatment. 
If  for  any  reason  it  is  impossible  or  improper  to  find  the  nerve  below  the  site 
of  injury,  expose  it  above. 

Exposure  of  Nerve  in  Upper  or  Middle  Part  of  Arm. — From  a  point  a  little 
lower  than  the  posterior  axillary  fold  make  an  incision  downwards  over  the 
interspace  between  the  long  head  and  the  external  (lateral)  head  of  the  triceps. 
Separate  the  two  heads  of  the  muscle  by  blunt  dissection  down  to  the  bone 
against  which  the  nerve  lies  accompanied  by  the  profunda  artery. 

Schwartz  and  Kuss  ("Revue 
de  Chir.,"  No.  6,  1912)  point  out 
that  the  classical  high  exposure  of 
the  musculo-spiral  nerve  gives  ac- 
cess to  a  very  limited  portion  of  it 
and  gives  no  opportunity  to  follow 
the  nerve  downwards,  while  to  ex- 
pose the  nerve  low  down  and  fol- 
low it  upwards  does  much  damage 
to  muscle  and  to  nerve  branches. 
They  advise  the  following  operation . 
Step  I . — Place  the  patient  on  his  back ;  hold  the  arm  vertically  but  slightly 
adducted;  hold  the  forearm  in  a  position  of  pronation  and  at  right  angles  to  the 
arm  so  that  the  hand  rests  on  the  chest  inside  the  opposite  axilla.  Draw  an 
imaginary  line  from  the  tip  of  the  olecranon  exactly  in  the  middle  line  of  the 
posterior  surface  of  the  arm  to  the  prominent  posterior  border  of  the  deltoid. 

Step  2. — Make  an  incision  through  the  skin  along  the  imaginary  line  from 
a  point  four  fingerbreadths  above  the  tip  of  the  olecranon  upwards  for  from 
12  to  18  cm.  according  to  the  supposed  site  of  nerve  lesion.  Cut  through  the 
subcutaneous  tissue  and  expose  the  deep  fascia. 

Step  3. — Carefully  incise  the  brachial  aponeurosis  throughout  the  whole 
length  of  the  wound  and  retract  the  edges  of  the  aponeurotic  wound.     Note 


Fig.  954. — {Schwartz  and  Kuss.) 


8o6  NERVES 

that  in  the  distal  part  of  the  wound  on  the  ulnar  side  of  the  median  line  there 
is  a  V-shaped  strip  of  tendon  (tendon  of  the  long  triceps).  The  radial  border 
of  this  V  of  tendon  lies  exactly  along  the  olecrano-deltoid  line  described  in 
Step  I  (Fig.  953). 

Step  4. — Incise  or  split  the  muscluar  fibres  along  the  radial  border  of  the 
V-shaped  tendon  between  it  and  a  quadrilateral  layer  of  tendon  (tendon  of 
external  head  of  the  triceps)  which  does  not  extend  so  far  up  the  arm  (Fig.  953). 

As  soon  as  the  tendinous  tissue  is  carefully  divided  in  the  distal  angle  of  the 
operative  field  a  sort  of  muscular  interstice  is  found  lying  between  the  outer 
head  of  the  triceps  (on  the  radial  side)  and  the  long  head  of  the  triceps  (on  the 
ulnar  side).  If  the  incision  or  the  dissociation  of  muscular  fibres  is  kept  rigor- 
ously in  the  median  line,  as  soon  as  the  whole  thickness  of  the  triceps  is  pene- 
trated a  yellowish-white  fascia  presents,  the  thickness  and  consistence  of  which 
vary.  This  fascia  binds  the  musculo-spiral  nerve  and  its  accompanying  vessels 
to  the  humerus  (Fig.  954). 

Step  5. — Carefully  divide  the  fascia  and  so  expose  the  nerve  from  the  axilla 
to  where  it  penetrates  the  extenal  intermuscular  septum  to  reach  the  anterior 
part  of  the  arm. 

It  sometimes  happens  that  the  ends  of  the  divided  nerve  cannot  be  found 
or,  e.g.,  after  fracture  of  the  external  condyle,  there  may  be  such  a  mass  of 
callus  pressing  on  the  nerve  that  restoration  of  conduction  seems  too  difficult 
or  impossible — under  such  circumstances  tendon  transplantation  may  restore 
function. 

At  the  International  Surgical  Congress  in  1914,  J.  B.  Murphy  exhibited 
a  patient  who  had  suffered  from  the  effects  of  division  of  the  musculo-spiral 
nerve.  Murphy  to  make  the  demonstration  more  striking  "handled  the  truth 
a  little  carelessly"  describing  the  treatment  as  if  it  had  been  neurorrhaphy. 
The  result  was  accepted  as  excellent.  He  then  confessed  the  excusable  "pious 
fraud"  and  explained  what  really  had  been  done.  The  Figs.  955,  956,  957, 
958  and  959,  with  their  legends  clearly  describe  the  operation.  After  suture  of 
the  superficial  fascia  and  fat  to  prevent  union  between  the  tendons  and  skin, 
the  skin  wound  is  closed  and  the  hand  immobilized  in  extreme  extension  until 
union  occurs.  Complete  restoration  of  function  may  be  expected  in  four 
weeks — an  enormous  saving  of  time  as  compared  with  the  year  which  must 
elapse  before  recovery  after  nerve  suture. 


MUSCULO-SPIRAL    PARALYSIS 


807 


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NERVES 


MUSCULO-SPIRAL    PARALYSIS 


809 


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NERVES 


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8l2  ARTERIORRIIAPIIV 

CHAPTER  LXI 
ARTERIORRHAPHY 

The  subject  of  arleiial  suture  is  old.  Hallowell  and  Lambert,  in  1759,  closed 
a  small  wound  of  the  brachial  artery  by  passing  a  pin  through  the  edges  of 
the  wound  and  winding  a  thread  round  it  as  in  the  old  hare-lip  operation. 
Though  born  so  long  ago,  arteriorrhaphy  has  only  recently  begun  to  grow,  and 
even  at  present  is,  in  many  respects,  merely  in  the  experimental  stage.  The 
subject  is  so  important,  so  many  procedures  are  being  transferred  from  the 
physiological  laboratory  to  the  operating-room,  and  it  so  often  happens  that 
in  an  emergency  one  wishes  knowledge  as  to  the  possibilities  and  methods  of 
arteriorrhaphy  that  the  writer  deems  it  wise  to  introduce  a  chapter  dealing  with 
it  at  this  place. 

For  success  in  arterial  suture  the  following  things  are  essential:  (i)  Perfect 
asepsis.  (2)  A  clean-cut  wound.  (3)  Absence  of  tension  on  the  sutures.  (4) 
No  rough  handling  of  the  vessel.  (5)  An  efficient  and  wow-injurious  method  of 
obtaining  temporary  hemostasis.     (6)  Good  suture  material. 

Suture  Material. — For  a  time  catgut  was  the  favorite  material  because 
when  in  site  it  became  swollen  and  so  filled  the  needle  punctures  that  hemor- 
rhage was  prevented.  The  use  of  fine  needles,  without  cutting  edges  (intestinal 
or  seamstress'  needles)  seems  to  prevent  hemorrhage  sufficiently.  To-day 
very  fine  silk  is  the  suture  of  choice.  Carrel  finds  it  most  important  to  impreg- 
nate the  suture  thoroughly  with  sterile  vaseline  so  as  to  prevent  the  deposit  of 
blood-clot  on  the  thread.  This  lubrication  of  the  thread,  a  trifle  though  it  may 
seem,  is  probably  the  cause  of  the  recent  wonderful  advances  and  successes  in 
experimental  arterial  surgery.  The  needles  used  are  fine  round  needles  (intes- 
tinal, cambric,  seamstress')  which  may  be  straight  or  curved.  Carrel  uses  No. 
15  or  16  needles.  For  sutures  he  formerly  procured  the  finest  silk  thread 
possible,  untwisted  it  and  used  one  of  the  strands  of  which  it  was  composed, 
this  delicate  strand  constituted  the  suture  after  it  had  been  impregnated  with 
sterile  vaseline.     He  now  obtains  silk  of  suitable  fineness  from  Lyons. 

Lilienthal  uses  No.  12  needles  and  No.  000  silk.  Dorrance  uses  No.  i 
Pagenstecher  thread  on  the  finest  needle  the  thread  will  pass  through. 

METHOD    OF   TEMPORARY  HEMOSTASIS 

In  a  few  cases  the  elastic  constrictor  may  be  used,  in  most  cases  its  use 
must  render  the  operation  unnecessarily  difficult  or  be  distinctly  harmful. 

An  assistant's  fingers  may  be  applied  to  the  vessel  above  and  below  site  of 
wound,  but  while  such  form  the  safest  clamps  yet  they  get  in  the  way  and  are  not 
so  practicable  as  mechanical  appliances. 

Clamps. — Clamps  the  blades  of  which  are  covered  with  rubber  tubing  are 
serviceable.     The  best-known  clamps  are:  (a)  Broad-bladed,  delicate,  eight- 


SUTURE   ARTERIES 


8^3 


inch  Billroth  forceps  (Murphy).  (b)  Miniature  Doyen  hysterectomy 
clamps  (Dorrance)  (Fig.  960).  (c)  Ordinary  hemostats  (Kiimmel). 
(d)  Herrick's  clamp  (Sweet),     (e)  Crile's  clamp  (Fig.  961). 

Tapes,  etc. — Fine  linen  strips  thrown  around  the 
vessel  and  fastened  by  forceps  instead  of  by  a  knot 
(Carrel  and  Guthrie).  Fine,  thin  tape  fastened  by 
forceps  or  serre-fins  (Lilienthal).  Heavy  twisted  silk 
used  in  the  same  manner. 

Whatever  means  of  hemostasis  is  used,  it  must 
be  used  most  gently.  The  forceps  or  tape  must 
only  exert  enough  pressure  to  control  the  circulation 
and  not  one  iota  more.  Crushing  or  injury  to  the 
intima  is  fatal  to  success. 

SUTURE   OF  ARTERIES 

Temporarily  occlude  the  artery  about  i  inch 
above  and  below  the  wound  with  clamps  or  tapes. 


Fig.  960. — Dorrance  clamp. 


Fig.  961. — Crile's  clamp. 


Gently  but  thoroughly  remove  all  blood  whether  clotted  or  not;  in  doing  this  use 
the  normal  salt  solution.  Examine  the  edges  of  the  wound;  if  they  are  lacerated 
or  contused  pare  them.  For  this  purpose  Carrel  uses  fine  scissors.  Coat  the 
vessel  both  inside  and  out  with  vaseline  (Carrel).  Carefully  resect  or  remove 
the  external  sheath  of  the  vessel  from  the  neighborhood  of  the  wound.     If  any 


Zme  of  section 

Adventitia. 


Fig.  962. 


Fig.  963. 


fibres  of  this  fibrous  tissue  tunic  get  between  the  edges  of  the  wound  and 
into  contact  with  the  blood,  a  thrombus  will  quickly  form.  The  easiest 
method  of  resecting  the  outer  coat  is  to  pull  it  forwards  over  the  inner  coat 
and  clip  it  off  with  scissors  (Fig.  962). 

Methods  of  Suture. — Interrupted  or  continuous  sutures  may  be  chosen  at 
the  option  of  the  operator;  the  continuous  suture  is  the  favorite. 

Method  A. — Pass  the  suture  as  in  Fig.  963  without  damaging  the  intima. 
This  is  possible  in  large  arteries,  but  impossible  in  medium-sized  ones  or  in 
veins.  The  disadvantages  of  the  method  are  the  limitations  of  its  applicability; 
its  difficulty;  the  possibility  of  fibrin  ferment  passing  from  the  arterial  walls 


8i4 


ARTERIORRIIAPHY 


to  the  blood-stream;  the  possible  presence  of  fringes  of  intima  hanging  into  the 
blood-stream  and  favoring  coagulation  and  the  possibility  of  blood  passing 
through  the  open  intima,  infiltrating  the  vessel-wall,  thus  causing  aneurysm. 

Method  B.  Through-and-Through  Sutures. — Close  the  wound  by  sutures 
penetrating  all  the  coats  of  the  vessel,  taking  care  "not  to  include  fragments  of 
the  connective-tissue  layer  in  the  line  of  suturing,  and  to  obtain  a  smooth  union 
and  approximation  of  the  endothelial  coats"  (Carrel). 


Fig.  964. 


Fig.  965. — Arterial  suture. 


Figs.  964  and  965  are  self-explanatory.  During  the  passage  of  the  sutures 
the  extreme  edges  of  the  wound  may  be  held  in  delicate  dissecting  forceps.  A 
thimble  is  useful  in  pushing  the  needle  through  the  tissues.  This  method  has 
given  many  excellent  results.  The  line  of  union  may  be  strengthened  by 
separate  suture  of  the  adventitia. 

Method  C.  Brieau-Jaboulay  Suture. — This  suture  is  highly  commended 
by  Archibald  Smith,  and  a  practically  identical  stitch  has  been  advised  by 
Dorrance. 

The  suture  produces  eversion  of  the  lips  of  the  wound  and  brings  intima  into 
contact  with  intima.     Prima  facie  one  would  think  such  a  suture  would  pro- 
duce stenosis,  but  A.  Smith's  researches  show  that 
such  is  not  the  case. 

Pass  a  stitch  from  without  inwards  through  all 
the  coats  of  the  wounded  vessel  at  the  point  a 
(Fig.  966);  pass  the  same  thread  from  within  out- 
wards through  all  the  coats  of  the  opposite  side  of 
the  wound  at  the  corresponding  point  b.  Reintro- 
without  inwards  at  c,  and  complete  its  course  by 
bringing  it  from  within  outwards  through  the  whole  thickness  of  the  vessel- 
wall  at  d.  This  leaves  in  place  a  U-suture  which  everts  the  lips  of  the  wound. 
In  a  short  wound  or  puncture  one  U-suture  may  suffice;  in  a  longer  wound 
several  will  be  necessary,  each  tied  separately  or  placed  in  a  continuous 
fashion. 

Method  D.  Brewer's  Adhesive  Plaster.^George  Brewer,  having  had  ill 
results  from  arterial  sutures  failing  to  hold,  has  wrapped  wounded  vessels  with 
an  "  elastic  plaster  made  up  of  a  strip  of  very  thin  gum  (rubber),  coated  with  an 


<«^^l^ 


duce 


Fig.  966. 
the   stitch   from 


ARlKKlOkUHAPIlY  815 

adhesive  material  like  that  used  in  the  zinc  oxide  plaster.  Experiments  were 
made  on  a  large  number  of  animals  and  some  of  the  results  were  good."  The 
method  does  not  seem  to  have  been  used  in  practice.  The  objections  to  the 
method  are:  Difficulty  in  applying  the  plaster  with  sufficient  and  not  too  much 
tension;  the  almost  certain  absence  of  the  material  when  it  is  required;  a  foreign 
body  being  left  in  the  wound. 

END-TO-END   ARTERIAL   ANASTOMOSIS 

Circular  arteriorrhaphy  is  of  value  when  an  artery  of  size  has  been  completely 
divided  or  a  portion  of  it  has  been  excised.  The  same  general  rules  laid  down 
for  suture  of  arterial  wounds  apply  to  the  operation  about  to  be  described. 

Sweet  prepares  the  divided  ends  of  the  vessel  for  suture  by  carefully  removing 
the  loose  connective-tissue  sheath  (adventitia)  about  the  ends  of  the  vessel 
(Fig.  962).  "This  can  be  done  very  nicely  by  grasping  the  sheath  with  forceps, 
drawing  it  over  the  end  of  the  vessel  and  clipping  it  off  with  scissors."  During 
the  operation  keep  the  vessels  from  drying  either  by  moistening  with  salt  solu- 
tion or  by  applying  sterile  vaseline.  When  the  suture  is  complete  and  the  blood 
allowed  to  resume  its  circulation  there  is  rarely  any  bleeding,  and  such  as  there 
is  is  easily  controlled  by  temporary  pressure. 


Fig.  067.  Fig.  968. 

Figs.  967  and  968. — Payr's  magnesium  rings. 

Pajrr's  Method. — Magnesium  Prosthesis. — Have  at  hand  a  number  of  rings 
grooved  on  their  outer  surface,  of  dififerent  sizes  and  made  of  very  thin 
magnesium. 

Step.  I. — To  the  cut  edges  of  the  central  segment  of  artery  apply  four  fine 
silk  sutures  penetrating  all  the  coats  of  the  vessel  (Fig.  967). 

Step  2. — Choose  a  ring  which  will  fit  accurately  round  the  artery.  Pass 
the  four  threads  through  the  ring  (Fig.  967).  With  the  threads  pull  the  artery 
through  the  ring  until  an  amount  of  artery  protrudes  from  the  ring  rather 
greater  than  the  width  of  the  ring  (Fig.  968). 

Step  3. — Aided  by  the  threads,  turn  the  protruding  cuflf  of  artery  backwards 
over  the  ring  and  fix  it  in  place  by  tying  a  fine  ligature  round  it  (Fig.  969).  The 
groove  in  the  ring  prevents  the  ligature  from  slipping. 

Step  4. — Introduce  four  sutures  into  the  cut  edge  of  the  peripheral  segment 
(Fig.  970). 

Step  5. — Make  traction  on  these  four  threads  and  so  distend  the  lumen  of 
the  peripheral  segment  (Fig.  969).  Push  the  central  segment  (with  its  rings) 
into  the  distended  peripheral  segment.  When  the  peripheral  segment  covers 
the  ring,  fix  it  in  place  with  a  ligature  (Fig.  971). 


8i6 


ARTERIORRHAPHY 


This  completes  the  operation.  It  will  be  seen  that  the  ring,  though  buried, 
is  extra-vascular.  Magnesium  is  dissolved  and  absorbed  in  the  body,  hence  no 
persistent  foreign  substance  is  left  in  the  wound.  (Payr,  "Archiv  fur  klin. 
Chir.,"  l.xii,  i;  lxiv,'''3;  Ixxii,  i.) 

Murphy's  Method. — Invagination. — Step  i . — Introduce  a  fine  cambric  needle, 
armed  with  fine  silk,  through  all  the  tunics  of  the  distal  segment  of  the  vessel 


Fig.  969.  Fig.  970. 

Figs.  969  and  970, — Payr's  magnesium  rings. 

from  without  inwards  at  the  point  A  about  3-^  inch  distant  from  the  divided 
edge  of  the  vessel  (Fig.  972).  Bring  the  needle  out  through  the  open  end  of 
the  vessel.  With  the  needle  pick  up  a  small  portion  of  the  adventitia  and 
media  (not  the  intima)  at  the  point  C,  near  the  cut  edge  of  the  proximal  segment 
of  vessel.  Introduce  the  same  needle  through  open  lumen  of  the  peripheral 
segment  and  make  it  penetrate,  from  within  outwards,  the  whole  thickness^of 
the  vessel  at  a  point  close  to  A.  The  result  of  this  is  a  U  or  mattress  suture. 
Introduce  two  other  sutures  in  the  same  manner  so  that  three  U-stitches  are  in 
position  at  equal  distances  from  each  other. 


Fig.  971. — Payr's  magnesium. 


Fig.  972.  Fig.  973. 

Figs.  972  and  973. — Murphy's  method. 


Step  2. — Pull  on  the  three  U-sutures  and  so  invaginate  the  proximal  into 
the  distal  segment  of  vessel  (Fig.  973).  Tie  the  sutures.  Before  invaginating 
it  may  be  necessary  to  make  a  slight  longitudinal  split  (x)  in  the  receiving  or 
distal  segment. 

Step  3. — With  fine  sutures  unite  the  edge  of  the  distal  to  the  side  of  the  proxi- 
mal segment  at  the  line  where  the  former  overlaps  the  latter.  If  a  longitudinal 
split  has  been  made,  close  it  also  with  a  stitch. 

Step  4. — Carefully  suture  any  available  tissues  near  the  vessel  in  such 
fashion  as  to  give  the  maximum  of  support  to  it. 

Eversion  Method.  Brieau  and  Jaboulay's  Sutures  Modified  by  Dorrance. — 
"The  clamps  are  applied  as  before.*     The  cut  edges  of  the  artery  are  grasped 

*  The  clamps  used  by  Dorrance  are  miniature  copies  of  Doyen's  hysterectomy  clamp. 


ARTERIORRHAPHY 


817 


^^ 


i^^ 


Fig.  974. — {Dorrance.) 


Fig.  975. — {Dorrance. 


Fig.  976. — {Carrel.) 


52 


8 1 8  ARTERIORRHAPHY 

with  dissecting  forceps,  and  the  suture  is  passed  through  the  upper  edge  of  the 
artery  from  without  in  and  through  the  lower  end  from  within  out;  the  needle  is 
then  reversed  and  brought  back  1.5  mm.  to  one  side  of  the  former  suture  and 
tied.  (This  suture  is  really  a  single  mattress  suture.)  The  suture  is  continued 
as  a  continuous  mattress  suture,  dropping  back  half  a  stitch  every  third  suture 
until  the  starting-point  is  reached;  then  a  half  stitch  is  made  and  the  suture  con- 
tinued back  as  a  whip-stitch  until  the  starting-point  is  reached  again;  then  the 
two  ends  are  tied  (Figs.  974  and  975).  The  suture  is  started  on  the  anterior 
surface  near  the  handles  of  the  clamps.  When  the  suture  reaches  the  farther 
side  of  the  artery  the  handles  of  the  clamps  are  taken  from  the  lower  portion 
of  the  wound  and  placed  in  the  upper  portion.  In  this  way  the  surface  of 
the  artery  which  was  anterior  is  now  posterior,  and  the  suture  can  always  be 
kept  in  sight." 

Carrel's  Method.- — Step  i.— Introduce  three  tension  sutures  of  very  fine 
silk  impregnated  with  vaseline  at  equidistant  points  of  the  circumference  of  the 
vessel  ends  (Fig.  976).*  These  sutures  penetrate  the  whole  thickness  of  the 
vessel-walls. 


Fig.  977. — {Carrel.) 

Step  2. — Have  an  assistant  apply  traction  to  two  of  these  sutures  so  as  to 
stretch  the  portion  between  the  two  sutures  into  a  straight  line  and  to  approxi- 
mate the  corresponding  cut  edges  of  the  vessel.  Apply  a  hemostat  to  the  third 
tension  suture  and  let  it  hang  so  as  to  pull  on  the  suture.  The  slight  pulling  on 
the  three  sutures  arranges  the  circumference  of  the  vessel  as  a  triangle,  and  this 
facilitates  suturing. 

Step  3. — Introduce  a  continuous  overhand  stitch  through  all  the  coats  all 
round  the  vessel.  The  stitches  should  be  very  close  together  and  only  drawn 
tightly  enough  to  secure  approximation,  but  not  tightly  enough  to  produce 
eversion  of  the  edges  of  the  wound  (Fig.  977). 

Step  4. — Remove  the  distal  clamp  (used  for  provisional  hemostasis).  Re- 
move the  proximal  clamp.     If  there  is  any  bleeding,  gentle  finger  pressure  will 

*  In  the  illustration  four  tension  sutures  have  been  employed. 


VENOUS    IMPLANTATION 


819 


almost  always  stop  it  (Fig.  978).     If  necessary  for  hemostasis,  introduce  one  or 
two  interrupted  sutures. 

Step  5. — Close  the  wound  after  putting  one  or  two  stitches  in  the  adventitia 
to  reinforce  the  main  arterial  suture. 


Fig.  978. — {Carrel.) 


VENOUS   IMPLANTATION 

When  the  severed  ends  of  the  artery  are  so  distant  that  approximation  is 
impossible  one  may  bridge  the  defect  by  implanting  a  segment  of  vein.  E. 
Lexer  ('*  Archiv  fiir  klin.  Chir.,"  Ixxxiii,  459)  reports  a  case  of  axillary  aneurysm 
which  he  excised;  approximation  of  the  ends  of  the  artery  being  impossible,  he 
excised  a  branchless  segment  of  the  great  saphenous  vein,  united  its  distal  end 
to  the  proximal  segment  of  artery  and  its  proximal  end  to  the  distal  portion  of 
artery.  The  union  was  effected  after  Carrel's  method.  There  was  no  hemor- 
rhage and  no  thrombosis  at  the  line  of  suture.  The  segment  of  vein  seemed  to 
act  well.  Experiments  have  show^n  that  veins  when  substituted  for  arteries 
become  thickened,  stronger,  and  adapt  themselves  to  their  new  duties. 

Some  of  Carrel's  experiments  on  dogs  and  cats  show  admirably  the  possi- 
bilities of  operations  on  the  vascular  system.  At  the  Rockefeller  Institute, 
New  York,  Carrel  exhibited  to  the  members  of  the  Society  of  Clinical  Surgery 
healthy  looking  animals  on  which  the  following  operations  had  been  performed: 
(a)  Excision  of  segment  of  abdominal  aorta,  a  corresponding  segment  of  vena 
cava  being  inserted  to  take  its  place,  ih)  Excision  of  segment  of  abdominal 
aorta,  a  corresponding  segment  of  an  aorta  which  had  been  kept  in  cold  storage 
for  some  days  being  implanted  into  the  gap.  (c)  Double  nephrectomy — both 
kidneys  being  replanted.  On  suture  of  the  vessels  and  ureters  secretion  of  urine 
quickly  manifested  itself,  {d)  Amputation  of  the  thigh  of  a  black  dog- — im- 
plantation of  the  corresponding  amputated  thigh  of  a  white  dog  on  to  the  stump. 
When  exhibited  healing  was  not  complete,  but  circulation  was  established  in  the 
implanted  thigh. 

Some  of  the  operations  described  in  the  preceding  paragraphs  almost  appear 
as  if  they  were  the  offspring  of  a  superheated  imagination,  but  many  of  them 
have  been  applied  in  surgery  with  most  conservative  and  gratifying  results.  It 
may  be  well  and  encouraging  to  briefly  note  a  few  cases  in  which  the  methods 
devised  after  animal  experimentation  have  been  applied  to  man. 

Frank  T.  Stewart  ("Annals  of  Surg.,"  July,  1908)  reports  two  cases  of  resec- 
tion of  the  brachial  artery,  one  by  the  Murphy  method  with  probable  thrombo- 
sis, the  other  by  Carrel's  method  with  success. 

Kiimmel,  during  an  operation  for  malignant  disease,  excised  about  i^  inches 
of  the  femoral  artery.  He  successfully  repaired  the  vessel  by  invaginating  the 
central  into  the  peripheral  end. 


820  ARTERIORRHAPHY 

E.  Martin  ("Med.  Klinik.,"  1908,  No.  38)  performed  circular  arteriorrhaphy 
(Carrel's  Method)  after  resection  of  1^4  inches  of  the  brachial  artery  injured  by 
a  trauma  near  the  elbow.  After  union  a  slight  murmur  was  audible  over  the 
scar. 

Braun  ("Archiv  fiir  klin.  Chir.,"  Ixxxvi,  707),  while  removing  a  retroperi- 
toneal tumor,  made  an  oblique  tear  in  the  aorta.  The  tear  involved  about  half 
the  circumference  of  the  vessel,  the  walls  of  which  had  been  thinned  from  pres- 
sure by  the  tumor.  In  anticipation  of  injuring  the  aorta  the  vessel  had  been 
provisionally  compressed.  Suture  of  the  wound  by  a  single  layer  of  stitches 
was  insufficient  to  prevent  bleeding,  and  a  second  row  when  introduced  pro- 
duced too  much  stenosis  (absence  of  femoral  pulse,  coldness  of  limbs),  so  Braun 
excised  the  injured  segment  of  aorta  and  united  the  cut  ends  by  Carrel's  method. 
A  small  iodoform  gauze  tampon  was  placed  against  the  line  of  suture  and  the 
abdominal  wound  closed  around  the  tampon.  The  tampon  was  removed  on 
the  eighth  day.  The  patient  was  confined  to  bed  for  four  weeks.  Three 
months  later  the  patient  was  well. 

On  Aug.  I,  191 7  an  English  soldier  had  his  popliteal  artery  wounded.  Two 
months  later  Harold  Neuhof  exposed  the  vessel  which  was  the  site  of  a  false 
aneurism  and  repaired  it  with  a  patch  of  fascia  lata.  On  Aug.  i,  191 8  the 
soldier  was  seen  driving  a  camion  at  La  Ferte  Milon  and  presented  no  symptoms 
of  trouble.  Neuhof  wrote  Feb.  21,  1920:  "I  can  now  give  you  a  report  on 
the  results  of  operation  in  two  cases  of  traumatic  aneurism  treated  by  resection 
of  the  sac  and  transplantation  of  fascia  lata  into  the  arterial  defect.  In  both 
cases  there  was  return  of  circulation  into  the  limb  without  any  evidence  of 
interference  with  the  circulation.  Operation  having  been  done  in  both  in- 
stances more  than  two  years  ago  and  the  reports  recently  received  indicating 
no  evidence  of  recurrence,  I  believe  the  result  can  be  termed  perfect  and  per- 
manent in  both." 

TREATMENT  OF  THROMBOSIS  AND  EMBOLISM  BY  OPERATIONS 

ON  THE   VESSELS 

It  is  necessary  to  distinguish  between  closure  of  an  artery  by  a  clot  forming 
on  an  injured  or  diseased  intima  and  closure  due  to  an  embolus  lodging  in  a  more 
or  less  healthy  artery.  In  the  first  case  removal  of  the  blood-clot  alone  is 
valueless,  as  another  clot  will  form  immediately.  If  the  injured  or  diseased 
portion  of  vessel  is  of  a  very  limited  extent,  that  portion  may  be  excised  and  the 
divided  ends  of  the  vessel  united  by  arteriorrhaphy  or  by  the  implantation  of  a 
segment  of  vein.  If  venous  implantation  is  attempted  do  not  use  the  companion 
vein  to  supply  the  defect;  this  would  be  calculated  to  seriously  interfere  with 
the  return  circulation.  Probably  in  thrombosis  it  may  be  better  to  send  blood 
down  into  the  limb  through  a  vein  (reversal  of  circulation),  as  will  be  described 
later.  When  the  closure  of  the  artery  is  due  to  the  lodgment  of  an  embolus,  it 
is  logical  to  open  the  vessel  by  a  longitudinal  incision  after  providing  for  tem- 
porary hemostasis,  extract  the  clot,  wash  the  interior  of  the  segment  of  vessel 
segregated  by  the  hemostatic  tapes  or  clips  with  salt  solution,  smear  it  with 
sterile  vaseline  and  close  the  wound  with  sutures.  Frank  Stewart  reports  an 
unsuccessful  case  of  such  an  operation  ("Annals  of  Surg.,"  Sept.,  1907).     To  be 


ARTERIOTOMY  82 1 

successful  it  is  necessary  that  the  diagnosis  of  obstruction  by  embolism  be  made 
early  and  operation  be  promptly  carried  out.  Of  course  the  procedures  men- 
tioned are  not  at  all  established,  but  it  is  necessary  for  operating  surgeons  to 
bear  them  in  mind.  Instead  of  attacking  arterial  obstruction  directly  the  sur- 
geon may  to  some  extent  reverse  the  circulation  in  the  limb  and  so  dodge  the 
impediment. 

Bauer  (''Zent.  f.  Chir.,"  xx,  Dec,  1913)  reports  the  case  of  a  man  aged  thirty 
who  experienced  a  sudden  severe  pain  in  both  legs  with  complete  loss  of  function. 
The  limbs  became  blue  and  cold.  After  the  lapse  of  three  hours  the  abdomen 
was  opened  and  the  aorta  was  found  pulseless  at  the  level  of  its  bifurcation.  A 
clot  having  two  short  prolongations  into  the  iliac  vessels  was  removed  by 
arteriotomy  from  the  aorta  and  the  vessel  was  closed  by  suture.  The  circula- 
tion was  established  satisfactorily  and  the  patient  went  home  on  the  twenty- 
fifth  day. 

J.  C.  Hubbard  (''Annals  Surg.,"  Oct.,  1906,  and  Sept.,  1907),  in  a  case  of 
gangrene  of  the  foot,  isolated  the  femoral  artery  and  vein  at  the  apex  of  Scarpa's 
triangle  below  the  origin  of  the  profunda  and  divided  them  after  providing  for 
temporary  hemostasis.  He  invaginated  the  upper  end  of  the  artery  into  the 
lower  end  of  the  vein  as  in  Murphy's  method  of  arteriorrhaphy.  After  the  opera- 
tion there  was  no  oedema,  dilatation  of  the  veins,  or  cyanosis.  The  gangrene 
present  before  operation  spread  a  little  and  then  a  line  of  demarcation  formed. 
When  the  foot  was  later  amputated  at  the  point  of  election  on  the  tibia,  both 
tibial  arteries  contained  arterial  blood.  The  stump  healed  satisfactorily  but 
slowly.  Hubbard  writes:  "It  seems  that  the  arterio-venous  anastomosis  must 
have  increased  in  some  way  the  amount  of  blood  in  the  leg,  for  it  is  hard  to 
believe  that  an  amount  of  blood  so  small  as  to  permit  gangrene  of  the  foot  would 
be  sufficient  to  nourish  for  ten  months  an  amputation  stump  made  only  a  short 
distance  above  the  gangrenous  area,  and  had  thrombi  formed  at  the  sites  of  the 
anastomosis,  it  seems  most  probable  that  the  gangrene  would  have  extended  up 
the  leg  instead  of  remaining  localized." 

Doberauer  reports  a  case  of  embolism  of  the  right  axillary  artery.  The 
trouble  had  lasted  fifty-two  hours,  and  there  was  already  present  a  commencing 
gangrene  and  ischaemic  contracture  of  the  limb. 

Doberauer  performed  arteriotomy,  removed  a  clot  about  3  cm.  in  length  and 
sutured  the  artery.  A  new  clot  formed  in  a  few  hours  and  was  removed  in  the 
same  manner.  Once  more  the  thrombus  reformed  and  after  two  days  the  gan- 
grene notably  progressed. 

Arterio-venous  anastomosis  was  now  made  between  the  axillary  artery  and 
vein.  As  soon  as  the  anastomosis  was  completed  and  the  blood  current  per- 
mitted to  flow,  "one  perceived  the  eruption  of  the  arterial  blood  into  the  vein  in 
the  form  of  a  little  explosion  and  one  saw  the  blood  advance  to  the  level  of  the 
wrist."  The  vein  pulsated  like  an  artery.  Twelve  days  after  operation  the 
circulation  remained  good. 

In  a  patient  who  had  lost  his  left  leg  from  gangrene  due  to  arterial  sclerosis, 
marked  symptoms  of  the  same  affection  appeared  in  the  remaining  lower  limb. 
Wieting  Pasha  exposed  the  femoral  artery  and  vein  at  the  apex  of  Scarpa's 
triangle,,  divided  the  artery  completely,  and  introduced  its  central  portion  into 


822 


ARTERIORRHAPIIY 


the  femoral  vein  for  a  distance  of  at  least  ^i^  inch  (i  cm.)  through  an  incision 
made  on  the  anterior  surface  of  the  vein.  The  union  was  effected  Ijy  sutures 
which  penetrated  the  whole  thickness  of  the  wall  of  the  vein  but  only  the  outer 
coats  of  the  artery.  The  vein  was  ligated  above  the  point  of  anastomosis.  The 
foot  soon  became  warm  and  rosy.  Two  months  after  the  operation  the  circu- 
lation remained  satisfactory  ("Deutsche  med.  Woch.,"  1908,  No.  28). 

In  October,  1908,  J.  B.  Murphy  exhibited  to  the  Society  of  Clinical  Surgery 
a  patient  in  whom  he  had  successfully  established  arterial  circulation  through 


Fig.  979. 
Figs.  979  and  980. — Murphy's  anastomosis  forceps. 


P'lG.  980. 
A.  A.  Cut  edge  of  vein. 


the  femoral  vein  for  gangrene  of  the  foot  due  to  endarteritis.     He  operated  as 
follows : 

(i)  Exposure  of  the  femoral  artery  and  vein  and  division  of  both.     (Divide 
the  vein  at  a  slightly  higher  level  than  the  artery.) 

(2)  Apply  forceps  (Fig.  979)  around  the  distal  segment  of  the  vein  near  its 
end  (A,  Fig.  980).     Pull  the  open  end  of  the  vein  back  over  the  forceps  (Fig.  981). 

(3)  Suture  the  open  end  of  the  proximal  segment  of  the  divided  artery  to  the 
inside  of  the  vein  where  it  is  reflected  over  the  forceps  (B,  Fig.  951). 

Caff  of  vein  iuniea 
I    wacA  over  forceps. 

'  ;::;;::i|::::J^ 

"/f/i/iUMiintmfiiti, 

ARTERY 


mwmFm 


Fig.  981. 

B  B.   Sutures  through  cut  edge  of  artery 
and  folded  edge  of  vein. 


Fig.  982. 


(4)  Pull  the  reflected  portion  of  vein  over  the  line  of  suture  (Fig.  982)  and 
suture  its  cut  end  to  the  surface  of  the  artery. 

(5)  Remove  the  forceps. 

In  speaking  of  the  operation  Murphy  said  that  it  would  have  been  better  to 
have  made  a  lateral  anastomosis  between  the  artery  and  vein  and  then  to  have 
tied  the  vein  proximal  to  the  site  of  anastomosis;  by  so  doing  it  would  have  been 
possible  to  continue  sending  blood  down  the  stenosed  artery  while  arterial  blood 
passing  down  the  vein  would  suppl}'  the  deficiency  created  by  the  narrowing  of 
the  artery. 

Bernheim  ("Annals  Surg.,"  Feb.,  191 2)  has  collected  52  cases  of  arterio- 
venous anastomosis.  Fifteen  of  these  (30  per  cent.)  were  successful,  the  re- 
versal, as  far  as  could  be  judged,  actually  saving  the  limb  from  present  or 
threatened  gangrene. 


ANEURYSM  ,  823 

CHAPTER  LXII 
ANEURYSM 

A  short  discussion  of  the  forms  and  varieties  of  aneurysm  may  be  of  benefit 
as  clarifying  the  consideration  of  their  treatment.  While  trauma  is  an  impor- 
tant cause  of  aneurysm,  e.g.,  gun-shot  wound  causing  arterio-venous  aneurysm, 
yet  a  weakening  of  the  arterial  wall  from  disease  is  by  far  the  most  common 
cause  of  the  trouble. 

(A)  When  an  artery  ruptures,  whether  from  trauma,  disease,  or  both, 
bleeding  into  the  surrounding  tissues  takes  place,  resulting  in  a  hematoma.  If 
the  wound  in  the  vessel  heals  there  may  be  no  further  trouble;  if  the  wound 
does  not  heal  and  if  from  pressure,  etc.,  the  tissues  surrounding  the  effused 
blood  become  condensed  so  as  to  form  a  capsule,  then  a  pulsating,  well-defined 
tumor  is  formed,  the  cavity  of  which  communicates  directly  with  the  lumen  of 
the  wounded  artery.     This  pulsating  tumor  is  known  as  a.  false  aneurysm. 

(B)  When  an  artery  and  a  vein  lying  alongside  each  other  are  simultane- 
ously wounded  and  the  wound  is  treated  by  compression,  the  two  vessels  may 
adhere;  the  superficial  wound  may  heal;  the  openings  into  the  vessels  may  not 
close,  but  may  form  an  arterio-venous  anastomosis,  the  arterial  blood  passing 
directly  into  the  vein.  This  condition  is  known  as  an  aneurysmal  varix  and  may 
or  may  not  occasion  any  trouble.  Instead  of  adhering  one  to  the  other,  the 
artery  and  vein  may  each  bleed  into  the  surrounding  tissues  and  give  rise  to  a 
false  aneurysm  which  communicates  directly  with  the  lumen  of  each  vessel, 
so  that  the  arterial  blood  passes  from  the  artery  to  the  vein  through  the  inter- 
mediate sac.  This  condition  is  known  as  a  varicose  aneurysm  and  is  of  more 
moment  than  aneurysmal  varix.  The  two  varieties,  viz.,  varicose  aneurysm 
and  aneurysmal  varix,  have  the  common  name  arterio-venous  aneurysm. 

(C)  Cirsoid  aneurysm  is  a  condition  in  which  a  number  of  dilated  arteries, 
held  together  by  connective  tissue,  form  a  tumor  which  is  the  arterial  equivalent 
of  the  venous  varicocele.  The  disease  is  most  common  in  the  scalp,  and  its 
treatment  is  very  similar  to  that  of  angioma. 

(D)  True  Aneurysm. 

1.  When  disease  {e.g.,  atheroma)  weakens  the  whole  circumference  of  an 
artery,  dilatation  is  liable  to  take  place  (Fig.  983,  8,  9,  10).  The  whole  circum- 
ference being  affected,  the  dilatation  is  uniformly  fusiform  except  in  so  far  as  it  is 
affected  by  surrounding  supporting  structures  (Fig.  983,  11,  12,  13).  This  is  a 
fusiform  aneurysm. 

2.  When  disease  weakens  a  limited  portion  of  the  circumference  of  an  artery, 
a  pouching  of  the  arterial  wall  outwards  is  liable  to  take  place,  just  as  a  bulging 
or  pouting  of  a  pneumatic  tire  forms  when  a  limited  portion  of  the  tire  has  be- 
come weakened  (Fig.  983,  i,  2,  3,  4,  5,  6,  7).  In  this  manner  a  larger  or  smaller 
sac  is  formed  communicating  with  the  lumen  through  a  more  or  less  circular 
opening  or  through  a  longitudinal  cleft  in  the  vessel-wall.  This  variety  is 
known  as  a  sacculated  aneurysm  (Fig.  983,  3).     If  the  sac  of  such  an  aneurysm 


824 


ANEURYSM 


is  opened,  only  one  orifice  may  be  seen  leading  into  ihe  artery;  if  two  orifices 
are  visible,  they  are  connected  by  a  groove  in  the  wall  of  the  sac  leading  from  one 
orifice  to  the  other  (Fig.  083,  7).  This  groove  consists  of  normal  artery  wall, 
and  in  fact  is  the  artery  which  communicates  with  the  sac  through  a  split  of 
limited  width  instead  of  through  an  opening  of  limited  length  and  width  (Fig. 


r 


C^"" 


1 


983, 14).  A  recognition  of  these  facts  is  very  important, as  such  aneurysms  may 
be  suitable  for  reconstructive  operations,  while  fusiform  aneurysms  with  which 
they  are  often  confounded  are  entirely  unsuited  to  such  treatment. 

(E)  A  true  aneurysm  may  rupture  and  form  a  false  aneurysm  in  addition. 
This  must  be  remembered  -as  the  condition  may  puzzle  an  operator  when 
performing  endo-aneurysmorrhaphy. 


ANEURYSM 


825 


LIGATION 

(a)  Operation  of  Antyllus.— Expose  the  aneurysm  along  with  the  artery 
immediately  above  and  below  it  (Fig.  984).  Ligate  the  artery  immediately 
above  and  below  the  aneurysm.  Open  the  sac;  turn  out  contained  blood-clots; 
excise  as  much  of  the  sac  as  convenient;  close  the  wound.  This  operation  is 
rarely  performed  except  in  very  superficial  vessels.  Other  and  better  methods 
are  available,  but  the  procedure  is  worthy  of  note  as  being  the  earliest  form  of 
operation  and  being  very  closely  allied  to  some  of  the  most  modern. 


Fig.  984. — Antyllus'  operation. 


Fig.  985. — Anel's  operation. 


(b)  Anel's  Operation. — Expose  the  artery  proximal  to  the  aneurysm.  Li- 
gate close  to  the  aneurysm,  so  close,  in  fact,  that  no  branch  is  given  off  from 
the'artery  between  the  ligature  and  the  sac.  The  objections  to  this  operation 
are  that  the  ligature  is  applied  on  more  or  less  diseased  tissue  (not  a  very  grave 
fault  in  view  of  the  success  of  Matas'  operation)  and  that  blood  may  soon  enter 
the  sac  through  collateral  circulation  (Fig.  985). 

(c)  Hunter's  Operation. — To  avoid  ligating  diseased  tissue  John  Hunter 
operated  at  a  distance  from  the  aneurysm.  In  popliteal  aneurysm  he  ligated 
the  femoral  in  Hunter's  canal;  later  surgeons  preferred  to  ligate  at  the  apex 
of  Scarpa's  triangle.  Collateral  circulation  does  not  pour  blood  into  the  sac 
so  early  as  after  Anel's  operation  (Fig.  986), 


Fig.  986. — Hunter's 
operation. 


Fig.  987.— Brasdor's      FiG.  988.— Wardrop's 
operation.  operation. 


(d)  Brasdor's  Operation. — When  an  aneurysm  is  so  near  the  trunk  that 
proximal  ligation  is  impracticable,  distal  ligation  may  form  a  barrier  to  the 
onflow  of  blood,  collateral  circulation  may  be  established,  and  a  cure  result. 

Brasdor's  operation  consists  in  ligating  the  main  artery  distal  to  the  aneu- 
rysm (Fig.  987). 

{e)  Wardrop's  Operation. — When,  for  example  in  innominate  aneurysm, 
the  artery  divides  into  two  great  vessels,  the  circulation  may  be  sufficiently 
checked  by  the  ligation  of  one  of  these  vessels  distal  to  the  disease  (Fig.  988). 
This  is  Wardrop's  operation.     If  ligation  of  the  one  vessel  prove  insufficient,  the 


826  ANEURYSM 

Other  branch  may  be  tied  as  well  so  that  the  same  condition  prevails  as  in  Bras- 
dor's  operation. 

(/)  Sjrme's  Operation  is  practically  obsolete.  It  consisted  in  incising  the 
aneurysm  freely,  quickly  inserting  the  finger  so  as  to  plug  the  afferent  vessel 
and  then  in  catching  with  a  forceps,  through  the  cavity  of  the  sac,  the  mouth 
of  the  vessel,  and  subsequently  obliterating  it  with  a  ligature  or  stitch. 

(g)  Dix's  Operation.— ("Brit.  Med.  Jour.,"  Oct.  30,  1875,  and  "Bryant's 
Surg.,"3ded.,i,  449.)  Gradual  constriction  of  the  afferent  artery.  This  method 
has  been  much  neglected,  and  yet  it  has  many  valuable  features.  It  imi- 
tates nature's  cure  by  gradually  decreasing  and  then  stopping  the  onflow 
of  blood.  If  coldness  of  the  limb  indicates  that  the  circulation  has  been  inter- 
fered with  too  much,  the  constriction  may  be  loosened  slightly  and  an  oppor- 
tunity given  for  a  sufficient  establishment  of  collateral  circulation.  Stratton, 
Halstead  and  Matas  have  used  this  same  principle  in  various  ways. 

Expose  the  artery,  encircle  it  with  a  strand  of  soft  silver  wire  about  nine 
inches  long.  With  a  needle  pass  the  ends  of  the  wire,  from  within  outwards, 
through  the  tissues  to  the  surface  so  as  to  emerge  on  the  skin,  one  about  a  quar- 
ter of  an  inch  and  the  other  three-quarters  of  an  inch  from  the  edge  of  the 
wound,  both  being  on  the  same  side  of  the  wound.  Divide  a  small  cork  longitudi- 
nally; place  one-half  of  this  between  the  emerging  ends  of  wire,  flat  surface  to 
skin,  with  its  long  axis  exactly  in  the  line  of  the  artery  and  press  down  upon  it; 
twist  the  ends  of  the  wire  over  the  cork  until  pulsation  ceases  in  the  aneurysm. 
Close  the  skin  wound.  "When  depression  of  anesthesia  goes  off  and  the  circu- 
lation revives,  it  will  be  found  that  a  feeble  pulsation  returns  in  the  aneurysmr 
This,  according  to  the  author  (who  strongly  advocates  the  gradual  rather  than 
the  rapid  method  of  producing  coagulation  in  the  sac),  should  be  allowed  to  go 
on  for  two  or  even  three  days,  when  the  wire  is  to  be  tightened"  (Thomas 
Bryant.)  To  tighten  the  wire,  press  down  on  the  cork  and  slip  small  wedges 
of  wood  (matches  would  do)  between  the  wire  and  the  cork.  Do  not  twist  the 
wire  afresh  lest  it  break.  "About  the  fifth  or  sixth  day  the  cure  is  complete" 
and  the  wire  may  be  removed. 

EXCISION  OF  ANEURYSM 

Adolf  Treutlein  ("Munch,  med.  Woch.,"  June  19,  1906)  recommends  that 
in  traumatic  aneurysm  finger  pressure  be  used  to  the  affected  part  two  or  three 
times  daily  for  fifteen  minutes  during  a  period  of  about  two  weeks  prior  to  opera- 
tion. The  object  of  this  preliminary  treatment  is  to  encourage  the  develop- 
ment of  collateral  circulation  and  lessen  the  dangers  of  gangrene.  Ellsworth 
Eliot,  Jr.,  has  preached  this  doctrine  for  years.  Freely  expose  the  aneurysm  by 
incision.  Ligate  the  artery  proximal  to  the  sac.  If  practicable  ligate  the  artery 
distal  to  the  sac.  Remember  that  branches  may  be  given  off  from  the  sac  and 
that  these  may  bleed.  Excise  the  sac  as  if  it  were  a  wo«-malignant  tumor.  It 
may  be  easy  to  remove  the  aneurysm  without  opening  it,  it  will  generally  be 
much  easier  if  the  sac  is  opened  and  its  contents  evacuated  not  merely  because 
of  increased  ease  in  manipulation,  but  because  the  openings  of  the  branch  vessels 
may  be  visible  and  thus  their  exposure  and  ligation  be  facilitated.  In  old  aneu- 
rysms with  their  numerous  irregularities  and  adhesions  extirpation  may  be  very 


MATAS'    OPERATION  827 

difficult.  When  the  wall  of  the  sac  is  closely  adherent  to  important  structures 
rather  leave  a  portion  of  the  sac  in  situ  than  jeopardize  such. 

If  temporary  hemostasis  has  been  obtained  by  an  elastic  constrictor,  hemor- 
rhage is  likely  to  be  so  considerable  on  its  removal  that  Hildebrand  gives  the 
following  advice:  Tampon  the  wound  and  elevate  the  limb  before  removing  the 
constrictor.  Remove  the  constrictor.  After  about  10  to  15  minutes  the  tem- 
porary hyperemia  always  noticeable  after  removal  of  a  constrictor  will  have 
disappeared,  and  it  becomes  easy  to  pick  up  and  tie  all  bleeding  points. 

The  development  of  arteriorrhaphy  renders  it  possible  to  substitute  a  more 
ideal  operation  for  the  classical  method  of  excision  of  an  aneurysm.  Instead  of 
ligating  the  artery  above  and  below  the  aneurysm,  it  is  temporarily  occluded 
by  means  of  Crile's  clamps  or  the  like  (unless  Esmarch's  elastic  constrictor  has 
been  used);  the  aneurysm  is  excised  and  the  afferent  and  efferent  segments  of 
the  artery  are  united  by  suture. 

Enderlen  (Wiirzburg)  ("Deutsche  med.  Woch.,"  1908,  No.  37),  excised  a 
popliteal  aneurysm.  The  vein  was  twice  wounded  during  the  dissection  and 
both  wounds  were  sutured.  The  aneurysm  was  isolated — all  collateral  branches 
were  ligated  and  the  sac  excised.  Flexion  of  the  knee  permitted  approximation 
of  the  divided  ends  of  the  artery  which  were  united  by  Carrel's  suture.  During 
after-treatment  the  knee  was  kept  flexed.  After  union  was  assured  the  knee 
was  gradually  extended.  At  the  end  of  six  months  the  patient  resumed  work. 
If  it  be  impossible  to  approximate  the  divided  ends  of  the  artery  the  gap  may  be 
filled  by  implanting  a  segment  of  vein  (e.g.,  long  saphenous).  This  method 
was  successfully  adopted  by  E.  Lexer  after  he  had  excised  an  aneurysm  of  the 
axillary  artery.  Einar  Key  (Zentralblatt  fiir  Chir.,  Oct.  14,  191 1)  in  extirpating 
a  popliteal  aneurysm,  excised  fully  4  cm.  of  the  artery.  The  knee  was  flexed  to 
45°,  and  arteriorrhaphy  performed.     After  4  weeks  the  knee  could  be  extended. 

OBLITERATIVE   ENDO-ANEURYSMORRHAPHY    (MATAS) 

In  situations  where  temporary  hemostasis  can  be  surely  secured  by  the  elastic 
constrictor  or  some  form  of  compressor,  or  where  all  the  main  vessels  entering 
or  leaving  the  aneurysmal  sac  can  be  secured  either  temporarily  by  clamps  such 
as  Crile's  or  permanently  by  ligatures,  Matas's  operation  is  easy  and  efficient. 

Step  I. — After  assuring  temporary  hemostasis,  make  a  free  incision  parallel 
to  the  long  axis  of  the  aneurysm  down  to  the  sac.  Do  not  injure  any  important 
structures. 

Step  2. — Freely  incise  the  sac  so  that  every  part  of  it  is  accessible  to  sight 
and  touch.  Remove  the  contents  of  the  sac  and  retract  its  walls  so  that  all  the 
orifices  which  open  into  it  are  visible.  Note  if  there  are  two  main  orifices  un- 
connected by  a  groove  of  more  or  less  normal  arterial  wall.  If  this  is  the  case 
the  aneurysm  is  fusiform  and  suitable  for  the  obliterative  operation.  If  the 
two  openings  are  connected  by  a  groove  of  more  or  less  healthy  arterial  wall, 
note  if  this  groove  is  wide  and  contains  enough  and  sufficiently  good  tissue  to 
permit  reconstruction  of  the  artery.  If  the  groove  is  narrow  and  composed  of 
suspicious  tissue,  the  aneurysm  is  either  fusiform  or  practically  fusiform  and  the 
obHterative  operation  is  imperative.  If  the  groove  is  wide  and  satisfactory  in 
character,  the  aneurysm  is  sacculated  and  may  be  suited  to  a  reconstructive 


828 


ANEURYSM 


operation.  If  only  one  opening  is  present  in  the  sac  wall,  the  aneurysm  is  sac- 
culated and  a  reconstructive  operation  is  usually  indicated.  On  opening  the 
sac  one  may  find  it  to  be  a  false  aneurysm;  if  this  is  the  case,  find  the  opening 


Fig.  989. — (Matas.) 


Fig.  990. — (Malas.) 


^^ 


991 


Fro.  QQ2. — {Malas.) 


into  the  arter\'  and  close  it  by  suture  or  ligate  the  vessel,  unless  the  false  aneu- 
rysm is  secondary  to  the  rupture  of  a  true  one,  when  one  must  treat  the  true 
aneurysm  after  clearing  out  its  contents.  The  sac  of  a  false  aneurysm  should 
be  treated  in  the  same  fashion  as  that  of  a  true  one. 


MATAS'    OPERATION  829 

Step  3. — The  aneurysm  is  "fusiform"  (Fig.  989).  With  sutures  of  catgut 
on  a  curved  needle  (without  cutting  edges)  close  all  the  orifices  entering  the  sac. 
With  a  similar  suture  (continuous),  inserted  in  the  Lembert  fashion,  obliterate 
the  deeper  portions  of  the  sac,  so  that  all  the  stitches  closing  the  orifices  are  hid- 
den (Fig.  990).  Turn  the  flaps  of  skin  plus  sac  wall  inwards  and  fix  them  by 
sutures  as  in  Figs.  991  and  992.  Remove  the  elastic  constrictor.  Apply 
dressings.  It  is  of  prime  importance  not  to  separate  the  sac  from  its  surround- 
ings, as  its  walls  are  poorly  nourished  at  best,  and  sloughing  is  to  be  avoided. 
Instead  of  inverting  the  skin  and  part  of  the  sac,  the  author  has  excised  some 
of  the  excess  of  sac  wall  and  obliterated  the  rest  of  the  cavity  of  the  sac  by  means 
of  several  rows  of  continuous  Lembert-like  sutures  of  catgut  and  closed  the 
superficial  wound  by  a  separate  line  of  stitches. 

In  a  few  cases  the  walls  of  the  aneurysm  are  so  thick  and  stiff  that  it  is  im- 
possible to  bring  them  together  with  sutures.  In  these  cases  C.  H.  Mayo  has 
operated  as  follows:  Occlude  all  the  vessels  entering  or  leaving  the  sac  by  sur- 
rounding each  with  a  purse-string  suture  of  catgut.  Very  moderate  tension  on 
these  sutures  suffices.  Next  place  a  layer  of  iodoform  gauze  over  the  bottom  of 
the  sac  and  fix  it  in  place  by  a  continuous  suture  of  catgut.  In  the  same 
manner  fix  layer  upon  layer  of  the  gauze  in  place,  bringing  the  end  of  each  piece 
of  gauze  out  of  the  wound.  Close  the  skin  wound  except  where  the  gauze  pro- 
trudes. Leave  the  gauze  in  situ  until  the  catgut  is  absorbed.  The  cavity  soon 
closes  satisfactorily.  E.  M.  Anderson  (Am.  Jour,  of  Surg.,  June,  1919)  by 
mistake  widely  opened  an  aneurism  thinking  it  was  a  psoas  abscess.  Packing 
with  six  yards  of  gauze  led  to  cure.  In  another  patient  with  subclavian  aneur- 
ism similar  treatment  was  successful.  The  gauze  packs  are  to  be  removed 
gradually  as  they  loosen  after  the  formation  of  granulation  tissue.  The  first 
of  the  gauze  may  be  removed  in  about  two  weeks,  the  deepest  packs  may  be 
left  as  long  as  four  weeks. 

Abbe's  case  of  obliterative  aneurysmorrhaphy  (''Annals  of  Surg.,"  July, 
1908,  p.  12)  for  gluteal  aneurysm  is  very  instructive.  "A  young  Russian  of 
twenty-four  years  had  been  developing  for  three  months  right  sciatic  neuralgia 
with  disability  in  walking  and  some  swelling  of  his  foot.  A  pulsating  tumor  of 
the  right  gluteal  region  prevented  his  lying  on  that  side  also.  The  man  had 
never  had  syphilis,  but  acknowledged  gonorrhea.  His  heart  showed  a  blowing 
aortic  murmur.  Examination  showed  a  spherical,  pulsating  tumor,  three 
inches  in  diameter,  beneath  the  gluteus  muscle  at  the  sciatic  notch,  where  its 
pressure  had  caught  the  sciatic  nerve,  and  held  it  tightly  against  the  bone — 
hence  the  neuralgia. 

"It  was  a  particularly  good  case  for  operation  by  the  plastic  method,  be- 
cause ligation  of  the  internal  iliac,  while  it  would  temporarily  arrest  the  current 
would  allow  free  anastomosis  and  possible  return;  meanwhile  leaving  the  dis- 
tended sac  to  continue  sciatic  pressure. 

"On  May  21, 1906,  I  opened  the  iliac  fossa  and  threw  a  temporary  silk  liga- 
ture about  the  internal  iliac  artery,  which  was  held  as  loop  by  my  assistant.  Dr. 
\\\  S.  Schley,  who  drew  it  up  against  his  index  finger-tip,  so  as  to  avoid  crushing 
it  by  tight  ligation.  This  compression  at  once  stopped  pulsation  in  the  tumor. 
I  then  incised  over  the  tumor,  and  separated  the  gluteus.     The  sac  was  well 


830  ANEURYSM 

distended  and  easily  isolated.  Its  neck  filled  the  uppermost  corner  of  the 
sciatic  notch.  On  compression,  after  the  ])ulsalion  had  been  stopped  from  above, 
it  emptied,  and  quickly  filled  again.  By  inference,  this  must  have  been  by 
anastomosis,  as  the  iliac  artery  was  quite  occluded  by  the  silk  loop. 

"Seeing  no  way  to  keep  it  entirely  empty;  I  ventured  to  cut  it  freely  open, 
and  relied  on  instant  internal  pressure  to  stop  loss  of  blood.  I  first  plugged  the 
opening  of  the  gluteal  artery  with  my  index  finger-tip,  and  found  no  other 
bleeding  occurred.  I  was  then  able  to  dry  its  walls  and  see  that  they  were  firm, 
with  good  serous  lining.  On  releasing  my  finger  pressure  ever  so  little,  a  sharp 
flow  of  blood  followed,  but  not  in  pulsating  current.  I  now  began  a  continuous 
suture  of  the  internal  wall,  with  fine  chromicized  catgut,  first  fixing  it  by  a  knot 
just  above  my  finger-tip.  The  next  stitches  were  placed  so  as  to  catch  in  the  sac 
wall,  on  both  sides  of  my  finger-tip,  which  I  drew  back  as  I  quickly  tightened 
them,  thus  sealing  up  the  deepest  part  of  the  funnel-shaped  cavity.  After 
placing  the  first  four  deep  stitches  there  was  no  bleeding,  and  I  leisurely  secured 
one  wall  against  the  other  by  continuous  back  and  forth  suturing,  with  the  same 
thread.  I  even  continued  this  until  I  had  obliterated  the  entire  sac,  and  closed 
the  superstructures,  with  no  additional  knot.  The  silk  thread  was  removed 
from  the  iliac.  The  wound  was  bloodless.  The  patient  made  an  immediate 
recovery.  The  patient  had  no  recurrence  of  tumor  or  sciatic  pain  up  to  three 
months  after  operation." 

RECONSTRUCTIVE   ENDO-ANEURYSMORRHAPHY   (MATAS) 

Steps  I  and  2  are  the  same  as  in  the  preceding  operation. 

(a)  The  aneurysm  is  sacciform.  Only  one  well-defined  opening  is  visible 
entering  the  sac.  Close  the  opening  by  a  line  of  sutures  introduced  in  the  Lem- 
bert  fashion.  These  sutures  should  be  of  No.  i  silk  impregnated  with  sterile 
vaseline  and  should  be  introduced  by  means  of  the  finest  possible  intestinal 
needles.  (Curved  needles  will  be  most  convenient.)  Before  suturing,  the  parts 
to  be  sutured  should  be  douched  with  salt  solution  or  coated  with  vaseline  (see 
Arteriorrhaphy).     Obliterate  the  sac  as  in  the  obliterative  operation. 

Matas  originally  closed  the  communication  between  the  artery  and  the  sac 
with  catgut,  but  the  method  described  above  is  better. 

The  author  operated  (using  catgut  throughout)  in  one  case,  and  while  the 
aneurysm  was  cured  he  feels  sure  that  the  reconstruction  of  the  artery  must  have 
failed  as  the  catgut  stitches  are  well  calculated  to  cause  obliteration  of  the  vessel. 
Even  if  the  artery  ultimately  becomes  obliterated,  it  probably  closes  somewhat 
slowly  and  gives  time  for  collateral  circulation  to  become  established. 

{h)  The  aneurysm  is  sacciform,  but  there  are  apparently  two  openings  into 
the  sac  connected  by  a  suflSciently  wide  groove  of  healthy  arterial  wall.  After 
douching  the  groove  and  the  openings  with  salt  solution  and  smearing  them  with 
vaseline  (see  Arteriorrhaphy),  pass  the  ends  of  a  piece  of  a  soft  rubber  catheter 
into  the  two  arterial  openings  and  let  the  tube  lie  in  the  groove  (Figs.  99,^  and 
994).  Have  a  loop  of  thread  round  the  catheter  with  which  to  extract  it  when 
it  has  served  its  purpose.  With  very  fine  silk  sutures  (vaselined)  on  fine  round 
needles  stitch  the  sac  on  one  edge  of  the  groove  (using  healthy  tissue)  to  the  cor- 
responding edge  on  the  other  side  of  the  groove,  over  the  catheter.     Extract 


MACE  wen's    operation 


831 


the  catheter  and  tighten  the  sutures.  If  an  extra  stitch  seems  indicated,  insert 
such.  Slowly  remove  the  elastic  constrictor  (or  temporary  hemostatic  agent). 
If  any  bleeding  takes  place  at  the  line  of  suture,  stop  it  by  one  or  more  extra 
sutures.     Obliterate  the  rest  of  the  sac  as  in  the  obliterative  operation. 

W.  J.  Frick  and  the  author  have  each  performed  this  operation  using  catgut 
as  recommended  originally  by  Matas  instead  of  vaselined  silk,  in  both  cases  the 
aneurysm  was  cured,  but  as  the  ankle  pulse  was  not  to  be  felt  either  before  or 
after  the  operation  there  is  no  proof  as  to  the  success  of  the  reconstruction 
of  the  artery.  Personally,  the  author  thinks  that  obliteration  of  the  vessel 
probably  occurred  due  to  the  kind  of  catgut  used. 


Fig.  993. — (Matas.) 


Fig.  994. — (Matas.) 


When  applicable,  the  author  believes  one  or  other  of  the  methods  of  Matas 
superior  to  all  others  in  the  treatment  of  aneurysm. 

Macewen's  Operation. — In  cases  of  otherwise  inoperable  aneurysm  Mac- 
ewen  has  endeavored  (successfully  in  some  cases)  to  assist  nature  in  forming  a 
"white  blood-clot"  on  the  walls  of  the  sac.  The  operation  consists  in  pushing 
long,  delicate,  finely  polished  steel  pins,  like  ladies'  hat  pins,  into  the  sac  and 
through  its  cavity  so  as  to  touch  but  not  penetrate  the  inner  surface  of  the  sac  on 
the  opposite  side.  The  current  of  blood  acting  on  the  pins,  makes  them  quiver 
and  continuously  scratch  the  intima.  On  the  scratched  intima  a  firm  white 
blood-clot  is  deposited  which  may  become  organized  and  result  in  a  cure. 
Macewen  recommends  that  the  scarification  be  carried  out  for  about  ten  minutes 
at  one  spot  and  then  that  the  pin  be  partly  withdrawn  and  applied  at  another 
point.  In  large  aneurysms  several  pins  may  be  inserted  at  the  same  time. 
"The  action  of  this  procedure  is  slow;  sometimes  it  may  be  weeks  before  any 
noticeable  thickening  of  the  coats  is  made  out;  sometimes,  on  the  other  hand,  it 
may  be  much  more  rapid.     The  pins  may  be  introduced  on  several  occasions; 


832  ANEURYSM 

it  is  well  to  leave  an  interval  of  a  week  to  a  fortnight  between  each  introduction" 
(Cheyne  and  Burghard). 

Aneurysm  of  the  Arch  of  the  Aorta  {Fibrous  ^cerclage'). — Tufiier  (Bui.  et 
Mem.  Soc.  de  Chir  de  Paris,  Feb.  3,  1920,  p.  166)  by  transverse  section  of  the 
sternum  exposed  an  aneurysm  of  the  ascending  portion  of  the  arch  of  the  aorta. 
The  aneurysm  was  situated  one  finger's  breadth  above  the  origin  of  the  aorta, 
was  about  5  cm.  (2  in.)  long  and  at  its  site  the  aorta  was  doubled  in  volume. 
A  long  strip  of  fascia  lata  about  two  finger's  breadth  wide,  was  wrapped  around 
the  vessel  in  two  layers,  each  fixed  separately  by  a  few  silk  sutures.  Enough 
tension  was  exerted  to  slightly  narrow  the  caliber  of  the  aorta.  The  result 
was  good.  After  5  years  the  patient  was  examined  and  the  aorta  was  found 
dilated  on  the  left  side  but  no  grave  functional  troubles  had  arisen. 

ARTERIO-VENOUS   ANEURYSM 

When  important  vessels  are  the  site  of  arterio-venous  aneurysm  and  when 
the  lesion  and  circumstances  permit,  it  is  most  proper  to  endeavour  to  destroy 
the  communication  between  the  vessels  and  to  repair  the  vessels  themselves. 
For  this  work  the  lessons  taught  by  the  laboratory  must  be  fully  and  judiciously 
utilized.  Where  it  is  impossible  to  gain  direct  access  to  the  lesion  one  may 
incise  the  vein  and  through  it  may  close  the  arterio-venous  fistula,  subsequently 
suturing  the  incision  made  in  the  vein  (Matas) .     This  has  been  done  successfully. 

The  classical  method  of  operating  on  arterio-venous  aneurysm,  whether 
aneurysmal  varix  or  varicose  aneurysm,  is  by  ligation  of  the  afferent  and 
efferent  vessels  with  or  without  excision  of  the  sac.  It  has  been  strongly  urged 
that  when  it  is  possible  to  save  one  of  the  vessels  constituting  the  aneurysm  the 
vein  should  be  preserved  rather  than  the  artery  so  as  to  avoid  dangers  of  gan- 
grene. Makins  (Gunshot  Injuries  to  the  Blood  Vessels,  191 9,  p.  loi)  has 
proved  that  there  is  much  less  danger  of  gangrene  developing  if  the  aneur>'sm 
is  excised  than  if  the  afferent  artery  is  alone  tied.  In  many  cases  of  vascular 
wounds  it  is  safest  to  ligate  both  the  artery  and  the  neighboring  vein.  Makins 
writes  "The  result  of  the  combined  procedure  is  to  maintain  within  the  limb 
for  a  longer  period  the  smaller  amount  of  blood  supplied  by  the  collateral 
arterial  circulation,  and  hence  to  improve  the  conditions  necessary  for  the  pres- 
ervation of  the  vitality  of  the  limb."  In  support  of  these  views  Makins  quotes 
Oppel's  six  cases  of  ligation  of  the  popliteal  vein  for  the  treatment  of  senile 
gangrene  of  the  foot,  in  all  of  which  the  extremities  were  seen  to  recover  not 
only  their  warmth  and  color  without  the  development  of  oedema,  but  also  a 
certain  degree  of  hyperemia  of  the  feet  and  toes. 

Methods  of  Operating  on  Arterio-venous  Aneurysm  Other  than  by  Simple 
Ligation. — If  possible  use  provisional  hemostasis  by  means  of  an  elastic  con- 
strictor; if  this  is  not  possible  expose  the  afferent  and  efferent  vessels  at  an 
early  stage  of  the  operation  and  control  them  as  in  arteriorrhaphy.  Incise  the 
sac  if  one  is  present  or  separate  the  adherent  artery  and  vein  one  from  the  other. 
If  the  wounds  in  the  artery  and  vein  can  be  closed  without  too  much  narrowing 
of  their  lumen,  do  so  in  the  Carrel  fashion.  Remove  the  clamps  or  constrictors 
and  close  the  wound. 


ARTERIO-VENOUS    ANEURYSM  833 

If  the  artery  is  completely  tlivided  or  nearly  so,  make  an  end-to-end  arterial 
anastomosis  either  by  Murphy's  invagination  method  (the  pioneer  operation) 
or  by  Carrel's  method.  In  one  case  of  popliteal  arterio-venous  aneurysm  E. 
Lexer  excised  the  injured  portions  of  the  artery  and  vein,  and  although  there  was 
5  cm.  (2  inches)  of  separation  betwen  the  vessel  ends  when  the  knee  was 
extended,  he  was  able  to  unite  artery  to  artery  and  vein  to  vein  with  Payr's 
prosthesis,  when  the  knee  was  flexed.  After  six  weeks  extension  of  the  knee 
was  possible. 

Stich  ("Deutsche  Zeitsch.  fiir  Chir.,"  xcv,  577)  extirpated  an  arterio- 
venous popliteal  aneurysm  and  united  the  divided  artery  by  Carrel's  circular 
suture.  The  operation  was  performed  as  follows:  Four-inch  incision  on  inner 
side  of  thigh  immediately  above  the  knee-joint.  Exposure  and  isolation  of  the 
aneurysmal  tumor  which  was  a  sacciform  dilatation  of  the  popliteal  artery. 
The  vein  was  torn  during  an  attempt  to  separate  it;  as  a  result  it  was  necessary 
to  resect  il^  inches  of  the  vein  at  the  level  of  the  aneurysm.  The  artery  com- 
municated with  both  the  vein  and  the  aneurysm  sac.  Suture  of  both  openings 
in  the  artery  would  have  produced  too  much  stenosis,  so  Stich  resected  a  short 
segment  of  the  artery  and  united  its  divided  ends  by  Carrel's  method.  Slight 
flexion  of  the  knee  permitted  easy  approximation  of  the  ends  of  the  artery. 
During  the  after-treatment  the  knee  was  kept  slightly  flexed.  Three  months 
after  operation  the  patient  was  found  to  be  well. 

When,  after  separation  of  the  unnatural  anastomosis  between  artery  and 
vein,  so  much  tissue  is  lost  that  direct  end-to-end  anastomosis  is  impossible,  a 
segment  of  another  and  unimportant  vessel  may  be  implanted.  E.  Lexer  has 
used  a  segment  of  the  long  saphenous  vein  to  replace  a  segment  of  the  axillary 
artery. 

Transvenous  aneurysmorrhaphy  suitable  in  cases  of  aneurysmal  varix 
where  the  circulation  can  be  controlled  during  the  operation  by  a  tourniquet. 
(Matas,  Med.  News,  Oct.  27,  1888.  Annals  Surg.,  Feb.,  1903.  Bickham, 
Armals  Surg.,  May,  1904.  WilHam  Pearson,  Brit.  Med.  Jour.,  June  14, 
1919.) 

Step  I. — -By  suitable  incision  expose  the  vessels. 

Step  2. — Open  the  vein  longitudinally  opposite  the  stoma.  Gently  irrigate 
with  salt  solution  to  get  rid  of  blood  which  may  be  present.  Never  wipe  the 
intima  with  gauze,  but  remove  the  excess  fluid  by  the  gentlest  of  mopping. 
Smear  the  interior  of  the  vessels  with  vaseline. 

Step  3. — Immediately  above  the  stoma  unite  the  vein  to  the  artery  by  a 
stitch  of  fine  vaselinized  silk  which  penetrates  the  fibrous  tissue  around  the 
stoma,  but  does  not  penetrate  the  vessels.  Tie  the  suture.  At  a  point  close 
to  one  end  of  the  stoma,  pass  the  needle  obliquely  through  the  wall  of  the  vein 
(from  without  inwards)  and  with  the  same  suture  close  the  opening  (the  stoma) 
between  the  artery  and  vein  exactly  as  in  Matas'  reconstructive  endo-aneurys- 
morrhaphy.  When  the  closure  is  complete  pass  the  needle  obliquely  from 
within  outwards  through  the  wall  of  the  vein  near  the  lower  end  of  the  stoma 
and  secure  it  outside  the  vessels  in  a  manner  similar  to  that  used  in  beginning 
the  stitch. 

Step  4. — Close  the  opening  in  the  vein  by  Carrel's  suture. 
53 


834  LIGATION   OF   ARTERIES   IN   CONTINUITY 

Gregoire  gives  a  good  review  of  the  treatment  of  arterio-venous  aneurysm 
in  a  paper  read  before  the  Societe  de  Chir  de  Paris,  March,  1919  (Am.  Jour,  of 
Surg.,  Oct.,  1919).  In  his  opinion  operation  should  not  be  performed  less  than 
six  weeks  after  the  causal  injury.  Matas'  paper  on  arterio-venous  aneurysm 
(Annals  of  Surg.,  April,  1920)  is  a  mine  of  information  and  is  invaluable. 


CHAPTER  LXIIl 

LIGATION   OF  ARTERIES  IN   CONTmUITY 

In  the  succeeding  pages  the  Hgation  of  but  a  few  of  the  principal  arteries  is 
described.  These  are  the  vessels  which  occasionally  call  for  ligation  in  actual 
practice.  At  the  present  day  operations  for  the  tying  of  other  vessels  are  almost 
exclusively  valuable  as  anatomic  exercise  and  hence  have  no  place  in  this  work. 

The  above  remarks  are  apphcable  to  the  surgery  of  arteries  during  times 
of  Peace,  but  in  War  Surgery  and  even  in  some  peace  time  accidents  there  is 
so  much  disintegration  of  tissue,  the  normal  anatomy  is  so  distorted  and  there 
is  so  much  doubt  as  to  what  vessel  is  injured  that  the  classical  methods  of  ex- 
posure are  inefficacious  even  if  the  surgeon  remembers  them  during  an  emer- 
gency. For  a  few  of  the  arteries  the  methods  of  exposure  worked  out  by 
Fiotte  and  Delmas  (Decouverte  des  Vaisseaux  profonds,  Voies  d'acces  larges. 
Masson  et  Cie.)  will  be  given. 

A  few  general  remarks  on  methods  of  ligating  arteries: 

1.  Refresh  the  memory  regarding  the  anatomic  details  of  the  region  to  be 
invaded. 

2.  Place  the  limb  in  good  position  and  mark  on  it  the  line  of  the  artery.  A 
line  of  scratches  or  very  shallow  incisions  is  the  best  mark  to  make. 

3.  Steady  the  skin  with  the  left  hand.  This  is  important,  as  in  making  the 
incision  the  skin  will  slide  on  the  deep  structures,  and  the  "marked  line"  will 
no  longer  correspond  to  the  artery.  Make  a  clean  incision  through  the  skin 
and  superficial  fascia.     The  incision  usually  must  be  2}^  to  3  inches  long. 

Precision  in  work  is  required,  hence  very  short  incisions  are  objectionable. 
Free  access  is  absolutely  requisite. 

4.  Retract  or  doubly  ligate  and  divide  all  vessels  which  come  in  the  way. 
Pick  up  thin  layers  of  the  deep  structures  in  forceps  on  each  side  of  the  line  of 
incision  and  thus  elevate  a  transverse  fold  of  the  tissue  which  becomes  emphy- 
sematous and  can  be  safely  cut.  Continue  this  proceeding,  dividing  the  tissues 
layer  by  layer  until  the  artery  in  its  sheath  is  reached.  When  penetrating  the 
deep  parts  through  intermuscular  septa  the  dissection  may  be  accomplished 
with  the  handle  of  the  scalpel. 

As  the  wound  is  deepened  its  edges  must  be  held  apart  by  blunt  retractors; 
but  the  retraction  must  be  made  with  care,  otherwise  the  depth  of  the  wound  will 
be  distorted  and  the  line  of  the  artery  lost.  The  deep  structures  must  be 
divided  as  extensively  as  the  skin  or  nearly  so. 

5.  The  artery  being  reached  must  be  distinguished  from  neighboring  veins 
and  nerves.  The  nerves  appear  as  white,  firm,  solid  cords.  The  veins  when 
empty  look  like  thin  fibrous  sheets,  when  full  they  are  soft,  easily  compressed. 


LIGATION 


835 


and  when  compressed  they  fill  up  on  Ihe  distal  side.  The  veins  are  larger  than 
and  often  overlap  the  arteries,  and  through  them  the  pulsation  of  the  artery 
may  be  felt.  Occasionally  nerves  may  transmit  pulsation  in  a  most  deceiving 
manner  from  the  artery  to  the  palpating  finger.  Arteries  feel  to  the  finger  like 
fairly  firm  tubes,  and  they  pulsate.  This  pulsation  may,  however,  be  feeble 
under  certain  circumstances  or,  as  already  noted,  it  may  be  transmitted  to  nerves, 
etc.,  and  thus  error  may  arise.  During  every  step  of  the  operation  from  skin 
incision  to  exposure  of  the  vessel  be  careful  to  recognize  ever}'  anatomic  guide 


Fig.  995. — Incision  of  arterial  sheath.     {Esmarch  and  Kowalzig.) 

either  by  eyesight  or  by  touch.  Farabeuf ,  speaking  of  the  importance  of  touch, 
says  the  surgeon  should,  in  the  dissecting-room,  "accustom  himself  to  ligate 
certain  arteries  with  his  eyes  in  the  air  and  his  fingers  in  the  wound  as  soon  as 
the  superficial  incision  has  been  made."  Accurate  hemostasis  and  a  dry  wound 
are  of  much  importance. 

6.  The  artery  lies  in  a  fibrous  sheath  much  as  a  tendon  does.     This  sheath 
must  be  opened.     When  the  fibrous  sheath  has  been  exposed,  with  dissecting 
forceps  pick  up  a  transverse  fold  of  it  (Fig.  995).     If  the  forceps  are  applied 
from  side  to  side  so  as  to  pick  up  a  longitudinal 
fold  of  the  sheath  they  may  include  in  their  bite  a 
portion  of  the  wall  of  the  vessel. 

Apply  a  scalpel  with  its  flat  surface  to  the 
vessel  and  cut  a  notch  in  the  elevated  fold  of 
sheath,  parallel  to  the  vessel.  Lay  aside  the  knife. 
Do  not  let  loose  the  forceps.  With  the  blunt  point 
of  a  probe,  director,  or  aneurysm  needle  insinuated 
through  the  opening  in  the  sheath  separate  the  sheath 
from  the  vessel  for  a  short  distance  and  catch  the 
edges  of  the  wound  in  the  sheath  with  fine-pointed 
hemostasis  forceps;  unless  this  is  done  it  may  be 
difiScult  to  find  the  opening  in  the  sheath  again. 
Pass  the  aneurysm  needle  between  the  sheath  and 
the  artery  half  way  round  the  vessel  in  one  direction, 
and  then  do  the  same  in  the  opposite  direction.  In  this  manner  about  i<4 
inch  of  the  artery  is  completely  separated  from  its  sheath.  From  the  vein 
side  of  the  artery  pass  the  aneurysm  needle  completely  round  the  vessel 
under  the  sheath.  When  the  eye  of  the  instrument  protrudes  at  the  opposite 
side  of  the  vessel,  thread  it;  withdraw  the  needle  and  thus  place  the  Hgature  in 
position.  If  the  needle  is  armed  with  a  stout  hgature  before  being  passed  the 
thread  greatly  impedes  the  manoeuvre.     On  the  other  hand,  it  is  often  difi&cult* 


Fig.  996. 


836 


LIGATION    OF    ARTERIES    IN    CONTINUITY 


to  thread  the  needle  after  it  has  been  passed.  To  avoid  these  difficulties  the 
author  arms  the  needle  with  a  fine  thread  of  silk  or  hemp,  passes  the  needle 
thus  armed  round  the  vessel,  picks  up  the  loop  of  the  fine  thread,  withdraws 
the  needle,  passes  a  stout  ligature  through  the  loop,  withdraws  the  loop,  and  so 
brings  the  ligature  into  position  (Fig.  996).  If  too  much  of  the  artery  is 
separated  from  its  sheath  nutrition  is  impaired  and  the  vessel  may  necrose. 

7.  The  ligature  may  be  of  catgut,  silk,  hemp,  tendon,  ox-aorta,  etc.,  accord- 
ing to  the  whim  of  the  operator.  Tie  the  ligature  in  a  reef  knot.  If  catgut 
is  used  make  three  ties.  Some  surgeons  recommend  that  the  ligature  be  tied 
tightly  enough  to  rupture  the  intima.  This  is  not  necessary,  all  that  is  requisite 
is  to  have  the  lumen  obliterated  and  the  inner  surfaces  of  the  intima  in  contact. 

8.  Close  the  wound  accurately.  Apply  dressings.  Keep  the  limb  at  rest, 
elevated  and  warm. 

LIGATION  OF  THE  COMMON  CAROTID  ARTERY 

(A)  Ligation  at  the  site  of  election,  i.e.,  above  the  omo-hyoid  muscle  in  the 
carotid  triangle. 

Place  the  patient  on  his  back  with  a  firm  pillow  under  the  shoulder  and 
neck  with  his  chin  directed  upwards  and  towards  the  opposite  side  (the  head 
moderately  extended  and  rotated). 

Step  I. — Method  A. — Make  a  three-inch  incision  along  the  anterior  margin 
of  the  sterno-mastoid  having  its  mid-point  opposite  the  cricoid  cartilage. 
Divide  the  subcutaneous  tissue  and  the  platysma  throughout  the  length  of  the 
wound.     Do  not  unnecessarily  injure  the  superfical  veins. 


Ext.  carotid 

Great  hornhyoid 

Ext.  jugular 

Sterno-mastoid 


Submax.  gland 
Stylohyoid  and 
digastric 
Lingual  art 
Descen- 
dens  noni 
Omo-hyoid 
Com. 
carotid 


Fig.  997. — Exposure  of  common  carotid  and  lingual  arteries.     {Kocfier.) 


Method  B. — Kocher's  Incision. — At  the  level  of  the  cricoid  cartilage  make  a 
three-inch  horizontal  incision  through  the  skin  and  platysma.  The  incision 
follows  the  direction  of  the  folds  in  the  neck  and  is  slightly  oblique  from  above 
downwards  and  inwards  (Fig.  997). 

The  centre  of  the  incision  must  correspond  to  the  anterior  edge  of  the  sterno- 
mastoid.  Divide  the  fascia  covering  the  sterno  mastoid.  Retract  the  edges 
of  the  wound. 


COMMON    CAROTID 


837 


Step  2. — Retract  the  sterno-mastoid  outwards.  Recognize  the  anterior 
belly  of  the  omo-hyoid.  Palpate  for  the  carotid  tubercle  (transverse  process, 
sixth  cervical  vertebra)  at  the  angle  formed  by  the  crossing  of  the  sterno-mastoid 
and  the  omo-hyoid.  The  artery  crosses  the  tubercle.  Observe  a  nerve  running 
downwards  throughout  the  wound  (descendens  noni);  it  lies  directly  on  the 
sheath  of  the  carotid  vessels.  Open  the  common  sheath  of  the  carotid  vessels 
to  the  inner  side  of  the  descendens  noni  nerve,  and  retract  outwards  the  nerve 
and  the  correspondinji:  portion  of  the  sheath  (Fig.  998). 


■^    perflcial  fascia 

-     ;  :  Jtysrra  myoides  m. 

..i— Superficial  layer 
*■■      .'f  rJeep  fascia 

.'-snJ^ns  hypog'osi' 

Widctle  s-te!ro-io,<:toi'! 


j^r  terii^r  bel'y  of  cmo-Hyoid  m. 
i>*.c'no-mastoid  m. 
Incisions  into  carotid  sheath  and  triit  artfoi  shestii 
Ansa  hypjgljsii  ;n  ') 


Fig.  QQS.^Exposure  of  common  carotid  artery.     {Deaver.) 

Step  3. — Note  the  internal  jugular  vein  lying  to  the  outer  side  of,  and  some- 
times overlapping  the  artery.  The  vagus  nerve  lies  behind  and  between  the 
artery  and  vein.  Pass  an  aneurysm  needle  round  the  artery  from  the  outer 
side  inwards.     Beware  of  including  the  vagus  nerve  in  the  ligature. 

LIGATION  BELO.W  THE  OMO-HYOID   MUSCLE 
(B)  Here  the  artery  is  deeply  seated  and  is  difficult  to  expose. 
Step  I. — ^Method  A.^ — ^Kocher's  Incision. 

Method  B. — Make  a  3-inch  incision  having  its  lowest  end  ^'4  inch  external 
to  the  sterno-clavicular  articulation.  This  incision  is  parallel  to  the  sterno- 
mastoid  and  lies  between  its  sternal  and  clavicular  portions. 


838  LIGATION    OF    ARTERIES    IN    CONTINUITY 

Method  C. — Make  a  3-inch  incision  along  the  anterior  margin  of  the  sterno- 
mastoid  from  the  level  of  the  cricoid  cartilage  downwards. 

Step  2. — Method  A. — Incision  (B)  has  been  made.  Divide  the  platysma 
throughout  the  length  of  the  wound.  Penetrate  between  the  two  heads  of  the 
sterno-mastoid,  until  the  internal  jugular  vein  is  seen.  Retract  outwards 
the  vein  and  the  clavicular  portion  of  the  sterno-mastoid.     Retract  inwards  the 


sternal  portion  of  the  sterno-mastoid  and  with  it  the  sterno-hyoid  and  sterno- 
thyroid muscles.  The  vagus  Hes  to  the  inner  side  of  the  vein,  the  carotid  artery 
lies  somewhat  more  internal  and  deeper,  under  the  vein  (Fig.  999). 

Method  B.— Incision  (a)  or  (c)  has  been  made.  Divide  the  deep  fascia 
along  the  anterior  edge  of  the  sterno-mastoid.  Expose  the  sterno-hyoid  and 
sterno-thyroid  muscles.  Retract  the  latter  muscles  inwards  and  the  former 
outwards.  This  exposes  the  carotid  sheath.  The  descendens  noni  nerve  is 
not  seen  on  the  front  of  the  sheath  in  this  region  (Da  Costa).     Feel  the  carotid 


COMMON   CAROTID  839 

tubercle  in  the  upper  part  of  the  wound.     As  the  artery  crosses  the  tubercle  it 
is  a  valuable  landmark. 

During  the  exposure  of  the  carotid  sheath  a  number  of  veins  may  require 
ligation  and  division. 

Step  3. — Open  the  sheath  on  its  inner  side,  clear  the  vessel,  and  pass  the 
aneurysm  needle  around  it  from  without  inwards,  carefully  avoiding  the  vagus 
nerve. 

Remarks. — Ligation  of  the  common  carotid  may  be  indicated  in  cases  of 
wounds,  aneurysm,  malignant  neoplasms  (in  order  to  starve  the  growths),  and 
in  hydrocephalus. 

Cerebral  disturbances  frequently  follow  ligation  of  the  common  carotid. 
These  accidents  have  become  less  frequent.  LeFort's  statistics  show  45  per 
cent.;  Siegrist's  38  per  cent.;  Jordan  accepts  25  per  cent,  as  being  correct;  De 
Fourmestraux  (French  Congress  of  Surg.,  1908)  has  experienced  the  accident  in 
2 1  per  cent,  of  his  personal  cases,  while  in  such  operations  as  for  exophthalmos 
that  surgeon's  death  rate  fell  to  5  or  6  per  cent.  De  Fourmestraux  thinks  the 
cerebral  disturbances  result  from  ascending  thrombosis  due  to  some  trifling 
infection  at  the  point  of  ligation.  Marquis  (Soc.  de  chir.,  March  5,  191 8)  re- 
ported 10  cases  of  traumatic  jugulo-carotid  aneurisms  in  which  he  had  tied  the 
common  or  internal  carotid  20  days  or  more  after  injury  without  any  cerebral 
symptoms  developing  while  in  5  cases  operated  on  earlier  such  symptoms 
developed.  Aumont  (La  Pr.  Med.,  Feb.  10,  1919)  was  compelled  to 
operate  soon  after  injury  in  2  cases  both  of  which  died  but  without  any  cerebral 
complications. 

Such  being  the  case,  the  surgeon  is  always  in  doubt  whether  the  patient  will 
come  out  of  the  anesthesia,  and  if  he  does  whether  he  will  exhibit  hemiplegia  or 
progressive  cerebral  softening.  In  view  of  these  difficulties  Jordan  recommends 
partial  constriction  of  the  artery  for  about  forty-eight  hours  before  definite 
ligation.  From  experiments  Jordan  finds  that  it  is  possible  to  apply  a  tape 
or  coarse  catgut  ligature  around  the  vessel  sufficiently  firmly  to  stop  the  periph- 
eral pulse  but  sufficiently  gently  not  to  injure  the  intima.  This  constriction 
can  be  kept  up  for  two  days  without  coagulation  taking  place,  and  when  the 
constrictor  is  removed  the  circulation  soon  becomes  normal  again.  The  pre- 
liminary tentative  ligation  must  be  accomplished  under  local  anesthesia  to 
permit  of  immediate  observation  of  any  cerebral  symptoms  which  may  develop. 
If  the  constrictor  causes  disturbance  it  may  be  loosened  or  removed.  By 
gradual  increase  of  constriction  it  may  be  possible  to  increase  collateral  circula- 
tion. If  no  objectionable  symptoms  develop,  the  ligation  may  be  made  com- 
plete and  permanent. 

Matas  attains  the  same  ends  by  bending  a  narrow  strip  of  metal  around 
the  vessel  with  pressure  sufficient  to  stop  the  blood  current  but  insufficient  to 
injure  the  vessel  wall.  This  metal  strip  is  buried;  if  no  symptoms  develop  it  is 
left  in  situ;  if  symptoms  develop  the  wound  is  reopened  and  the  metal  removed. 
Hydrocephalic  children  bear  Ugation  of  the  common  carotid  well.  In  these 
cases  both  arteries  must  be  tied,  but  ten  days  must  elapse  between  the  opera- 
tions (Ballance). 

Ransohoff  (''Surg.,  Gyn.,  Obstet.,"  August,  1906)  advocates  ligation  of  the 


840 


LIGATION    OF    ARTERIES    IN    CONTINUITY 


common  carotid,  external  carotid,  and  superior  thyroid  arteries  in  cases  of 
pulsating  exophthalmos. 

Instead  of  permanently  occluding  the  common  carotid,  temporary  occlusion 
may  be  employed  to  pevent  hemorrhage  during  various  operations.  For  this 
purpose  Fowler  threw  a  tape  around  the  vessel,  securing  the  tape  by  forceps, 
while  Crile  successfully  uses  his  special  forceps. 


LIGATION  OF   INTERNAL  JUGULAR   VEIN 

Ligation  of  the  vein  may  be  necessary  in  cases  of  sigmoid  sinus  thrombosis 
The  operation  is  practically  the  same  as  for  ligation  of  the  carotid.  Particular 
care  must  be  exercised  in  passing  the  ligature  around  the  vein,  as  its  walls  are 
very  thin  and  its  size  varies  greatly  during  expiration  and  inspiration. 

LIGATION  OF   THE   EXTERN.AL   CAROTID   ARTERY 

Position  of  patient  as  in  ligation  of  the  common  carotid. 

Method  A. — Step  i. — Make  an  incision  about  2^^  to  3  inches  in  length 
along  the  anterior  margin  of  the  sterno-mastoid.  The  centre  of  the  incision 
must  be  opposite  the  greater  horn  of  the  hyoid  bone.     Divide  the  platysma  and 

Pharyngeal  art. 

Lingual  art. 
Facial  art. 

Hyoglossus 
Digastric 

I    Myo-hyoid 
Temporal  art  ' 

Int.  max.  art.     x^ 
Post,  auric 

Stylo-hyoid 
Digastric 

Occipital  art. 

Int.  car. 

Ext.  car. 
Sup.  thyroid 

Com.  car. 


Omo-hyoid 


Sterno-thyroid 


Fig.  iooo. — (Esinarch.) 

the  deep  fascia  (attached  to  the  sterno-mastoid)  throughout  the  length  of  the 
wound.     Retract  the  sterno-mastoid  outwards. 

Siep  2. — Find  the  posterior  belly  of  the  digastric  muscle  in  the  upper  part  of 
the  wound  (Fig.  1000).  Find  the  hypoglossal  nerve  a  little  below  the  digastric 
(Fig.  1 001).  Retract  these  structures  upwards.  Avoid  injuring  the  facial  and 
superior  thyroid  veins. 


EXTERNAL   CAROTID 


841 


Note  the  tip  of  the  great  cornu  of  the  hyoid  bone  and  expose  the  artery 
opposite  this  guide.  As  the  internal  carotid  has  been  mistaken  for  the  external, 
it  is  very  wise  to  demonstrate  one  of  the  branches  of  the  external  carotid  before 
passing  a  ligature  around  the  vessel. 

Step  3. — Pass  a  ligature  around  the  vessel  from  without  inwards,  avoiding 
the  vein  which  Hes  to  the  outer  side  of,  and  frequently  overlaps  the  vessel,  and 
also  avoiding  the  superior  laryngeal  nerve  which  runs  behind  it. 


J)i^asfric   ///. 
G/ieat  cor/2 u  or  hz/oid  bom. 


3:t.  rarofid  arteri/. 
zBetradi??^  facial ueinic. 

Sup.  tfii/roid  arL 
-^etractin^  stermmastoid m. 

Fig.  iooi. — Exposure  of  right  external  carotid. 

W.  P.  Nicolson  (Surg.,  Gyn.  and  Obst.,  July,  1919)  writes:  "A  skin  incision 
4  inches  in  length  is  usually  advised  but  an  opening  of  from  i  to  ij^^  inches, 
with  its  center  opposite  the  upper  border  of  the  thyroid  cartilage  is  usually 
ample.  The  incision  should  go  through  the  skin  and  platysma  muscle.  After 
the  deep  fascia  has  been  opened,  I  know  of  no  operation  in  which  the  finger  is 
more  useful.  With  the  index-finger  the  way  can  be  rapidly  torn  down  to  the 
vessel,  without  damaging  any  of  the  structures.  We  are  often  told  that  the 
guide  to  the  vessel  is  feeling  the  pulsation  with  the  finger,  but  the  rapid  breath- 
ing of  the  patient  makes  this  very  unreliable.  It  is  a  useful  thing  to  remember 
that  the  common  carotid  always  has  a  bulbous  swelling  just  as  it  bifurcates, 
and  this  I  have  found  a  valuable  guide.  The  vessel  is  recognized  by  its  yellow- 
ish white  color.  I  do  not  find  any  distinct  sheath  at  this  point,  though  we  are 
told  to  pick  it  up  and  open  it.  My  rule  is  to  pick  my  way  down  to  the  bare 
artery  with  a  tissue  forcep  and  the  point  of  the  finger.  .  .  I  take  issue  with 
what  is  usually  described  as  the  point  of  election,  namely,  between  the  facial 
and  lingual  branches.  The  point  of  election  with  me  is  the  immediate  crotch 
of  the  vessel,  for  thus  no  space  is  left  in  which  thrombus  can  form.  I  have 
never  seen  any  allusion  to  the  relation  of  the  anatomy  or  surgery  of  this  vessel 
to  the  dense  connective  tissue,  the  remains  of  the  carotid  gland  which  binds 
the  trunks  together.  At  this  point,  the  space  between  the  vessels  is  simply  an 
indistinct  groove.  The  aneurism  needle  is  passed  from  within  outward,  and 
when  it  comes  against  this  tissue,  it  appears  as  if  coming  directly  through  the 
walls  of  the  artery.  I  rub  the  point  through  with  the  finger  or  some  instrument, 
and  thread  it,  and  withdraw  the  ligature  with  it.  This  seems  to  work  more 
satisfactorily  than  when  it  is  threaded  beforehand. 

"j\  practical  point  of  extreme  value  is  to  have  the  anaesthetist  place  his 


842 


LIGATION    OF    ARTERIES    IN    CONTIN^nTY 


finger  upon  the  temporal  artery,  and  the  operator  either  cross  or  pull  upon 
the  ligature,  to  see  that  it  stops  the  circulation  in  the  temporal.  I  know  this 
is  important,  because  once  when  I  did  not  take  this  precaution.  I  tied  the  in- 
ternal by  mistake. ■■ 

Method  B. — Kocher's  Incision. — Step  i. — Choose  a  point  on  the  anterior 
margin  of  the  sterno-mastoid  muscle,  one  finger's  breadth  below  the  angle  of  the 
jaw.  Make  a  sUghtly  oblique  incision  horizontal  having  its  centre  at  the  above 
point  (Fig.  1002).  After  exposing  the  anterior  edge  of  the  sterno-mastoid  the 
operation  becomes  practically  the  same  as  Method  A. 


acces- 
sory n. 
Atuicttlaris 
magnns  n. 
Ext.  jug.  V. 

Descendeos  noni 

Int.  jugular 
Sterno-mastoid 


Hypoglossal  n 
Gaeater  horn 
hyoid 
Sup.  laryn- 
geal n. 
Ext.  carotid 
Sup.  thyroid  art 


Fig.   1002. — E.xposure  of  external  carotid.     (Kocher. 


Indicatioiis. — (a)  Hemorrhage  from  wounds  of  branches. 

(6)  As  a  preliminary  step  in  the  removal  of  some  tumors,  e.g.,  of  the  retro- 
phar^mgeal  space. 

(c)  Aneurysm.  ^ 

{d)  Occasionally  to  prevent  hemorrhage  from  the  middle  meningeal  artery 
during  operations  on  the  Gasserian  ganglion. 

Remarks. — Hearn  ligates  the  external  carotid  as  a  preliminary  to  excision 
of  the  superior  maxilla  for  malignant  disease,  and  states  that  in  doing  so  he 
exposes  some  enlarged  lymph  nodes  which  would  otherwise  escape  notice. 
Armstrong  ligates  both  external  carotids  while  excising  the  lymphatic  areas 
before  remo\nng  the  cancerous  tongue.  \V.  P.  Nicolson  strongly  recommends 
single  ("if  necessar\-  double)  ligation  immediately  before  undertaking  any  facial 
or  maxillary  operation  which  would  otherwise  be  dangerously  bloody.  He 
especially  favors  ligation  to  control  the  middle  meningeal  artery*  while  removing 
the  Gasserian  ganglion.  Matas  thinks  it  important  to  place  the  ligature  well 
above  the  bifurcation  of  the  common  carotid  to  avoid  the  danger  of  cerebral 
embolism.     Nicolson  takes  exception  to  this. 


LINGUAL    ARTERY  843 

Step  I. — Expose  the  external  carotid  (see  p.  840).  The  internal,  at  its 
origin,  lies  a  little  behind  and  to  the  outer  side  of  the  external  carotid. 

Step  2. — Gently  retract  the  external  carotid  inwards.  Open  the  sheath  of 
the  internal  carotid  immediately  over  the  artery.  Remember  that  the  artery, 
the  internal  jugular  vein  and  the  vagus  occupy  the  same  sheath,  the  vein  being 
external  and  the  nerve  behind  and  between  the  vessels.  Pass  the  aneurysm 
needle  around  the  artery  from  without  inwards. 

Indications. — For  intra-cranial  aneurysm  of  vessels  other  than  the  menin- 
geal. For  hemorrhage,  e.g.,  after  tonsillectomy.  If  the  operation  seems  called 
for  because  of  hemorrhage  after  tonsillectomy,  expose  and  apply  pressure  to  the 
external  carotid — if  this  controls  the  bleeding  it  must  be  from  the  tonsillar 
artery  and  ligation  of  the  internal  carotid  becomes  unjustifiable. 

Lingual  Artery. — The  lingual  artery  arises  from  the  external  carotid  at  the 
level  of  the  great  horn  of  the  hyoid  bone  (Fig.  looo).  After  running  a  curved 
course  it  dips  under  the  hyoglossus  muscle  and  proceeds  forwards  parallel  and 
close  to  the  greater  horn  of  the  hyoid.  It  is  crossed  by  the  digastric  and  stylo- 
hyoid muscles.  The  hypoglossal  nerve  runs  paraUel  to  the  lingual  artery,  but 
is  more  superficial,  being  separated  from  it  by  the  hyoglossus  muscle. 


Hypoglossal  n. 
Mylo-hyoid  m 


Lingual  art. 
Fig.  1003. — ^Ligation  of  left  lingual  artery.     {Esmarch  and  Kowalzig.) 
d.  Digastric.     Oh,  Great  horn  hyoid.     hg,  Hyoglossus.     gl.  Salivary  gland,     st,  Stylohyoid. 


The  Operation. — Step  i. — ^Method  A.— Make  an  incision  parallel  to  and 
about  i^  inches  above  the  great  horn  of  the  hyoid.  Divide  the  skin  and  the 
platysma.  Divide  the  deep  fascia.  Ligate  and  divide  or  retract  any  veins 
which  come  in  the  way. 

Step  2. — Retract  the  submaxillary  gland  upwards  (Fig.  1003).  Expose  the 
posterior  belly  of  the  digastric  under  which  lies  the  hypoglossal  nerve.  The 
nerve  forms  a  good  guide  to  the  hyoglossus  muscle  on  which  it  lies.  The 
lingual  vein  may  lie  either  superficial  to  the  hyoglossus  or  beneath  it  along  with 
the  artery.     Avoid  injury  to  the  nerve  and  vein. 

Step  3. — Carefully  divide  the  hyoglossus  (on  a  director)  between  the  hypo- 
glossal nerve  and  the  great  horn  of  the  hyoid.  This  exposes  the  lingual  artery, 
which  is  accompanied  by  a  vein  or  vena  comites. 

Method  B. — ^Kocher. — Step  i. — Make  an  incision  parallel  to  and  immedi- 
ately above  the  hyoid  bone,  from  the  anterior  edge  of  the  sterno-mastoid  to 
the  body  of  the  hyoid. 

Divide  skin,  platysma,  and  fascia,  as  if  to  lay  bare  the  great  horn  of  the  hyoid. 


844  LIGATION    OF    ARTERIES    IX    CONTINUITY 

The  digastric  and  stylohyoid  muscles  and  the  submaxillary  gland  appear  in  the 
upper  part  of  the  wound. 

Step  2. — ^Let  the  assistant  exercise  vertical  pressure  on  the  great  horn  of  the 
hyoid  on  the  opposite  side  of  the  neck;  this  pushes  the  bone  into  the  wound. 
Seize  the  horn  of  the  hyoid  with  a  hook  and  pull  it  up,  so  that  the  whole  region 
becomes  superficial.  Note  the  fibres  of  the  hyoglossus  muscle  running  upwards 
and  the  hypoglossal  nerve  passing  from  behind  forwards  over  the  muscle. 

Step  3. — With  utmost  care  divide  the  hyoglossus,  transversely,  immediately 
above  the  bulbous  end  of  the  great  horn  of  the  hyoid.     This  exposes  the  artery. 

Indications  for  ligation  of  the  lingual  artery: 

(i)  Preliminary  to  excision  of  the  tongue.  (2)  To  starve  malignant  neo- 
plasms in  territory  supplied  by  the  artery.     (3)  To  stop  hemorrhage. 

Superior  Th5rroid  Artery. — ^Kocher's  Method. — ^Ligation  of  the  superior 
thyroid  artery  is  done  at  the  top  of  the  upper  horn  of  the  thyroid  gland. 

Step  I. — (A)  Make  an  incision  parallel  to  and  immediately  above  the  hyoid 
bone,  from  the  anterior  edge  of  the  sterno-mastoid  to  the  body  of  the  hyoid. 
Divide  the  skin,  platysma,  ^nd  fascia.  Retract  the  lower  edge  of  the  wound 
strongly  downwards. 

(B)  If  the  upper  horn  of  the  thyroid  gland  does  not  extend  far  up  the  neck, 
make  the  incision  ^^  inch  lower,  corresponding  to  the  upper  margin  of  the 
thyroid  cartilage. 

Step  2. — Feel  the  pulsations  of  the  anterior  branch  of  the  artery  on  the 
median-anterior  side  of  the  upper  horn  of  the  thyroid  gland  beside  the  larynx. 
Follow  this  vessel  over  the  apex  of  the  gland  until  the  main  artery  is  reached. 

Step  3. — ^Ligate  the  main  artery. 

The  only  indication  for  ligation  of  the  superior  thyroid  artery  is  hyperthy- 
roidism. C.  H.  Mayo,  Stamm  and  others  prefer  to  ligate  the  upper  pole  of 
the  thyroid  gland,  thus  tying  the  branches  of  the  superior  thyroid  artery  in  a 
mass  ligature. 

LIGATION   SUPERIOR   POLE  OF  THYROID 

If  general  anesthesia  is  to  be  used  administer  morphine  gr.  3^  with  atropine 
gr-  Moo  about  half  an  hour  before  operation. 

Step  I. — Make  a  transverse  incision,  if  possible  in  a  natural  crease,  two  and 
one-half  inches  in  length,  crossing  the  central  part  of  the  thyroid  cartilage. 
The  cut  divides  the  skin  and  platysma  and  gives  access  to  the  gland  on  both 
sides. 

Step  2. — Retract  the  inner  border  of  the  sterno-mastoid  outwards  and  ex- 
pose the  omo-hyoid.  Retract  the  omo-hyoid  upwards  and  inwards.  Under 
the  omo-hyoid  lies  the  upper  pole  of  the  thyroid. 

Step  3. — Pass  a  ligature  (Unen,  silk)  round  the  upper  pole  and  tie  it  (Fig. 
1004).  If  a  vein  is  pierced  by  the  aneurysm  needle  and  causes  bleeding  pull 
upon  the  ligature  and  pass  a  second  ligature  including  more  tissue.  The 
ligature  includes  veins,  arteries,  and  gland  tissue.  There  is  no  danger  of 
injuring  the  recurrent  laryngeal  nerve  (Mayo,  "Annals  of  Surg.,"  Dec,  1909). 

Stamm  and  Jacobson  strongly  recommend  ligation  of  the  upper  pole  in  ex- 


INFERIOR    THYROID 


845 


ophthalmic  goitre  when  more  radical  operations  seem  inadvisable.     The  author 
finds  the  operation  by  no  means  difficult. 

Inferior  Th)a-oid  Artery. — Step  i. — Expose  the  common  carotid  artery  and 
internal  jugular  vein  immediately  below  the  tendon  of  the  omo-hyoid.  (Do 
this  either  through  Kocher's  incision  or  through  an  incision  along  the  inner 
margin  of  the  sterno-mastoid). 


Fig.   1004. — Ligation  of  superior  pole  of  thyroid.     {Mayo,  Annals  of  Surgery.) 


Step  2.- — Gently  retract  outwards  the  carotid  packet  of  vessels  and  nerves. 
Pull  the  tendon  of  the  omo-hyoid  upwards.  Push  the  thyroid  gland  and  the 
trachea  inwards  {i.e.,  towards  the  opposite  side). 

Note  the  transverse  process  of  the  sixth  cervical  vertebra  (carotid  tubercle). 
Opposite  this  fixed  point  the  inferior  thyroid  artery  may  be  seen  appearing  from 
behind  the  common  carotid  at  about  the  same  level  as  the  omo-hyoid  tendon 
crosses  in  front  of  that  vessel. 


846 


LIGATION    OF    ARTERIES    IN    CONTINUITY 


Step  3. — ^I>igale  the  artery  as  far  from  the  thyroid  gland  as  possible  to  avoid 
injury  to  the  recurrent  laryngeal  nerve  which  crosses  the  artery  behind  the  gland. 
Be  careful  not  to  include  in  the  ligation  the  middle  cervical  ganglion  or  the 
recurrent  laryngeal  nerve. 

The  indications  for  ligation  of  the  inferior  thyroid  artery  (and  for  the 
superior  as  well)  are  certain  forms  of  goitre. 

Subclavian  Artery.- — Place  the  patient  on  his  back,  support  the  shoulders 
on  a  pillow  so  that  the  head  may  be  extended  and  turned  to  the  opposite  side. 
Keep  the  arm  well  pulled  downwards  (when  possible  pass  the  arm  behind  the 
back  so  as  to  keep  it  in  proper  position). 

Step  1. — Choose  a  point  one-half  inch  above  and  one  inch  internal  to  the 
middle  of  the  clavicle.  Let  this  point  be  the  centre  of  a  three-inch  incision 
parallel  to  the  clavicle  and  extending  from  the  Trapezius  to  the  sterno-mastoid. 


7   8    9  10 


Fig.  1005. — Exposure  of  subclavian  artery.     (Farabeuf.) 
I.  Ext.   jugular  vein — retracted  outwards.     2.   Arterj'.     3-   First  rib.     4.   Subclav.   vein.     5.  Supra- 
scap.  art.     6.  Stemo-mastoid.     7.  Scalenus  ant.     8.  Transverse  cervical  art.  (post,  scapular).     9.  Brachial 
plexus.     10.  Omo-hyoid. 

In  making  this  incision  be  careful  not  to  injure  the  external  jugular  vein.  Divide 
the  skin  and  the  platysma.  Retract  the  external  jugular  outwards  or,  if  requi- 
site, divide  it  between  two  ligatures  (Fig.  1005).  At  this  stage  difficulties  may  be 
encountered  due  to  the  venous  plexus  formed  by  the  transverse  cervical  and 
suprascapular  veins.  If  these  veins  cannot  be  retracted  out  of  the  way,  they 
must  be  ligated  and  divided.  A  dry  wound  is  essential.  Divide  the  deep  fascia 
throughout  the  extent  of  the  wound. 

Step  2. — Note  the  outer  edge  of  the  scalenus  anticus  muscle.  The  sub- 
clavian vein  lies  in  front  of  the  muscle,  the  subclavian  artery  behind  it  and  at  a 
slightly  higher  level  than  the  vein.  Pass  the  finger  along  the  edge  of  the  muscle 
until  the  scalene  tubercle  on  the  first  rib  is  felt.  The  artery  lies  immediately 
outside  and  behind  the  tubercle.  If  the  omo-hyoid  muscle  is  in  the  way,  retract 
it  upwards. 

Step  3. — The  lowest  cord  of  the  brachial  plexus  lies  immediately  above  the 
artery  and  has  been  mistaken  for  it.  Systematically  expose  this  nerve  cord 
sufficiently  to  permit  of  precise  recognition  (Treves). 

Pass  the  aneurysm  needle  around  the  artery  from  above  downwards  and 
from  behind  forwards,  guiding  the  needle  with  the  finger  and  holding  the  vein 
out  of  harm's  way.     Pull  a  ligature  around  the  vessel  and  tie  it. 

Step  4.- — Close  the  wound. 


SUBCLAVIAN    ARTERY 


847 


Ligation  of  the  third  part  of  the  subclavian  artery  has  alone  been  de- 
scribed here  as  the  other  segments  of  the  vessel  are  unsuitable  for  and  very 
rarely  require  ligation. 

Indications. — Axillary  aneurysm;  axillary  hemorrhage;  wounds;  preliminary 
to  excision  of  the  scapula,  or  of  the  entire  upper  limb,  etc.,  and  as  treatment  for 
innominate  and  aortic  aneurysms. 

Riedel  (" Zentralblatt  fur  Chir.,"  1907,  No.  32)  objects  to  the  classical 
method  of  ligating  the  subclavian  because  the  work  is  not  sufficiently  guided  by 
the  eye.     He  advocates  the  following  method: 

1.  Make  an  incision  parallel  to  the  direction 
of  the  great  vessels  of  the  neck  from  the  level  of 
the  transverse  process  of  the  fifth  cervical 
vertebra  to  the  middle  of  the  clavicle.  Divide 
the  skin  and  platysma. 

2.  Doubly  ligate  and  divide  the  numerous 
veins  which  appear;  also  the  transversalis  coli 
artery.  The  superior  nerve  trunk  soon  appears 
emerging  from  between  the  scalenus  anticus 
and  medius. 

3.  Work  into  the  groove  between  the  scalenus  anticus  and  medius  (distin- 
guished one  from  another  by  the  emerging  nerve  trunks).  Working  downwards, 
expose  the  second  and  third  nerve  trunks,  below  the  last  of  which  lies  the  artery. 
In  spite  of  the  depth  of  the  wound,  it  is  comparatively  easy  to  sufficiently  expose 
the  artery  and  to  ligate  it.  The  whole  operation  should  be  performed  without 
introducing  the  finger  into  the  wound  (Riedel)  unless  gloves  are  worn. 


Fig.  1006. — Exposure  of  axillary 
artery.     {Farabeuf.) 


Fig.  1007. — Exposure  of  axillary  artery.     {Farabeuf.) 
The  retractor  supports  the  ist  landmark,  the  coraco-brachialis  (i)  with  the  musculo-cutaneous  n. 
the  director  supports  the  2nd  landmark,  the  median  n.  (2.,  2').     3  =  the  art.     4  =  int.  cutaneous  n. 
deeply  seated  small  collateral  veins. 


(I"); 
5  = 


Axillary  Artery. — ^Farabeuf' s  Method. — Place  the  patient  on  his  back  at  the 
edge  of  the  table  with  the  arm  at  right  angles  to  the  body.  Do  not  either  flex  or 
extend  the  forearm  fully. 

Step  I. — From  the  apex  of  the  axilla  make  a  three-inch  incision  down  the 
arm,  immediately  behind  the  anterior  wall  of  the  axilla,  along  the  inner  and 
posterior  border  of  the  coraco-brachialis  (Fig.  1006).  As  soon  as  the  skin  is 
divided,  the  posterior  edge  of  the  wound  retracts  and  discovers  the  brachial 
plexus  and  axillary  vein  visible  through  the  aponeurosis  (Farabeuf).     Elevate 


848  LIGATION    OF    ARTERIES    IN    CONTINUITY 

the  pectoralis  major  and  under  it,  i.e.,  anterior  to  the  vessels  and  nerves,  divide 
the  fascia  so  as  to  expose  the  coraco-brachialis  muscle. 

Step  2. — Recognize  the  coraco-brachialis  muscle  (first  guide)  and  free  its 
inner  border  for  a  short  distance.  Relax  the  muscle  by  bringing  the  arm  nearer 
to  the  patient's  side.     Retract  the  muscle  forwards  with  a  blunt  hook. 

Step  3. — With  the  finger  introduced  between  the  coraco-brachialis  and  the 
packet  of  vessels  and  nerves,  push  the  latter  backwards.  Very  slowly  and 
lightly  remove  the  finger.  As  this  is  done  one  cord  escapes  from  the  pocket 
and  slips  forwards  {i.e.,  upwards,  the  patient  lying  on  his  back)  (Fig.  1007). 
The  cord  lies  free;  it  does  not  perforate  the  muscle  as  the  musculocutaneous 
nerve  does;  it  is  the  median  nerve  (second  guide).  Isolate  the  nerve  and 
retract  it  with  the  coraco-brachialis.  The  next  cord  felt  under  the  finger 
is  the  axillary  artery,  readily  recognized  by  touch  and  sight.  In  order  to  be 
sure  of  tying  the  artery  above  where  the  circumflex  branches  oflf,  isolate  the 
vessel  in  the  upper  part  of  the  wound. 

Step  4.' — With  the  finger  push  the  rest  of  the  axillary  vessels  and  nerves 
backwards  (the  median  nerve  is  already  out  of  the  way).  Pass  an  aneurysm 
needle  around  the  artery  from  behind  forwards. 

Brachial  Artery .^ — The  superficial  position  of  the  brachial  artery  is  such  that 
its  ligation  seems  easy,  but  the  reverse  is  the  case.  Numerous  and  rather 
humiliating  errors  have  been  reported  by  good  operators.  The  artery  is  subject 
to  abnormalities,  (a)  The  artery  may  lie  in  front  of  instead  of  behind  the 
median  nerve  (one  out  of  six  cases),  (b)  The  artery  may  divide  high  up  and 
thus  during  the  operation  two  arteries  may  be  met  instead  of  one,  each  or  both 
of  which  may  require  ligation,  (c)  "The  artery  may  be  partially  covered  by  a 
muscular  slip  given  off  from  the  pectoralis  major,  biceps,  coraco-brachialis  or 
brachialis  anticus." 

The  brachial  is  rarely  tied  elsewhere  than  in  the  middle  of  the  arm. 

Step  I. — With  the  forefinger  hold  a  thread  against  the  skin  of  the  deepest 
point  (the  apex)  of  the  axilla.  Hold  the  other  end  of  the  thread  (drawn  tense) 
on  the  mid-point  of  the  fold  of  the  elbow.  The  course  of  the  thread  gives  the 
line  of  the  brachial  artery. 

Step  2. — Along  the  line  of  the  artery,  make  a  2^2  inch  incision  through  the 
skin  on  the  inner  border  of  the  biceps.  Divide  the  fascia  covering  the  muscle, 
thus  exposing  the  muscle  itself. 

Step  3. — Free  the  inner  edge  of  the  muscle  and  very  gently  retract  it  out- 
wards; the  forearm  being  slightly  flexed  to  relax  the  muscle.  This  exposes  the 
median  nerve. 

Step  4. — Mobilize  the  nerve  and  retract  it  outwards  or  inwards  as  may  be 
most  convenient.     This  exposes  the  artery  accompanied  by  its  two  veins. 

Step  5. — Open  the  arterial  sheath.    Ligate. 

Note. — During  the  operation  the  arm  must  be  abducted  and  supported  by 
the  elbow  or  forearm.  The  arm  itself  must  not  be  directly  supported,  as  pres- 
sure on  the  triceps  would  alter  anatomic  relations,  thus  making  exposure  of  the 
artery  difficult. 

Iliac  Arteries. — The  iliac  arteries,  especially  the  internal  vessel,  are  of 
so  much  and  varied  surgical  importance  that  they  deserve  full  consideration. 


ILIAC   ARTERIES 


849 


The  usual  anatomical  works  do  not  cast  much  light  on  the  subject  from  the 
surgeon's  standpoint.  Quenu  and  Duval  ("Revue  de  Chirurgie,"  Nov.,  1898) 
study  the  anatomy  of  the  iliac  arteries  in  a  soul-satisfying  and  practical  manner; 
the  following  paragraphs  are  based  on  their  work. 

The  common  iliac  arteries  bifurcate  at  the  lower  level  of  the  fifth  lumbar 
vertebra,  i.e.,  at  the  sacro-vertebral  angle,  1%  inches  (3.5  c.)  from  the  middle 
line  (Fig.  1008).     Near  their  origin  the  external  and  internal  iliac  arteries  lie 


Fig.  1008. — Exposure  of  iliac  arteries.     {Quenu  and  Duval.) 
M,  median  line;  Hsl,  int.  iliac;  Ur,  ureter;  I.s.i.,  sacro-iliac  joint;  D.S.,  brim  of  pelvis. 


close  together;  at  the  very  brim  of  the  true  pelvis  they  are  hardly  ^  inch  apart. 
The  ureter  crosses  the  external  iliac  artery  slightly  outside  and  above  the  inter- 
nal iliac  at  the  point  of  election  for  ligation  of  the  latter,  i.e.,  a  little  below  the 
brim  of  the  pelvis.  The  ureter  is  fortunately  more  adherent  to  the  peritoneum 
than  to  the  subjacent  structures,  and  hence  is  easily  retracted  along  with  the 
peritoneum.  Such  are  the  relations  of  the  iliac  arteries  near  the  bifurcation  on  the 
right  side;  on  the  left  side  the  surgical  anatomy  may  be  the  same  or  very  different, 
according  to  the  arrangement  of  the  sigmoid  or  pelvic  colon  and  its  meson. 
Let  us  consider  the  sigmoid  as  consisting  of  two  parts,  one  superior  (the 


850  LIGATION    OF    ARTERIES    IN   CONTINUITY 

colonic  sigmoid),  the  other  inferior  (the  rectal  sigmoid).  The  meson  belonging 
to  the  inferior  or  rectal  sigmoid  arises  always  in  the  middle  line  of  the  lumbo- 
sacral region.  The  meson  belonging  to  the  superior  or  colonic  sigmoid  has  no 
fixed  line  of  origin.  Its  lower  part  is  always  attached  along  with  the  meson 
of  the  rectal  sigmoid,  but  its  upper  part  may  be  attached  to  the  parietes  any- 
where between  the  spleen  (foetal  type)  and  the  pelvic  brim  (adult  type). 

The  point  of  junction  of  the  meson  of  the  two  portions  of  sigmoid  constitutes 
the  dome  of  the  intersigmoid  fossa,  and  on  the  floor  of  this  fossa  lie  the  iliac 
vessels  and  the  spot  where  the  internal  iliac  must  be  tied. 

The  length  of  the  sigmoid  varies  greatly  and  with  it  the  length  of  the  meson. 
If  the  sigmoid  is  long,  it  can  be  turned  upwards  with  the  whole  of  its  meson  in 
such  a  manner  that  the  intersigmoid  fossa  becomes  obliterated  and  the  iliac 
bifurcation  is  as  easily  exposed  as  on  the  right  side  of  the  body.  If  the  sigmoid 
is  short  its  meson  is  short  likewise;  by  turning  the  gut  upwards  its  meson 
becomes  folded  on  itself;  it  is  impossible  to  expose  the  point  of  union  of  the  supe- 
rior and  inferior  portions  of  the  meson;  the  intersigmoid  fossa  is  a  true  fossa  or 
tunnel;  it  is  impossible  to  reach  the  bifurcation  of  the  iliac  artery  without  going 
through  the  meso-sigmoid.  This  second  arrangement  of  the  sigmoid  is  the 
rule. 

LIGATION  OF  THE   INTERNAL  ILIAC    ARTERY 

(A)  On  the  Right  Side. — Step  i. — Place  the  patient  in  the  Trendelenburg 
position  (75°). 

Method  A.— Open  the  abdomen  by  a  vertical  incision  either  in  the  middle 
line  or  through  the  rectus  muscle  reaching  from  the  pubis  to  near  the  umbilicus. 
This  more  or  less  median  incision  is  the  best  if  the  vessels  on  both  sides  are  to 
be  tied. 

Method  B. — Make  a  vertical  incision  through  the  skin  and  anterior  layer 
of  the  rectus  sheath  near  the  outer  edge  of  the  rectus.  Either  split  the  rectus 
muscle  or  pull  it  towards  the  middle  line.  Incise  the  posterior  layer  of  rectus 
sheath  and  the  peritoneum  along  a  line  corresponding  to  the  skin  incision. 

Method  C. — Open  the  belly  by  the  gridiron  or  muscle-splitting  method 
devised  by  McBurney  for  appendicectomy. 

Especially  in  fat  patients,  method  A  is  the  best,  as  very  free  access  to  the 
vessels  is  of  great  value. 

Step  2. — Widely  retract  the  edges  of  the  abdominal  wound.  Push  the  small 
intestines  out  of  the  way  and  protect  them  with  pads.  Put  the  index  finger  on 
the  sacro-lumbar  promontory  in  the  middle.  Note  a  point  i^^  inches  (3.5  c.) 
to  the  right  side  at  the  same  level.  At  this  place  a  pulsating  prominence  is 
visible  running  from  above  downwards  and  outwards.  This  pulsating  promi- 
nence consists  of  the  common  and  external  iliac  arteries.  Another  prominence 
(the  ureter)  can  be  seen  crossing  it.  Run  the  finger  down  the  common  iliac 
artery  until  the  bifurcation  is  reached  when  pulsation  will  be  felt  on  both  sides 
of  instead  of  only  under  the  finger. 

Step  3. — Make  an  incision  i3^  inches  long  through  the  parietal  peritoneum, 
1%  inches  to  the  right  of  the  middle  line,  parallel  to  the  iliac  vessels  and  hav-ing 
its  mid-point  opposite  the  lumbo-sacral  prominence.     Elevate  the  edges  of  this 


INTERNAL    ILIAC  •  851 

wound  by  blunt  dissection.  The  ureter  comes  away  with  the  outer  edge  of  the 
wound  and  is  thus  lifted  out  of  harm's  way.  At  the  upper  angle  of  the  perito- 
neal wound  lies  the  common  iliac,  at  the  centre  of  the  wound  lies  the  bifurcation, 
at  the  lower  angle  lie  the  external  and  internal  iliacs,  side  by  side,  still  covered 
by  a  sheath  of  fascia. 

Step  4. — Incise  the  fascial  sheath  secundum  artem;  denude  the  internal  iliac; 
pass  an  aneurysm  needle  from  without  inwards,  closely  hugging  the  artery  so 
as  to  avoid  injury  to  the  external  iliac  vein,  and  apply  a  ligature  %  inch  from  the 
origin  of  the  vessel,  i.e.,  at  a  point  a  very  little  below  the  brim  of  the  true  pelvis. 
Do  not  forget  that  the  internal  iliac  vein  lies  to  the  inner  side  of  the  artery. 

(B)  On  the  Left  Side. — Step  i. — Put  in  Trendelenburg's  position.  Open 
the  abdomen  either  in  the  middle  line  or  on  the  left  side. 

Step  2. — (a)  If  the  sigmoid  is  long  and  provided  with  a  long  meson,  turn 
it  upwards.  This  obliterates  the  intersigmoid  fossa  and  leaves  the  vessels  as 
well  exposed  as  on  the  right  side.  Ligate  the  vessel  in  the  same  manner  as  on 
the  right  side. 


Fig.  1009. — Exposure  of  left  iliac  artery. 


{b)  If  the  sigmoid  is  short  and  has  a  short  meson  it  cannot  be  turned  up  so 
as  to  expose  the  vessels.  Pull  the  sigmoid  downwards  so  as  to  spread  out  its 
meson.  Note  the  position  of  the  mesenteric  vessels  in  the  meson;  they  must 
not  be  injured.  At  a  point  i^  inches  from  the  middle  line  on  a  level  with  the 
lumbo-sacral  prominence  make  a  vertical  incision  through  the  meso-sigmoid, 
carefully  avoiding  injury  to  any  of  its  vessels  (Fig.  1009).  The  middle  of  this 
incision  corresponds  to  the  lumbo-sacral  prominence  and  its  lower  end  must  not 
approach  the  sigmoid  closer  than  i}^  inches,  lest  some  of  the  arterial  loops 
be  damaged.  If  the  meson  is  thick  and  much  infiltrated  with  fat,  it  must  be 
penetrated  slowly  by  blunt  dissection  to  avoid  injuring  the  vessels. 

When  the  meso-sigmoid  is  penetrated  as  described,  the  floor  of  the  sigmoid 
fossa  is  reached  and  the  rest  of  the  operation  becomes  the  same  as  on  the  right 
side,  except  that  the  whole  work  must  be  accomplished  through  the  rent  or  gap 
made  in  the  meso-colon. 


852  LIGATiOX    OF    ARTERIES    IN    CONTINUITY 

LIGATION   OF   COMMON   ILIAC   ARTERY 

Sulzenbacher  (Zentralbl.  fiir  Chir.,  1882,  No.  23)  collected  50  cases  among 
which  there  were  12  operative  successes.  The  operation  is  therefore  justifiable 
in  certain  grave  conditions,  e.g.,  of  pelvic  en  chondroma,  etc.  As  the  common 
iliacs  are  exposed  during  ligation  of  the  internal  iliac  vessels  the  same  method 
may  be  used.  Chalier  and  Murard  (Rev.  de  Chir.,  Feb.,  191 2)  advise  the  fol- 
lowing method  for  ligation  either  of  the  right  or  left  vessel. 

1.  Trendelenburg's  position.  Median  incision  from  just  above  the  umbili- 
cus to  near  the  pubis. 

2.  Usually  the  vessels  can  be  seen  and  felt  so  clearly  through  the  peritoneum 
that  the  rest  of  the  operation  is  easy.  But  (a)  the  transverse  portion  of  the 
duodenum  may  occasionally  lie  so  low  that  it  interferes.  If  this  is  the  case,  a 
cautiously  made  incision  through  the  peritoneum  below  the  duodenum  permits 
its  mobilization  exactly  as  its  descending  portion  may  be  mobilized  in  Finney's 
gastro-duodenostomy  or  Vautrin's  exposure  of  the  retro-duodenal  choledochus; 
{b)  the  mesentery  and  the  pelvic  meso-colon,  both  very  vascular  and  sometimes 
connected  by  a  mesenteric  meso-colic  ligament,  may  interfere.  This  difficulty 
may  be  overcome  as  follows:  Carefully  incise  the  posterior  parietal  peritoneum 
vertically  in  the  middle  line  from  a  point  just  above  the  promontory  of  the  sacrum 
upwards  for  2-3  finger-breadths,  i.e.,  up  to  or  above  the  bifurcation  of  the  aorta. 
Care  is  required  so  as  to  avoid  injuring  the  left  common  iliac  vein  which  crosses 
the  body  of  the  fifth  lumbar  vertebra  obliquely,  lying  in  the  crotch  of  the  bifur- 
cating aorta.  Through  the  peritoneal  wound,  dissecting  with  a  director  and 
blunt  forceps,  one  can  raise  the  peritoneum  to  right  or  left  and  with  it  the  root 
of  the  mesentery  or  of  the  meso-colon  and  so  expose  the  artery  to  be  tied.  In 
this  operation  the  ureter  is  out  of  danger. 

EXTERNAL   ILIAC   ARTERY 

(A)  Transperitoneal  Operation.— The  external  iliac  artery  may  be  exposed 
high  up  by  the  same  method  as  is  described  for  the  internal.  If  it  is  desired 
to  ligate  the  vessel  at  a  lower  level,  it  is  easy  to  expose  it  through  the  abdomen 
and  place  a  ligature  round  it  at  any  level. 

(B)  Extra-peritoneal  Operation.  Cooper's  Method.— 5/c^  i.^From  a 
point  1}^  inches  external  to  the  pubic  spine  and  about  }  2  inch  above  Poupart's 
ligament  make  an  incision  parallel  to  the  ligament  to  a  point  opposite  the 
junction  of  the  middle  and  outer  thirds  of  the  ligament.  Continue  the  incision 
in  a  curve  upwards  to  a  point  one  inch  above  and  internal  to  the  anterior  superior 
spine.  Be  sure  that  the  incision  is  large  enough.  Divide  the  abdominal  wall 
layer  by  layer  until  subperitoneal  fat  is  reached. 

Step  2. — With  fingers  and  gauze  push  the  peritoneum  (unopened)  upwards 
and  inwards  from  the  iliac  vessels.  When  the  vessels  are  exposed  keep  the 
wound  open  by  means  of  a  broad-bladed  retractor.  Trendelenburg's  posture 
is  a  great  aid. 

Step  3. — The  external  iliac  artery  will  be  felt  running  along  the  brim  of 
the  pelvis  near  the  inner  end  of  the  wound.  Open  the  sheath  on  its  outer  side 
to  avoid  the  vein  which  lies  internal  to  the  artery. 


FEMOKAI.    AKTKin  853 

Demonstrate  and  f)ull  aside  the  <i;enito-crural  nerve  which  lies  upon  or  near 
the  artery.     Pass  a  ligature  around  the  vessel  from  the  inner  side.     Tie. 

Slef)  4. — Remove  the  retractor.  Permit  the  peritoneum  to  fall  back  into 
place.     Suture  the  abdominal  wall,  layer  by  layer,  as  in  an  operation  for  hernia. 

The  usual  site  for  ligation  is  about  i3-2  inches  above  Poupart's  ligament. 

As  a  means  of  temporary  hemostasis  a  temporary  ligature  or  tape  or  Crile's 
clamp  may  be  applied  to  any  of  the  iliac  vessels.  This  was  the  means  adopted 
by  Balch  to  control  the  circulation  when  he  performed  reconstructive  aneurys- 
morrhaphy  on  the  external  iliac  artery. 

LIGATION   OF  THE   COMMON   FEMORAL  ARTERY 

The  common  femoral  may  be  ligated: 

(a)  As  a  preliminary  step  in  amputation  of  the  hip. 

(b)  For  hemorrhage  resulting  from  wounds  or  from  disease  in  Scarpa's 
triangle. 

(c)  For  aneurysm  of  the  superficial  femoral  high  up. 

Ligation  of  the  external  iliac  is  usually  preferable  for  many  reasons.  The 
operation  is  rarely  indicated.  The  writer  once  did  it  successfully  for  hemorrhage 
after  a  high  amputation  of  the  thigh  where  the  bleeding-point  could  not  be 
found. 

The  dangers  of  gangrene  are  of  course  great.  In  cases  of  wounds  arterial 
suture  to  a  large  extent  takes  the  place  of  ligation.  The  common  femoral 
varies  in  length,  but  usually  extends  for  about  i3>^2  inches  below  Poupart's 
ligament.  The  line  of  the  femoral  (common  and  superficial)  stretches  from 
a  point  midway  between  the  anterior  superior  iliac  spine  and  the  middle  of 
the  pubis,  to  the  inner  margin  of  the  internal  condyle  of  the  femur  (adductor 
tubercle). 

The  Operation. — Semiflex  the  hip  and  knee.  Abduct  and  rotate  the  limb 
somewhat  outwards.  Locate  the  artery  by  means  of  its  line  and  by  palpation. 
From  a  point  one  finger's  breadth  above  Poupart's  ligament  make  a  23^^  inch 
incision  downwards  along  the  line  of  the  artery.  Divide  the  skin  and  superficial 
fascia.  Retract  or  remove  any  glands,  retract  or  doubly  ligate  and  divide  any 
veins  which  may  overlie  the  vessel.  Feel  for  the  artery  just  below  Poupart's 
ligament  and  divide  the  deep  fascia  over  it.  Avoid  injuring  the  crural  branch 
of  the  genito-crural  nerve  which  lies  over  the  artery.  The  femoral  vein  being 
on  the  inner  side  of  the  artery,  pass  the  ligature  from  within  outwards.  Place 
the  ligature  as  remote  as  possible  from  any  branches  of  the  artery. 

Ligation  of  the  Superficial  Femoral  at  the  Site  of  Election — Apex  of  Scarpa's 

Triangle 

The  operation  may  be  performed:  {a)  for  aneurysm  low  down  on  the  artery; 
(b)  for  hemorrhage  which  cannot  be  treated  by  more  direct  means;  (c)  for  ele- 
phantiasis.    The  value  of  the  operation  in  elephantiasis  is  very  doubtful. 

The  Operation. — Place  the  limb  as  for  ligation  of  the  common  femoral. 
The  line  of  the  artery  is  the  same  as  that  of  the  common.     From  a  point  about 


854  LIGATION    OF    ARTERIES    IN    CONTINUITY 

2\^  inches  below  Poupart's  ligament  make  a  three-inch  incision  downwards 
along  the  line  of  the  artery.  Divide  the  skin  and  superficial  fascia.  Retract 
and  divide,  between  ligatures,  any  superficial  veins  which  may  be  in  the  way. 
Split  the  deep  fascia  the  whole  length  of  the  wound.  Note  the  sartorfus  crossing 
the  lower  part  of  the  wound  and  retract  it  outwards.  Find  the  artery  by  palpa- 
tion. The  long  saphenous  and  the  nerve  to  the  vastus  internus  are  in  contact 
with  the  artery;  avoid  them.  Open  the  sheath  of  the  artery  on  its  outer  side. 
The  vein  lies  to  the  inner  side  of,  and  behind  the  artery,  therefore  pass  the 
aneurysm  needle  from  within  outwards  and,  as  the  vein  has  often  been  damaged 
during  this  step,  be  most  careful  to  hug  the  artery  with  the  point  of  the 
instrument. 

Jacobson  advises,  when  the  vein  is  injured,  to  make  pressure  on  the  vein  at 
the  lower  angle  of  the  wound  and  then  to  ligate  the  artery  at  a  point  either 
above  or  below  the  site  originally  intended,  but  by  no  means  to  persist  in 
attempting  to  finish  the  ligation  where  the  accident  occurred. 

Exposure  of  femoral  vessels  in  Hunter's  canal  and  incidentally  in  the 
upper  part  of  the  popliteal  space. 

Place  the  patient  on  his  back.  Flex  hip  and  knee.  Abduct  the  thigh  and 
rotate  it  outwards  as  much  as  possible.  Let  the  surgeon  stand  facing  the  inner 
aspect  of  the  thigh. 

Step  I. — Note  the  prominent  cord  formed  by  the  tense  adductor  magnus. 
Make  an  incision  along  the  adductor  magnus  from  its  insertion  upwards  for 
about  6  inches.  In  the  upper  part  of  the  wound  note  the  Sartorius  and  retract 
it  backwards  after  mobiUzing  it.  With  finger  and  gauze  clear  away  fat  and 
areolar  tissue  from  both  the  anterior  and  posterior  surfaces  of  the  adductor 
magnus. 

Step  2. — The  roof  of  Hunter's  canal  now  lies  exposed.  Carefully  divide  it. 
The  various  vessels  and  especially  the  internal  saphenous  nerve,  which  perforate 
the  roof  of  the  canal  are  easily  seen  and  avoided.  The  canal  being  thus  exposed 
freely  and  its  walls  suitably  retracted,  the  vessels  are  accessible  for  ligation  or 
for  conservative  treatment. 

Step  3. — As  soon  as  the  retractors  are  removed  the  deep  wound  closes  natu- 
rally.    Suture  of  the  skin  is  all  that  is  necessary. 

Ligation  of  Anterior  Tibial  Artery. — Fiotte  and  Delmas  (Decouverte  des 
Vaisseaux  Profond.  Masson  &  Cie,  191 7),  method  is  easier  and  gives  freer 
access  than  does  the  classical  operation  and  this  is  of  considerable  importance  as 
in  cases  of  hematomas  resulting  from  wounds  one  does  not  know  where  the 
wound  in  the  vessel  is  situated  or  even  whether  the  artery  has  escaped  while  the 
vein  has  been  injured. 

In  the  middle  third  of  the  leg  note  the  crest  of  the  tibia  and  by  palpation 
recognize  the  tibialis  anticus  muscle.  Immediately  external  to  the  muscle  there 
is  a  depression  separating  it  from  the  extensor  longus  digitorum.  Mark  a  point 
in  this  depression  a  little  below  the  middle  of  the  leg. 

Make  a  mark  in  the  depression  in  front  of  the  head  of  the  fibula.  Join  these 
two  marks  by  an  incision  penetrating  the  skin  (Fig.  loio).  The  incision  will  be 
about  5?. 2  inches  long  and  must  be  continued  downwards  until  the  separation 
between   the  tibialis  anticus  and  extensor  longus  muscles  is  unmistakable. 


TIBIAL    ARTERIES 


855 


Make  a  longitudinal  incision  through  the  fascia  covering  the  intermuscular 
space.  Separate  the  two  muscles  thus  exposing  the  packet  of  vessels  and  the 
nerve.  Using  the  finger  pushed  from  below  upwards  in  front  of  the  vessels,  as 
a  guide  it  is  easy  to  separate  the  muscles  and  divide  the  fascia  until  the  most 
free  exposure  is  obtained  (Fig.  ion).  When  the  wound  is  closed  no  disability 
results. 

Ligation  of  the  Posterior  Tibial  and  the  Peroneal  A  rteries  at  the  Level  of  the 
Calf. — The  classical  method  of  exposing  the  posterior  tibial  artery  is  by  an 
incision  parallel  to  and  a  short  distance  behind  the  inner  border  of  the  tibia. 
After  division  of  the  deep  fascia,  the  inner  head  of  the  gastrocnemius  is  pulled 
backwards  to  expose  the  soleus.  The  soleus  is  now  divided  fully  half  an  inch 
from  the  tibia  and  the  intermuscular  septum  is  exposed  stretching  from  tibia 
to  fibula  and  covering  the  deep  flexor  muscles.  In  this  intermuscular  septum 
lies  the  artery  with  its  venae  comites.  A  more  or  less  similar  operation  with 
external  incision  serves  for  exposure  of  the  peroneal  artery. 


Fig. 


loio. — {Fiotte  and 
Delmas.) 


Fig. 


loii. — {Fiolle  and 
Delmas.) 


Fig. 


1012. — {Fiotte  and 
Delmas.) 


When  the  soleus  is  penetrated  recognition  of  the  septum  is  difficult  especially 
if  the  tissues  are  badly  infiltrated  with  blood.  For  precise  work  a  better  ex- 
posure and  especially  simultaneous  exposure  of  both  the  tibial  and  peroneal 
vessels  and  of  the  posterior  tibial  nerve  are  desirable. 

Fiotte  and  Delmas  Method.- — -Place  the  patient  in  the  prone  position  with  the 
dorsum  of  the  foot  resting  on  the  table,  thus  relaxing  the  tendo  Achilles. 

Step  I. — From  a  point  two  finger  breadths  below  the  flexion  fold  of  the  knee 
make  an  incision  downwards  between  the  two  heads  of  the  gastrocnemii. 
Continue  the  cut  downwards  to  the  bottom  of  the  belly  of  the  muscle  and  then 
direct  it  medianwards  to  end  midway  between  the  tendo  Achilles  and  the  internal 
malleolus  about  2  cm.  (%  inch)  above  the  insertion  of  the  tendon,  Fig.  1012. 
Retract  the  external  saphenous  vein  and  nerve  outwards.  The  nerve  is  a 
good  guide  to  the  interstice  between  the  two  heads  of  the  gastrocnemius. 

Step  2. — At  the  lower  end  of  the  incision  divide  the  fascia  along  the  inner 
side  of  the  tendo  Achilles  and  through  this  button  hole  introduce  the  finger  as 


856 


OPERATION'S    OX    VEIN'S 


if  to  hook  up  the  tendon.  Push  the  linger  upwards  in  the  loose  connective 
tissue  anterior  to  the  tendon  until  it  lies  anterior  to  the  soleus,  i.e.,  it  is  inevitably 
in  the  intermusclar  septum  containing  the  vessels  (Fig.  1013). 

Step.  3.— Keeping  the  linger  in  front  of  the  soleus  as  a  guide,  separate  the 
two  heads  of  the  gastrocnemius  and  incise  the  soleus  vertically  in  the  middle 
line  until  the  guiding  finger  is  reached  (Fig.  1013).  Enlarge  the  wound  in  the 
soleus  as  much  as  necessary.  Retract  the  edges  of  the  wound  in  the  muscle  and 
withdraw  the  guiding  finger. 


Fig.  1013. — {FioUc  and  Delmas.) 


Fig.  1014. — {Fiolte  and  DeUnas.) 


Under  a  thin  layer  of  fascia  it  is  easy  to  see  the  posterior  tibial  nerve  which 
is  white  and  of  good  size,  with  the  tibial  vessels  internal  and  close  to  it. 
The  peroneal  vessel  lies  about  3  2  ^^ch  external  to  the  nerve. 

It  is  easy  to  expose  about  3  to  4  inches  of  the  vessels  and  nerve  by  the  above 
method  (Fig.  1014). 

Step  4. — Close  the  deep  wound  with  buried  sutures.  Close  the  skin  wound. 
If  drainage  is  required  a  tube  may  be  laid  in  the  tunnel  formed  by  the  finger 
in  front  of  the  tendo  Achilles. 


CHAPTER  LXIV 


OPERATIONS  ON  VEINS 

Most  of  the  operations  on  veins  are  so  similar  to  those  on  arteries  that  no 
special  description  of  them  is  necessary;  a  few,  how^ever,  demand  more  particular 
consideration. 

WOUNDS   IN  VEINS 

When  a  small  vein  is  wounded,  the  best  treatment  is,  of  course,  to  stop  the 
bleeding  by  the  pressure  of  a  com.press  or  forceps  or  by  the  application  of  a 
ligature.  When  a  larger  vein  is  completely  divided,  the  same  treatment  is 
proper.  Occasionally  a  vein  is  wounded  in  such  a  location  that  it  is  impossible 
to  apply  a  ligature;  in  this  case  the  bleeding  may  be  stanched  by  packing  the 


WOUNDS    OF   VEINS  857 

wound  with  gauze,  or  a  forceps  be  applied  and  left  in  place  for  from  twenty- 
four  to  forty-eight  hours  or  longer.  During  operation  in  various  localities, 
notably  the  neck  and  axilla,  a  large  vein  may  easily  be  wounded  by  accident 
or  design.  The  wound  may  be  picked  up  in  the  jaws  of  an  artery  forceps  and 
a  ligature  applied  laterally,  so  that  the  wound  is  closed,  while  circulation  con- 
tinues in  the  vein  whose  calibre  is  of  course  considerably  diminished. 

Schede  improved  on  the  above  treatment  by  closing  the  wound  with  sutures. 
He  used  thin  catgut  introduced  by  fine  Hagedorn  or,  better,  rounded  or  intes- 
tinal needles.  The  swelling  of  the  catgut  after  it  has  been  introduced  closes 
the  needle  punctures  and  prevents  escape  of  blood  through  them. 

The  method  of  suture  employed  is  the  ordinary  continuous  stitch,  including 
in  its  bite  all  the  coats  of  the  vein.  Bleeding  is  prevented  during  suturing  by 
finger  or  sponge  pressure  applied  above  and  below  the  wound,  or  by  forceps 
attached  close  to  the  wound  itself.  In  the  hand  of  Schede,  venous  suture  has 
never  failed  in  giving  satisfaction. 

In  removing  a  cancerous  kidney  Schede  threw  an  elastic  ligature  around  the 
pedicle  and  included  a  portion  of  the  vena  cava  in  the  ligature.  On  examination 
of  the  pedicle  it  was  found  that  the  walls  of  all  the  vessels  were  diseased  and 
individual  ligation  was  impossible.  It  was  impossible  to  leave  the  elastic 
constrictor  in  situ.  "Under  careful  compression  of  the  vena  cava,  above  and 
below,  by  means  of  spongesticks,  the  ligature  was  removed.  Violent  hemor- 
rhage took  place  from  the  opposite  renal  vein.  The  wound  in  the  vena  cava  was 
quickly  closed  by  two  artery  forceps  so  placed  that  their  blades  surrounded  the 
wound  by  converging  from  above  and  below,  their  points  meeting  near  the  middle 
of  the  vena  cava.  Bleeding  ceased  and  the  remnants  of  the  tumor  could  be 
removed.  A  hole  about  ^  inch  in  length  was  found  in  the  vena  cava.  This 
was  sutured.  The  forceps  were  removed.  There  was  no  bleeding."  The 
patient  lived  for  thirteen  days.  Postmortem,  narrowing  of  the  vena  cava  was 
found  at  the  site  of  operation,  the  wound  was  solidly  healed,  the  intima  was 
smooth,  and  there  was  not  the  slightest  trace  of  thrombosis.  Damar  Harrison 
has  has  a  similar  experience. 

J.  Petit  (ref.  Journ.  de  Chir.,  Aug.,  191 2)  finds  that  50  per  cent,  of  the  pub- 
lished cases  of  wounds  of  the  inferior  vena  cava  occurred  during  operations  for 
renal  cancer.  Treatment  by  permanent  tamponade  need  not  be  considered  as 
its  results  are  deplorable.  Forcipressure  by  leaving  hemostats  in  situ  gave 
2  recoveries  in  7  cases;  lateral  ligature  2  recoveries  in  3  cases.  This  method 
"should  be  reserved  for  cases  of  tearing  of  the  renal  vein  when  a  short  pedicle 
exists  convenient  for  ligation."  In  14  cases  of  complete  ligation  of  the  vena 
cava  there  were  6  deaths.  After  ligation  "the  circulation  in  the  lower  limbs 
is  rarely  troubled,  in  but  3  cases  was  there  oedema  and  that  soon  disappeared 
in  two  of  them.  Ligation  then  may  be  employed  in  wounds  situated  below  the 
renal  vein."  Lateral  suture  is  the  treatment  of  choice;  in  19  cases  of  lateral 
suture  there  were  only  2  deaths.  When  the  lesion  is  above  the  renal  vein,  lateral 
suture  should  be  attempted  in  every  case.  Below  the  renal  vein  lateral  suture 
should  be  done  except  when  the  operation  has  been  too  prolonged;  when  the 
wound  is  infected  or  when  the  wound  is  irregular  and  transverse. 

Eloesser  (Jour.  A.  M.  A.,  Jan.  30,  191 5)  in  excising  a  cancer  had  to  cut  away 


858  OPERATIONS    ON   VEINS 

part  of  the  femoral  vein.  The  patient  was  78  years  of  age,  the  veins  were 
thick  and  sclerotic.  Hemorrhage  was  temporarily  stopped  by  pressure.  "A 
bit  of  fatty  tissue  removed  from  the  wound  in  the  groin  was  tacked  over  the 
opening  in  the  vein  by  a  fine  silk  stitch  which  did  not  pierce  the  vein  itself,  but 
passed  through  the  adjacent  tissue  and  was  crossed  over  the  graft.  On  re- 
leasing the  pressure  there  was  no  further  bleeding.'"  Death  ensued  in  12  days 
from  senile  delirium.  The  graft  had  united,  was  not  necrotic  and  there  was 
no  clotting  of  blood  in  the  vein. 

INFUSIONS  AND  TRANSFUSIONS 

Since  the  popularization  of  intravenous  medication  and  especially  since  the 
wide  spread  use  of  Salvarsan  or  its  equivalents,  the  operation  of  intravenous 
injection  of  salt  solution  and  of  blood  whether  'whole'  or  citrated,  has  become 
almost  a  medical,  rather  than  a  surgical  operation,  physicians  having  more 
opportunity  than  surgeons  to  become  skilled  in  the  introduction  of  cannulae 
into  veins.  When  the  veins  are  small  and  much  collapsed  exposure  by  incision 
is  still  necessary.  During  the  Great  War  the  treatment  of  shock  and  the  result 
of  hemorrhage  was  relegated  in  the  A.  E.  F.  to  teams,  each  consisting  of  one 
physician,  one  nurse  and  one  orderly. 

Apart  from  the  transfusion  of  blood  in  pernicious  anemia,  infusions 
and  transfusions  are  mainly  indicated  for  the  treatment  of  shock  and  hemor- 
rhage. They  are  valuable  also  as  prophylactic  measures  before  and  after 
severe  operations.  They  have  their  use  in  the  treatment  of  stubborn  sepsis. 
In  some  cases  of  hemorrhage  without  demonstrable  cause,  blood  from  another 
suitable  individual  may  not  only  replace  that  lost,  but  may  add  the  constituents 
necessary  for  the  prevention  of  further  bleeding. 

In  severe  wounds  it  is  practically  impossible  to  separate  the  manifestations 
of  shock  and  hemorrhage.  A  patient  suffering  from  hemorrhage  may  require 
restoration  of  (a)  the  volume  of  the  circulating  medium,  (6)  the  oxygen  carrying 
agent,  (c)  both  the  volume  and  the  oxygen  carrying  agents. 

To  restore  volume,  normal  salt  solution  is  excellent  but  unfortunately  it 
often  soon  leaves  the  vessels  and  passes  into  the  serous  cavities,  the  intestines 
or  is  excreted  in  the  urine.  To  overcome  this  fault  gum  acacia  has  often  been 
added  to  the  salt  solution  but  clinical  experience  has  shown  this  to  be  far  from 
without  danger  and  the  results  have  not  met  the  claims  made  for  it  originally  by 
Bayliss,  Cannon  and  others.  With  all  its  drawbacks  infusion  of  salt  solution 
remains  the  best  means  for  increasing  volume  of  circulating  medium.  Water 
by  mouth,  rectum  or  under  the  skin  (preferably  by  mouth)  must  be  used  to 
keep  up  the  volume  as  intravenous  infusion  is  only  a  means  to  temporarily  aid 
the  patient. 

Transfusion  of  blood  is  supreme  in  providing  oxygen  carrying  agents  but 
it  also  must  be  aided  by  the  routine  administration  of  water,  and  when  volume 
is  too  scanty  by  infusion  of  salt  solution. 

Methods  for  Estimating  the  Volume  of  the  Blood  and  Its  Hemoglobin  Content.— 
Determine  the  hemoglobin  of  blood  drawn  preferably  from  a  vein  in  the  arm. 
Infuse  500  c.c.  of  salt  solution  into  a  vein.  Promptly  determine  the  hemoglobin 
of  the  now  diluted  blood.     If  the  patient's  hemoglobin  was  80  per  cent,  be- 


ROGER   LEE   ON   TRANSFUSION  859 

fore  the  infusion  of  500  c.c.  of  salt  solution  and  if  after  the  infusion  it  was 
10  per  cent,  less,  then  10  :  80  ::  500  :  x  or  the  blood  volume,  i.e.,  4000  c.c.  after 
the  infusion  or  3500  c.c.  before  the  infusion.  Assuming  that  the  normal  blood 
volume  is  between  5000  and  6000  c.c.  according  to  the  size  of  the  individual  the 
loss  in  volume  is  easily  apparent  and  one  can  estimate  the  absolute  hemoglobin 
in  terms  of  percentage  (Roger  I.  Lee). 

These  data  determine  whether  the  patient  requires  increase  in  blood  volume, 
increase  in  the  oxygen  carrying  constituent  or  increase  in  both.  Roger  I.  Lee 
writes  (Am.  Jour.  Med.  Sc,  Oct.,  1919)  "theoretically,  at  least,  the  percentage  of 
total  hemoglobin  when  subtracted  from  100  gives  the  percentage  of  blood  loss. 
For  example,  a  man  presents  a  blood-volume  of  4500  c.c.  against  his  estimated 
normal  of  6000  c.c,  or  75  per  cent.  His  relative  hemoglobin  is  80  per  cent. 
His  actual  total  hemoglobin  is  60  per  cent.  Presumably  he  has  lost  40  per 
cent,  of  his  blood  or  2400  c.c.  However,  he  has  replaced  by  fluid  either  from 
his  tissues  or  his  fluid  intake  or  both  900  c.c,  as  his  blood-volume  deficiency 
is  only  1500  c.c.  We  assume  that  it  is  the  900  c.c.  of  fluid  addition  to  his  de- 
pleted blood-volume  which  has  diluted  his  hemoglobin  from  100  to  Soper  cent. 
Of  course,  this  argument  presupposed  that  the  man  originally  had  both  a  nor- 
mal blood-volume  and  normal  hemoglobin.  In  general  the  evidence  indicates 
that  these  presuppositions  are  reasonably  sound. 

In  some  instances  these  losses  represented  well  over  half  the  total  amount 
of  blood.  In  those  cases  we  early  came  to  recognize  a  very  important  fact. 
If  the  blood-volume  was  not  being  restored  at  least  to  an  appreciable  extent 
the  prognosis  was  very  grave,  irrespective  of  treatment.  In  other  words,  when 
natural  forces  tended  to  restore  in  its  normal  fashion  the  blood-volume  the 
prognosis  was  relatively  good.  We  came  to  recognize  the  fact  that,  contrary 
to  the  usual  off-hand  snap  judgment,  but  strictly  in  accord  with  logical  reason- 
ing, if  a  patient  presented  himself  at  the  end  of  twenty-four  hours  or  more  with 
a  relatively  low  hemoglobin,  say  of  60  to  80  per  cent.,  that  patient  was  in  much 
better  condition  than  one  who  presented  himself  with  a  hemoglobin  of  over 
100  per  cent.,  or  the  well  known  phenomenon  of  blood  concentration  in  shock. 
In  the  most  severe  cases  we  found  an  astonishingly  low  blood-volume,  some- 
times under  30  per  cent,  of  normal  and  an  absolute  hemoglobin  of  under  20 
per  cent.  It  may  be  repeated  parenthetically  here  that  in  such  cases  the  rela- 
tive hemoglobin  might  be  normal.  Such  cases  in  our  experience,  unless  due 
to  very  recent  large  hemorrhage,  and  unless  immediately  corrected  by  large 
transfusions,  were  fatal.  It  became  clear  that,  as  had  been  observed  clinically, 
there  was  a  considerable  group  of  cases  of  hemorrhage  and  shock  in  which,  on 
account  of  the  severity  of  the  condition,  little  could  be  expected  of  any  remedial 
measures.  Another  not  inconsiderable  group  was  made  up  of  those  cases  who 
had  no  tremendous  blood-loss  but  who  had  a  blood-volume  ranging  around 
60  per  cent.  In  those  cases  the  execution  of  the  obvious  indication  of  partially 
restoring  the  blood-volume  by  infusion  was  followed  by  elevation  of  the  blood- 
pressure  and  of  the  apparent  restoration  of  the  patient  to  a  condition  of  relative 
well  being. 

Perhaps  the  most  interesting  group  of  patients  was  the  intermediate  group 
between  the  two  above  groups.     In  this  group  the  indication  was  for  both  the 


86o  OPERATIONS    ON   VEINS 

restoration  of  blood-volume  and  of  the  oxygen-carrying  constituent.  In  some 
of  these  cases  simple  transfusion  was  enough.  Other  cases  required  both 
transfusion  and  infusion.  In  some  cases  within  a  relatively  short  time  over 
looo  c.c.  of  blood  and  in  addition  over  looo  c.c.  of  fluid  were  administered." 

Infusion  of  Salt  Solution. — In  an  autoclave  sterilize  a  0.9  per  cent,  solution 
of  common  salt  in  distilled  water  for  one  hour  at  15  lb,  pressure. 

A  rough  and  ready  means  of  preparing  the  solution  is  to  add  a  heaping  tea- 
spoonful  of  salt  to  one  pint  of  water  and  to  boil  the  solution.  The  water  must 
be  free  from  floating  particles.  As  some  bacteria  such  as  bacillus  capstdatus 
aerogenes,  are  very  resistant  to  boiling,  it  is  safer  to  use  the  autoclave. 

All  the  apparatus  required  for  infusion  is  a  glass  funnel,  a  few  feet  of  rubber 
tubing  and  an  aspirating  needle.  A  salvarsan  outfit  is  excellent.  All  these 
are  easily  sterilized  by  boiling. 

Apply  a  bandage  around  the  arm  of  the  patient  sufficiently  tightly  to  cause 
the  veins  at  the  front  of  the  elbow  to  become  prominent.  Sterilize  the  skin 
with  tincture  of  iodine.  Fill  the  funnel  with  salt  solution  at  a  temperature  of 
about  io5°F.  Introduce  the  cannula  very  obliquely  into  the  chosen  vein  with 
the  point  of  the  cannula  directed  towards  the  heart.  Let  a  little  of  the  solution 
flow  out  of  the  tube  to  make  sure  there  is  no  air  in  it. 

As  soon  as  blood  flows  from  the  cannula  connect  the  rubber  tube  to  it  and 
permit  the  solution  to  flow.  Slowly  remove  the  bandage  compressing  the  arm. 
Elevate  the  funnel  and  keep  it  well  filled  with  the  warm  salt  solution.  Watch 
the  patient's  respiration  and  heart  action.  Any  sign  of  pulmonary  oedema  or 
cardiac  embarrassment  calls  for  immediate  stoppage  of  the  infusion. 

If  the  vein  is  so  collapsed  that  insertion  of  the  cannula  is  difficult  or  impossi- 
ble, expose  it  by  incision  and  introduce  the  cannula  into  it  directly. 

TRANSFUSION  OF  BLOOD 

The.  Donor. — ^In  the  A.  E.  F.  convalescent  patients  acted  as  donors.  The 
donor  ought  to  be  in  good  physical  condition  and  be  free  from  any  communicable 
disease.-  Unless  time  is  too  precious  the  Wassermann  test  should  be  made. 
The  blood  of  the  donor  must  be  compatible  as  regards  hemolysis  with  that  of 
the  recipient.  Every  individual  may  be  classified  in  one  of  four  groups  accord- 
ing to  the  agglutinative  reaction  of  their  serum  and  corpuscles  with  the  sera 
and  corpuscles  of  individuals  of  the  three  other  groups.  Hemolysis  never 
occurs  when  agglutination  is  absent. 

The  following  table  shows  the  relation  of  the  four  grou])s  with  respect  to 
agglutination. 

Scrum 


cells  ■ 


1... 
II.. 
III. 
IV. 


I 

11 

III 

IV 

0 

+ 

+ 

+ 

0 

0 

+ 

+ 

+  =  agglutinalioa 

0 

+ 

0 

+ 

—  =  no  agglutination 

In  group  I  it  will  be  noticed  that  the  serum  agglutinates  no  corpuscles  but  that  its  cor- 
puscles are  agglutinated  by  the  sera  of  each  of  the  other  groups.     Thus  members  of  group  I 


TESTS    FOR    AGO  I. ITI  NATIONS  86 1 

may  be  transfused  from  any  other  group,  tliey  are  "uni\ersal  rciipients  while  members  of 
group  IV  are  universal  donors." 

If  recipient  is  in  Group  I  donor  may  be  selected  from  groups  I,  II,  III,  IV. 

If  recipient  is  in  Group  II  donor  may  be  selected  from  groups  II-IV. 

If  recipient  is  in  Group  III  donor  may  be  selected  from  groups  III-IV. 

If  recipient  is  in  Group  IV  donor  must  be  selected  from  group  IV, 

"Mctiiod  of  determining  Blood  Groups. 

In  order  to  determine  the  group  of  an  individual,  it  is  sufficient  to  test  his  corpuscles  against 
known  sera  of  Groups  II  and  III.  This  is  readily  accomplished  by  a  microscopic  test  de- 
scribed by  Vincent,  which,  in  addition  to  the  two  known  sera,  requires  only  a  glass  slide,  a 
needle,  and  two  small  glass  rods.  (Citrated  sera  for  this  test  are  furnished  by  the  Division 
of  Laboratories.) 

The  test  is  prepared  as  follows: 

Place  a  drop  of  Group  II  serum  on  the  left  half  of  a  glass  slide  (slide  need  not  be  sterile, 
but  should  be  clean  and  dry)  and  a  drop  of  Group  III  serum  on  the  right  half  of  the  slide. 
Puncture  the  ear  or  finger  of  the  individual  to  be  tested,  and  transfer  in  turn  to  each  of  the 
sera,  about  }i  of  a  droj)  of  blood,  on  the  end  of  the  glass  rod,  mixing  the  blood  intimately  with 
the  serum.  In  making  the  test,  care  should  be  taken  to  transfer  the  blood  before  coagulation 
has  commenced,  and  also  to  avoid  mixing  the  two  sera.  A  separate  glass  rod  should  be  used 
for  each  transfer.     Agitation  of  the  slide  accelerates  the  appearance  of  an  agglutination. 

The  red  cells  make  a  uniform  suspension  in  the  citrated  serum.  If  there  is  no  agglutination 
and  the  test  is  negative,  this  suspension  persists.  If  the  test  is  positive  and  agglutination  takes 
place,  it  usually  appears  in  less  than  a  minute  in  the  form  of  masses  of  agglutinated  cells,  easily 
discernible  to  the  naked  eye.  In  the  rare  instances  in  which  the  reaction  is  questionable, 
the  donor  should  not  be  used. 

Rarelj'  there  is  a  tendency  to  rouleaux  formation  which  may  be  confusing.  Rouleaux 
formation  appears  more  slowly  than  agglutination,  and,  contrary  to  agglutination,  is  dissi- 
pated if  the  rouleaux  are  broken  up  by  stirring  the  serum.  (Report  on  Transfusion  of  Blood 
for  the  recentl}'-  wounded  in  the  U.  S.  Army.     Pubhshed  by  Am.  Red  Cross.     France.) 

The  formal  grouping  of  donors  is  convenient  and  important  when  it  is 
desired  or  necessary  to  keep  a  roster  of  such  but  the  whole  test  can  be  made 
less  formally  as  described  by  Fred  H.  Clark. 

"First  sterilize  the  arm  of  the  patient  with  alcohol,  ether  and  iodine  and  into  a  sterile 
centrifuge  tube  containing  a  small  amount  of  i  per  cent,  sodium  citrate  solution  draw  i  c.c. 
of  blood,  then  into  a  dry  centrifuge  tube  draw  3  or  4  c.c.  of  blood  from  the  same  needle.  Cen- 
trifuge the  citrated  tube  until  the  blood  is  thrown  down,  pipette  ofif  the  supernatant  fluid  and 
wash  the  sediment  with  normal  saline;  now  centrifuge  this  tube  a  second  time  and  pipette  off 
the  saline  and  then  make  of  this  sediment  a  10  per  cent,  emulsion  by  adding  normal  saline. 

Centrifuge  the  tube  containing  the  3  or  4  c.c.  of  pure  blood  until  clot  separates  from  serum 
and  pipette  off  serum  from  above  clot.  Now  carry  out  the  same  procedure  as  above  for  each 
donor,  taking  care  to  mark  each  test  tube  so  the  bloods  will  not  become  mixed. 

Tests:  i.  Into  a  small  test  tube  deposit  one  drop  of  donor's  10  per  cent,  red  cell  emulsion 
and  add  four  drops  of  the  recipient's  serum. 

2.  In  the  same  way  add  to  one  drop  of  recipient's  10  per  cent,  red  cell  emulsion,  four  drops 
of  donor's  serum. 

3.  To  one  drop  of  donor's  red  cell  emulsion,  add  four  drops  of  his  serum. 

4.  To  one  drop  of  recipient's  red  cell  emulsion  add  four  drops  of  his  serum. 

Finally  add  to  each  tube  i  c.c.  of  normal  salt  solution,  shake  gently  and  place  in  an  incu- 
bator for  two  hours. 

Tests,  1,2,3  and  4  should  be  made  with  the  recipient's  and  each  donor's  blood,  great  care 
being  taken  to  mark  and  keep  each  series  of  four  test  tubes  separate.  Any  tube  in  which  the 
donor's  and  recipient's  blood  have  been  mixed  and  which  at  the  end  of  two  hours  show  no 
agglutination  or  hemolysis  may  be  considered  as  compatible  and  the  blood  from  that  or  those 
donors  safe  for  use." 


862  OPERATIONS    ON   VEINS 

TRANSFUSION  OF  'WHOLE"  BLOOD 

Simple  Syringe  Transfusion  (Lindeman,  Am.  J.  Dis.  of  Children,  July, 
1913). — ^Lindeman  thus  describes  the  operation: 

"The  entire  apparatus  for  simple  syringe  transfusion  consists  of  two  sets 
of  cannulas,  two  tourniquets  and  twelve  syringes. 

^'Cannulas. — Two  sets  of  cannulas  are  employed,  one  for  the  donor,  the 
other  for  the  recipient  (Figs.  1015  and  1016). 

"There  are  three  cannulas  to  each  set  (Fig.  1016;  i,  2,  3,).  Each  cannula 
telescopes  within  the  other  as  shown  in  Fig.  1015. 


'?__§_ 


Fig.  1015. — {Lindeman.) 

"The  innermost  cannula  is  practically  a  hollow  needle,  2^16  inches  long, 
20-gage,  wdth  one  end  ground  to  a  fine  point  and  short  bevel. 

"The  hollow  needle  (i,  Fig.  1016)  is  fitted  snugly  into  cannula  2.     Cannula 

2  is  5  mm.  shorter  than  the  needle  and  is  fitted  snugly  into  cannula  3.     Cannula 

3  is  5  mm.  shorter  than  cannula  2.     The  proximal  ends  of  i  and  2  are  capped 
wath  stationary'  thumb-screw  caps. 


ii 


TIENANh 

Fig.  10  i6. — {Lindeman.) 

"The  proximal  end  of  3  is  capped  with  a  receiver  to  fit  any  Record  syringe. 

"Cannula  3  is  2  inches  long,  14-gage,  .064  diameter.  The  calibre  of  this 
cannula  is  the  same  as  the  tip  of  a  Record  syringe. 

"In  very  small  infants  with  very  small  veins  only  cannulas  i  and  2  are 
employed,  2  being  capped  with  the  receiver  to  fit  tip  of  syringe. 

"The  syringes  used  are  Record  syringes  of  new  improved  tj-pe  \vith  a 
capacity  of  20  c.c.  and  can  be  sterilized  by  boiling. 

"Operation. — One  operator  manages  syringe  of  recipient.  Another  opera- 
tor manages  syringe  of  donor.  An  assistant  stands  between  operators,  who 
are  in  a  position  close  to  the  assistant.  Donor  and  recipient  are  placed  in  the 
recumbent  position.     Suitable  veins  are  selected. 

"In  adults  and  most  children  over  2  years  of  age  the  median  basilic  is 
easily  accessible.  In  infants  the  external  jugular  or  one  of  its  tributaries  is 
entered  more  advantageously.  In  some  cases  the  internal  saphenous  may 
prove  the  vein  of  preference. 


TRANSFUSION    BLOOD  863 

A  tourniquet  is  placed  in  position,  and  the  skin  is  sterilized  with  iodin. 
The  cannula  is  then  held  in  a  position  almost  parallel  to  the  vein  with  the  thumb 
on  the  thumb-screw  cap  of  the  innermost  cannula  (i,  Fig.  1015).  The  skin  is 
then  punctured  and  the  cannula  is  forced  into  the  vein.  After  the  first  joint 
A  has  entered  vein,  cannula  i  is  withdrawn  a  distance  of  about  one-half  inch 
(this  prevents  the  vessel  wall  from  being  injured  or  punctured  by  the  needle 
after  the  vein  is  entered). 

"With  the  thumb  now  on  the  thumb-screw  cap  of  2  the  cannula  is  forced 
further  in  until  the  second  joint  B  (Fig.  1015)  has  entered  the  vein.  Cannula  2 
is  then  withdrawn  a  distance  of  about  one-half  inch  (cannula  3  alone  can  come 
into  contact  with  the  vessel  wall).  Cannula  3  is  then  gently  pushed  into  the 
vein  to  a  desirable  length;  usually  three-quarters  to  one  inch  will  suffice. 

"  Cannulas  i  and  2  are  now  withdrawn  entirely.  If  the  vein  has  been  suc- 
cessfully entered,  blood  will  flow  through  the  cannula.  When  the  first  drop 
appears,  a  syringe  containing  warm  saline  solution  is  immediately  attached 
and  a  very  slow  flow  of  saline  is  maintained  through  cannula.  Escape  of  blood 
is  thus  prevented. 

"There  is  no  need  of  haste  at  this  stage. 

"A  cannula  is  next  inserted  in  vein  of  donor  in  a  like  manner;  again  a  syringe 
containing  warm  saline  is  attached  and  loss  of  blood  thus  prevented.  Every- 
thing is  now  in  readiness  for  the  transfusion. 

"An  empty  syringe  is  substituted  for  the  one  containing  saline  solution, 
and  blood  is  withdrawn  from  donor  as  rapidly  as  possible. 

"  When  the  syringe  is  full  the  assistant  passes  it  to  the  operator  on  the  recipi- 
ent, who  removes  its  saline  syringe,  attaches  the  syringe  containing  blood  and 
evacuates  the  contents  gently  but  speedily  into  the  vein. 

"One  syringeful  of  blood  is  followed  by  another  in  rapid  succession  until  the 
desired  quantity  of  blood  has  been  transfused. 

"A  little  normal  saline  is  injected  through  cannula  of  recipient  after  each 
syringeful  of  blood.  This  keeps  the  cannula  free  of  blood  and  precludes  the 
possibility  of  clotting. 

"It  has  been  found  advisable  for  the  assistant  (or  third  man)  to  remove  the 
syringe  from  the  cannula  of  the  donor  as  soon  as  filled. 

"The  operator  can  thus  hold  the  cannula  in  place  with  one  hand  while 
with  the  other  hand  he  may  at  once  adjust  an  empty  syringe  into  the  cannula. 
Loss  of  blood  is  thus  reduced  to  a  minimum. 

"Rules. — I.  Bright  polished  surfaces  of  syringe  and  cannulas  are 
requisite. 

"2.  A  syringe  used  once  should  not  again  be  employed  until  thoroughly 
cleansed  with  sterile  water. 

"3.  Air  must  be  avoided.     This,  however,  offers  no  difficulty. 

"4.  Tourniquet  of  patient  must  be  removed  after  vein  is  entered  with 
cannula. 

"  5.  Tourniquet  remains  on  donor  throughout  operation;  momentary  release 
of  tourniquet  may  be  advisable  once  or  twice  during  course  of  operation. 

"6.  Dexterity  and  speed  are  requisite  for  success. 

"7.  Syringes  can  be  evacuated  more  rapidly  than  they  can  be  filled  with- 


864  OPERATIONS    ON   VEINS 

out  any  harmful  effects.  This  difTerence  in  time  allows  attachment  of  syringe 
with  warm  saUne  following  each  syringeful  of  blood. 

"Comments. — The  time  elapsing  in  filling  and  evacuating  the  syringe  is  so 
brief  that  blood  does  not  undergo  any  alteration  from  donor  to  recipient. 

"No  lubricant  has  been  employed  except  in  one  case.  Cannulas  are  lined 
with  a  film  coating  of  albolene. 

"Both  arms  of  the  donor  may  be  used  simultaneously. 

"Larger  syringes  with  larger  calibred  cannulas  may  be  used,  but  the  present 
sizes  have  worked  satisfactorily  and  fittings  of  syringe  and  cannulas  are  of 
universal  gage. 

"  Syringes  and  cannulas  may  be  kept  sterile  in  individual  metal  containers. 
They  are  thus  in  readiness  for  immediate  use  and  no  preparation  for  operation 
is  required. 

"The  same  vein  can  be  used  repeatedly  for  subsequent  transfusions, since 
no  thrombosis  nor  permanent  injury  to  vessel  occurs. 

"Any  quantity  of  blood  can  be  transfused  and  the  quantity  definitely 
measured  at  the  time  of  transfusion." 

Lindeman  (Jour.  A.  M.  A.,  June  7,  1919)  has  succeeded  in  making  214 
consecutive  transfusions  of  1000  c.c.  or  more  of  blood  without  a  chill.  This 
result  was  due  not  merely  to  the  method  emplo3^ed  but  to  the  careful  choice 
of  donors.  The  post-transfusion  rise  of  temperature  is  somewhat  higher  when 
more  than  1400  c.c.  is  used.  The  rise  of  temperature  usually  begins  from  two 
to  four  hours  after  the  operation  and  begins  to  decline  in  from  four  to  eight 
hours.  Occasionally  a  transient  urticaria  is  observed.  Lindeman  believes  that 
reactions  after  transfusion  are  due  to  four  causes:  "(i)  hemolysis  and  agglu- 
tination; (2)  toxic  substances  developed  in  the  blood  on  remaining  outside  of 
the  body;  (3)  chemicals  such  as  anticoagulants  and  physiologic  sodium  chloride 
solution,  and  (4)  sensitization  and  anaphylaxis." 

Citrate  of  Soda  or  Lewisohn's  Method  (Jour.  A.  M.  A.,  March  17,  191 7,  page 
862). — This  method  was  universally  adopted  by  the  Allies  in  the  Great  War. 

Principles  Involved.- — i.  Citrate  of  soda  in  two-tenths  of  i  per  cent.  (0.2  per 
cent.)  concentration  prevents  the  coagulation  of  blood  outside  the  body  for 
from  two  to  three  days. 

2.  Five  grams  of  citrate  of  soda  can  be  safely  introduced  into  an  adult. 
Larger  amounts  are  very  toxic. 

3.  Citrated  blood  causes  a  temporary  shortening  of  the  coagulation  time 
of  the  recipient's  blood,  but  this  is  usually  adjusted  in  less  than  twenty-four 
hours. 

The  Operation. — (i)  Obtaining  the  Blood  from  Donor. — Apply  a  tourniquet 
to  the  donor's  arm  sufficiently  tightly  to  make  the  superficial  veins  prominent. 
Choose  one  of  the  prominent  veins  in  the  elbow  region  (usually  the  median 
cephalic)  and  sterilize  the  skin  over  it  with  Tr.  iodine  or  with  alcohol.  Punc- 
ture the  vein  with  a  cannula  of  fairly  large  caliber.  Watson  faciUtates  the 
insertion  of  the  needle  by  transfixing  the  skin  and  the  superficial  segment  of 
the  vein  with  an  ordinary  seamstress  needle,  Fig.  1017.  Collect  the  blood  in 
a  graduated  glass  jar  which  contains  some  two  per  cent.  (2  per  cent.)  sodium 
citrate  solution.     If  it  is  expected  to  use  450  c.c.  of  blood  there  should  be 


HL(JUU    TRANSFUSION 


865 


50  c.c.  of  the  2  per  cent,  citrate  in  the  jar  thus  giving  a  0.2  per  cent,  solution 
when  the  blood  is  added.  Lewisohn  advises  the  use  of  a  few  cubic  centimeters 
of  the  citrate  solution  lest  the  resultant  blood  mixture  should  contain  less  than 
the  minimum  percentage  of  citrate. 

(2)  Infusion  of  the  Blood  into  Recipient. — As  the  recipient  is  usually  exceed- 
ingly anemic,  the  vein  must  l)c  exposed  by  incision  in  about  80  per  cent,  of  the 
cases.     Insert  the  cannrla  into  the  vein.     Attach  to  the  cannula  a  salvarsan 


Fig.  1017. — A,  Cross-section  of  vein  transfixed  in  its  upper  se<^ment  to  skin  bv  a 
straight  intestinal  needle.  B,  Introducing  Kaliski  cannula  into  the  cephalic  vein  of  the 
donor.  The  vein  is  steadied  and  prevented  from  rolling  from  under  the  cannula  by  means 
of  slight  traction  exerted  upon  the  transfixing  needle.  C,  Cannula  introduced  in  vein  of 
recipient.     {Pemberton  in  "Surgery,  Gynecolog}'  and  Obstetrics.") 

apparatus  which  contains  20  or  30  c.c.  of  normal  salt  solution.  Pour  the  citrated 
blood  into  this  apparatus  and  let  it  flow  into  the  vein  exactly  like  an  ordinary 
saline  infusion.  Rarely  more  than  1000  c.c.  of  blood  requires  to  be  used  and 
thus  only  contains  two  grams  of  sodium  citrate,  a  perfectly  safe  dose. 

Infective  Phlebitis. — For  many  years  it  has  been  customary  to  ligate  the 
internal  jugular  vein  to  prevent  dissemination  of  infection  in  cases  of  sigmoid 
sinus  thrombosis.     The  same  treatment  is  applicable  in  acute  thrombophlebitis 


866  OPERATIONS    ON   VEINS 

in  other  localities.  The  principle  of  the  operation  is  to  ligate  the  vein  at  a  point 
proximal  to  the  thrombus  and  then  to  open  and  clean  out  the  vein  where  it  is 
diseased,  or  still  better  to  excise  the  diseased  segment.  Trendelenburg  records 
a  case  of  general  chronic  puerperal  infection  which  recovered  after  double  liga- 
tion of  the  inflamed  and  thrombosed  right  hypogastric  (internal  iliac)  and 
spermatic  veins.  The  details  of  the  operation  required  are  practically  the 
same  as  for  similar  procedures  on  the  arteries. 

Varicose  Veins. — The  excuse  for  the  superficial  veins  of  the  leg  becoming 
varicose  is  that  being  outside  the  deep  fascia  they  are  poorly  supported. 

The  principle  of  treatment  of  varicose  veins  is  the  transference  of  the  venous 
circulation  from  the  superficial  to  the  deep  veins,  but  before  attempting  to  do 
this  it  must  be  shown  that  there  is  neither  thrombosis  of  the  deep  veins  nor 
marked  obstruction  to  the  return  of  blood  through  them.  It  must  be  remem- 
bered that  varicosed  superficial  veins  may  be  nature's  means  of  dodging  ob- 
struction of  the  deep  vessels. 

Mayo,  in  doubtful  cases,  applies  an  elastic  support  to  the  limb  for  a  week; 
if  this  gives  comfort  it  is  fairly  evident  that  the  deep  vessels  are  capable  of 
doing  their  duty. 

Trendelenburg,  struck  by  the  fact  that  regurgitation  of  blood  takes  place 
from  the  deep  femoral  into  the  long  saphenous  vein,  doubly  ligated  and  divided 
the  latter  close  to  the  saphenous  opening.  The  operation  is  a  good  one  when 
the  condition  is  due  to  regurgitation.  The  test  for  regurgitation  is  as  follows: 
(i)  Elevate  the  limb  until  the  veins  empty  themselves.  (2)  Make  pressure 
over  the  vein  near  the  saphenous  opening.  If  the  superficial  veins  now  quickly 
become  prominent  Trendelenburg's  operation  will  probably  be  ineflScient.  (3) 
The  veins  have  not  become  prominent;  still  keeping  up  pressure  at  the  saphenous 
opening,  let  the  limb  hang  down.  Remove  the  pressure.  If  a  column  of  blood 
passes  down  the  vein,  Trendelenburg's  method  will  probably  be  efficient. 

Trendelenburg's  Operation. — Local  anesthesia  usually  suflaces.  Place  a 
rubber  band  around  the  upper  part  of  the  thigh  suflSciently  tightly  to  cause 
dilatation  of  the  superficial  veins.  This  precaution  may  be  dispensed  with  if 
desired.  At  the  junction  of  the  upper  and  middle  thirds  of  the  thigh  make  a 
longitudinal  incision  about  one  and  one-half  inches  in  length  along  the  course  of 
the  vein.  A  transverse  incision  is  preferable  in  fat  patients.  Expose  and 
isolate  the  vein;  ligate  it  with  catgut  at  the  upper  and  lower  ends  of  the  wound; 
excise  the  portion  lying  between  the  ligatures.  Close  the'wound  with  sutures. 
Dress.  Repeat  the  above  procedure  at  a  point  immediately  below  and  one 
immediately  above  the  internal  condyle.  Keep  the  limb  at  rest  for  from  two 
to  three  weeks.  When  painful  varicose  tumors  are  present,  the  author  always 
supplements  the  Trendelenburg  operation  by  excising  such. 

Delbet's  Operation. — As  Trendelenburg  noted,  varicosity  of  the  long  saphe- 
nous vein  is  due  to  inefiicient  valve  action  at  its  junction  with  the  femoral,  thus 
the  whole  weight  of  the  blood  in  the  inferior  vena  cava  comes  to  bear  on  the 
saphenous  vein.  Below  the  junction  of  the  two  veins  valves  exist  in  the  femoral 
vein.  Hesse  and  Schaak  found  these  valves  constant  in  a  hundred  subjects 
and  that  while  they  were  usually  present  3  to  4  cm.  (i3^-iH  '^'^•)  below  the 
junction  yet  occasionally  they  were  7  to  10  cm.  (2^-4  in.)  below.     If  the 


VARICOSE  VEINS  867 

saphenous  vein  is  doubly  ligated  and  divided  high  up  as  in  Trendelenburg's 
operation  and  its  lower  segment  is  anastomosed  to  the  femoral  vein  below  the 
site  of  the  valves  then  there  can  be  no  serious  reflux  of  blood  and  yet  circulation 
through  the  saphenous  vein  is  not  impeded  or  prevented  as  is  the  case  after 
most  of  the  classical  operations.  The  operation  consists  in  isolating  and  ligating 
the  long  saphenous  vein  at  its  upper  end  and  in  making  an  end-to-side  anasto- 
mosis between  the  lower  segment  of  the  saphenous  and  the  femoral  veins,  i.e., 
uniting  the  open  end  of  the  saphenous  vein  to  the  sides  of  a  suitable  incision 
made  in  the  femoral  vein.  As  in  73  per  cent,  of  patients  the  femoral  valves  are 
situated  close  to  the  normal  sapheno-femoral  junction  Delbet  establishes  the 
anastomosis  4-5  cm.  (i3^-2  in.)  below  that  point  while  Hesse  and  Schaak 
prefer  to  make  it  10  cm.  (4  inches)  below  the  junction,  i.e.,  about  20  to  25  cm. 
(8-g/-i  in.)  below  Poupart's  ligament.  Delbet  has  had  excellent  results  in 
25  cases  while  out  of  23  cases  Hesse  and  Schaak  lost  one  from  severe  streptococcic 
infection.  To  the  author  venous  anastomosis  seems  entirely  too  serious  an 
operation  for  varicose  veins  and  that  much  simpler  measures  give  very  satis- 
factory results. 

Cecca's  Operation. — In  certain  uncomplicated  cases  of  varicose  veins  where 
the  long  saphenous  presents  no  old  secondary  lesions  and  where  its  branches 
are  not  extensively  dilated,  R.  Cecca  (Ref.  "Journal  de  Chir.,"  i,  No.  9)  sug- 
gests giving  support  to  the  diseased  vessel  by  transplanting  it  under  the  fascia. 
The  operation  consists  of  exposure  of  the  vein  by  a  long  incision — incision  of 
the  fascia — insertion  of  the  vein  through  the  long  wound  in  the  fascia — suture 
of  the  fascia  over  the  vein — closure  of  the  skin  wound. 

Katzenstein  performs  an  operation  very  similar  to  Cecca's.  Through  a 
long  incision  isolate  the  long  saphenous  vein  and  its  affluents;  isolate  the  sar- 
torius;  place  the  vein  under  the  muscle  applying  a  few  sutures  to  the  borders  of 
the  muscle.  "The  saphenous  vein  is  thus  imprisoned  in  a  contractile  muscular 
tunnel  and  while  the  varices  in  the  leg  do  not  completely  disappear  yet  the  pain 
disappears,  the  leg  loses  its  feeling  of  weight  and  the  patients  state  that  they 
are  relieved." 

Phelp's  Operation. — Multiple  subcutaneous  ligation.  Pass  a  handled  needle 
with  its  eye  near  the  point,  through  the  skin,  behind  the  vein,  and  out  through 
the  skin  on  the  opposite  side  of  the  vein.  Thread  the  needle  with  stout  silk; 
withdraw  the  needle  and  unthread  it.  Through  the  same  puncture  reintro- 
duce the  needle;  pass  it  in.  front  of  the  vein  and  out  through  the  skin  puncture 
on  the  opposite  side  of  the  vein  made  in  the  previous  movement.  Thread  the 
free  end  of  the  silk  ligature  in  the  needle  and  withdraw  the  needle.  By  the 
above  means  a  silk  ligature  has  been  made  to  surround  the  vein,  and  its  ends 
emerge  through  the  same  puncture  in  the  skin.  Tie  the  ligature  tightly. 
Repeat  the  operation  at  about  thirty  or  forty  places.  Apply  dressings  and 
prescribe  rest  in  bed. 

Mayo's  Operation. — C.  H.  Mayo  excises  the  long  saphenous  vein  as 
follows:  Expose  and  isolate  the  vein  near  the  saphenous  opening.  Divide 
the  vein  between  ligatures.  Seize  the  peripheral  portion  of  the  vein  with  a 
hemostat. 


868 


OPERATIONS    ON   VEINS 


Pass  the  end  of  the  vein  through  the  loop  of  Mayo's  dissector  (Fig.  1018,  a). 
Guided  by  the  vein  push  the  dissector  under  the  skin  down  to  a  point  near  the 
knee;  cut  through  the  skin  over  the  end  of  the  dissector;  clamp  the  vein,  pull 
it  out  through  the  wound,  ligate  and  excise  the  loose  portion.  If  the  dissector 
is  obstructed  in  its  work  by  adhesions  around  the  vein,  pass  the  closed  forceps 
(Fig.  1018,  b)  alongside  it,  and  when  the  adhesions  are  reached  open  the  blades 


Fig.  1018. — Excision  of  varicose  veins.     {Mayo.) 


of  the  forceps  slightly;  this  usually  overcomes  the  trouble  and  the  dissector  can 
complete  the  work.  In  the  same  manner  remove,  subcutaneously,  as  many 
other  veins  as  may  be  necessary.  The  dissection  should  be  from  above  down- 
wards to  avoid  the  danger  of  detaching  thrombi  and  throwing  them  into  the 
circulation. 

Removal  by  Inversion. — W.  L.  Kellers  operation  ("N.  Y.  Med.  Journ.," 
Aug.  19,  1905).  Elevate  the  limb.  Expose  the  long  saphenous  vein  near  the 
saphenous  opening.  Divide  the  vein  between  clamps.  Ligate  the  proximal 
stump.  Split  the  upper  end  of  the  distal  segment  for  about  three-quarters  of 
an  inch  on  its  anterior  wall.  Tie  a  strong  ligature  to  the  upper  end  of  the  vein 
(Mamourian  uses  a  suture),  care  being  taken  not  to  include  more  tissue  in  the 
ligature  than  will  pass  through  the  lumen  of  the  vessel.  Apply  traction  to  the 
distal  stump  and  thus  make  the  vein  prominent  along  its  course  as  far  as  the 


VARICOSE   VEINS  869 

knee.  Expose  the  vein  by  a  small  incision  on  the  inner  aspect  of  the  knee. 
Divide  the  vein  between  two  clamps.  Ligate  the  distal  segment.  Remove  the 
clamp  on  the  proximal  segment  and  pass  a  long  probe,  eye  first,  up  the  lumen 
of  the  vein  until  it  comes  out  of  the  first  incision.  Thread  the  ligature  on  the 
probe.  Pull  on  the  distal  end  of  the  probe  and  so  extract  the  vein  at  the  same 
time  turning  it  outside  in. 

Marmourian  writes  ("Brit.  Med.  Journ.,"  July  16,  1901):  "All  the  promi- 
nent veins  of  the  leg  can  be  dealt  with  in  similar  fashion.  If  they  are  very  tor- 
tuous, a  gum-elastic  catheter  should  be  used  instead  of  the  probe.  The  method 
is  not  applicable  to  cases  of  general  or  cirsoid  varicosities." 

Babcock's  Operation. — ("Journ.  A.  M.  A.,"  July  i6,  1910.)— Babcock  has 
improved  an  operation  which  he  published  in  1907.  A  special  instrument 
required  is  a  long,  pliable  probe  with  a  small  acorn  tip  at  one  end  capable  of 
passing  through  the  lumen  of  the  vein  to  be  removed;  at  the  other  end  is  a  larger 
acorn  tip,  the  shaft  surface  of  the  acorn  being  so  cuffed  as  to  catch  the  wall 
of  the  vein  and  prevent  its  inversion  and  slipping  over  the  end  of  the 
instrument. 

Expose  the  vein  either  at  the  upper  or  lower  end  of  the  segment  to  be  re- 
moved (preferably  the  upper  end,  to  obviate  dangers  of  embolism  (J.  F.  B.)). 
Grasp  the  vein  with  a  hemostat.  Incise  the  vein  and  introduce  the  smaller 
end  of  the  probe.  Pass  the  probe  along  the  inside  of  the  vein  for  the  required 
distance  or  until  some  obstruction  is  encountered.  With  strong  silk  tie  the 
vein  to  the  shaft  of  the  probe  close  to  its  larger  acorn  end.  Divide  the  vein  be- 
tween the  hemostat  and  the  probe.  Replace  the  hemostat  by  a  ligature.  Incise 
the  soft  parts  including  the  wall  of  the  vein  over  the  smaller  end  of  the  probe 
which  may  be  felt  or  seen.  Grasp  the  small  end  of  the  probe  and  pull  it  out  of 
the  wound  by  firm  traction  combined  with  a  series  of  short  jerks.  The  vein 
comes  away  pleated  firmly  in  a  small  fusiform  mass  against  the  concavity  of 
the  larger  bulb  of  the  instrument.  The  procedure  may  be  repeated  on  other 
varicose  veins  as  required. 

Excision  of  Varicose  Veins. — Excision  of  the  whole  Internal  Saphenous  Sys- 
tem.— Make  an  incision,  slightly  curved  with  convexity  posterior,  from  the 
upper  end  of  the  saphenous  opening  to  the  posterior  border  of  the  internal  con- 
dyle of  the  femur.  Expose  the  vein  where  it  dips  through  the  saphenous  open- 
ing, doubly  tie  and  divide  it  as  high  as  possible,  above  the  point  of  entrance  of 
the  superficial  external  pudendal  vein  (Alglave).  If  there  are  varicosities  of 
the  superficial  abdominal  veins  Alglave  recommends  that  they  also  be  ligated 
through  an  extension  of  the  incision  upwards.  (The  author  would  be  chary  of 
doing  this  lest  the  varicosities  should  happen  to  be  the  result  of  some  intra- 
abdominal venous  obstruction.)  Reflect  the  edges  of  the  skin  wound  widely 
so  as  to  expose,  from  above  down,  the  saphenous  trunk  and  its  branches.  The 
whole  inner  side  and  some  of  the  anterior  surface  of  the  thigh  is  exposed.  If 
there  is  found  a  collateral  trunk  of  the  vein  this  must  be  followed,  if  necessary, 
through  a  secondary  incision.  Large  varicose  branches  must  also  be  included 
in  the  excision.  Grasp  the  upper  end  of  the  vein  and,  making  slight  traction 
on  it,   dissect  downwards.     The  traction  makes  all  branches  prominent  so 


Syo  OPERATIONS    ON   VEINS 

that  they  are  easily  clamped  and  divided.  When  the  lower  end  of  the  wound  is 
reached  do  not  cut  away  the  mobilized  packet  of  veins.  Attend  to  hcmo5.tasis. 
Suture  and  protect  the  major  portion  of  the  wound.  Continue  the  incision 
down  the  leg  to  a  point  in  front  of  the  internal  malleolus.  Below  the  knee 
reflect  the  skin  forwards  to  near  the  tibial  crest  and  backwards  to  about  the 
middle  of  the  calf.  Putting  slight  tension  on  the  veins  already  removed  from 
the  thigh,  continue  the  dissection  downwards  to  beside  the  ankle.  Along  with 
the  veins  remove  the  surrounding  fat  and  connective  tissue,  i.e.,  excise  every- 
thing between  the  deep  fascia  and  the  skin.  Save  as  many  branches  of  the 
internal  saphenous  nerve  as  possible.     Close  the  wound. 


Fig.  1019. — Friedel's  operation.     (Friedel.) 


If  the  skin  is  healthy  the  above  operation  is  easy  but  if  there  are  many 
adhesions  and  if  the  skin  is  thin  and  much  altered  it  becomes  impossible  or 
improper. 

If  the  skin  lesion  is  not  extensive  it  may  be  best  to  excise  that  area  of  skin 
along  with  the  veins;  if  it  is  extensive  and  if  the  dissection  is  difl5cult  one  must 
be  content  with  excising  the  main  trunks,  if  necessary  removing  large  varicose 
branches  through  separate  incisions.  It  is  not  always  necessary  to  make  a 
continuous  incision  from  Scarpa's  triangle  to  the  ankle.  If  one  desires  one 
may  make  suitable  incisions  in  the  thigh  and  leg  and  burrow  under  the  skin 
between  them  opposite  the  knee.  Naturally  if  the  internal  saphenous  is 
affected  only  in  the  leg,  the  operation  on  the  thigh  may  be  omitted. 

Excision  of  External  Saphenous  System. — Make  an  incision  through  the  skin 


\AkirOSE   VEINS 


871 


from  the  middle  of  the  popHteal  space  to  a  little  above  the  external  malleolus. 
Remove  the  vein  and  its  branches  in  the  manner  already  described. 

When  limited  areas  of  veins  are  alone  varicose,  these,  of  course,  may  be 
excised  through  any  suitable  incision. 

Schede's  Operation. — In  the  upper  third  of  the  leg  make  an  incision  com- 
pletely round  the  limb,  dividing  all  the  tissues  down  to  the  deep  fascia.  As 
the  cut  is  being  made  doubly  ligate  and  divide  all  the  veins. 

Von  Wenzel's  operation  is  the  same  as  Schede's  plus  a  similar  circular 
incision  at  the  junction  of  the  middle  and  lower  thirds  of  the  thigh. 

Friedel's  Operation  ("Archiv  fur  klin.  Chir.,"  Ixxxvi,  p.  143). — When  the 
veins  in  the  leg  are  not  only  increased  in  size  but  in  numbers  and  repeated 
attacks  of  inflammation  have  so  imbedded  them  in  scar  tissue 
that  excision  is  impossible,  Friedel's  operation  gives  promise  of 
value.  Much  oedema  is  usually  present,  giving  the  limb  an 
appearance  of  elephantiasis — ulcers  are  almost  always  evident 
and  the  question  of  amputation  arises. 

The  Operation. — Step  i. — Doubly  ligate  and  divide  the  long 
saphenous  high  up  in  the  thigh. 

Step  2. — With  a  knife  mark  a  spiral  line  running  round  and 
round  the  leg  from  a  point  below  the  disease  to  a  point  well 
above  it.  The  closer  together  the  rings  of  the  spiral  lie,  the 
oftener  will  the  veins  be  divided  and  the  greater  the  probability 
of  cure.  When  ulcers  are  present  the  spiral  should  surround 
the  leg  both  above  and  below  them.  Necrosis  of  the  skin  has 
not  developed  as  a  result  of  the  spirals  being  close  together. 

Step  3. — Guided  by  the  marks  on  the  skin,  make  an  incision 
down  to  the  deep  fascia.  As  this  cut  is  made  inch  by  inch, 
widely  retract  the  edges  of  the  wound  and  ligate  or  throw  a  stitch  around  each 
vein  which  does  not  stop  bleeding  under  simple  tamponade.  Continue  the 
cut  until  it  follows  the  entire  length  of  the  spiral  traced  on  the  skin  in  Step  2 
(Fig.  1019). 

Where  an  ulcer  exists  join  the  spirals  above  and  below  it  by  two  vertical 
incisions  so  as  to  cut  off  the  veins  coming  from  the  ulcer  (Fig.  1020). 

Step  4. — Pack  the  whole  length  of  the  wound  so  that  it  must  heal  by  granu- 
lation. During  the  after-treatment  destroy  all  superficial  granulations  which 
might  fill  up  the  wound  before  epidermization  takes  place.  It  is  of  importance 
to  have  the  epithelium  spread  from  the  skin  down  into  the  depth  of  the  wound 
so  that  a  very  deep  permanent  spiral  gutter  is  formed  giving  the  leg  somewhat 
the  appearance  of  rolled  beef. 

The  author  has  used  Friedel's  operation  or  some  modification  of  it,  with 
satisfaction. 


Fig.  1020. — 
Friedel's  opera- 
tion.    (Friedel.) 


RESULT  OF  OPERATIONS   FOR  VARICOSE   VEINS 

Jeannel  (French  Congress  of  Surgery,  19 10)  remarks  that  some  surgeons 
class  as  cured  cases  in  which  there  may  be  persistence  of  varicosities  if  they  are 
less  voluminous  or  less  painful  and  disabling  than  before  operation;  other  sur- 


872  OPERATIONS   ON   VEINS 

geons  only  class  as  cured  patients  in  whom  the  varices  no  longer  exist  and  who 
have  restored  to  them  a  healthy,  vigorous,  painless  limb.  In  the  following 
tables  taken  from  Jeannel  the  latter  conception  of  the  word  "cured"  is  adopted. 

A.  Results  of  operations  directed  against  the  superficial  reflux  of  blood. 

(a)  Trendelenburg's  operation  and  its  variants. 

Six  hundred  and  ninety-seven  limbs  operated  on  and  examined  after  the 
lapse  of  from  two  months  to  twelve  years. 

393  cured 56  per  cent. 

90  doubtful 13  per  cent. 

214  failures 31  per  cent.  44  per  cent. 

(b)  Resection  of  whole  femoral  part  of  the  internal  saphenous  vein. 
Twenty-three  limbs  operated  on  and  examined  after  from  two  months  to 

seven  years. 

*i2  cured 52  per  cent. 

3  doubtful 22  per  cent. 

6  failures 26  per  cent.  48  per  cent. 

B.  Results  of  operations  directed  against  the  deep  reflux  of  blood. 
(a)  Excision  of  isolated  varices. 

Seventy  limbs  operated  on. 

*52  cured 74  per  cent. 

3  doubtful 4  per  cent. 

IS  failures 22  per  cent.  26  per  cent. 

(6)  Resection  of  all  or  most  of  the  internal  saphenous  or  of  the  external 
saphenous  vein. 

Fifty-seven  limbs  operated  on  and  examined  after  from  two  months  to 
eight  years. 

*26  cured 46  per  cent. 

12  doubtful 19  per  cent. 

20  failures 35  per  cent.  54  per  cent. 

C.  Results  of  operations  directed  against  both  superficial  and  deep  reflux 
of  blood. 

(a)  Trendelenburg's  operation  with  its  variants  plus  multiple  ligations  and 
resections  both  in  the  thigh  and  leg. 

Ninety-five  limbs  operated  on  and  examined  after  from  one  month  to  four- 
teen years. 

57  cured 60  per  cent. 

21  doubtful 22  percent. 

17  failures 18  per  cent.  40  per  cent. 

*  These  figures  are  copied  from  the  abstract  of  Jeannel's  article  in  the  J.  de  Chir.,  Vol. 
V,  1910,  p.  637.     The  author  is  not  responsible  for  the  apparently  peculiar  arithmetic. 


LYMPHANGIOPLASTY  873 

{b)  Complete  saphenectomy. 

Seventy-seven  limbs  operated  on  and  examined  after  periods  of  from  a  few 
months  to  seven  years. 

73  cured 95  per  cent. 

4  failures 5  per  cent 

These  tables  of  Jeannel's  show  the  importance  of  recognizing  in  any  indi- 
vidual case  whether  the  trouble  is  purely  due  to  superficial  reflux  of  blood  when 
Trendelenburg's  operation  or  one  of  its  variants  ought  to  suffice;  or  whether  the 
trouble  is  due  to  a  deep  reflux  of  blood  or  to  both  superficial  and  deep  reflux 
when  one  of  the  more  radical  operations  will  be  necessary. 


LYMPHANGIOPLASTY   (HANDLEY'S   OPERATION) 

In  about  i6  per  cent,  of  cases  of  breast  cancer  diffusion  of  the  disease  and 
perilymphangitis  causes  obstruction  of  the  lymphatics  about  the  shoulder 
which  leads  to  oedema  of  the  arm.  This  oedema  causes  intense  suffering  and 
disability  for  which  opiates  or  amputation  were  the  only  relief  until  Handley 
devised  his  simple  operation. 

The  operation  of  lymphangioplasty  has  no  effect  on  the  carcinoma;  it  merely 
provides  new  means  for  the  lymphatic  drainage  of  the  arm.  Handley's  results 
have  been  most  gratifying  in  relieving  suffering,  deformity  and  disability. 

Materials  required:  Several  long  probes  provided  with  an  eye  at  one  end; 
a  supply  of  No.  12  tubular  woven  silk. 

The  Operation. — Step  i. — Make  a  one-inch  incision  through  the  skin  in  the 
midline  of  the  front  of  the  forearm  immediately  above  the  wrist  (Fig. 
1021,  a). 

Step  2. — Introduce  a  probe  under  the  skin  through  incision  a.  Pass  the 
probe  upwards  and  outwards  to  the  point  b  near  the  elbow.  At  this  point  incise 
the  skin  and  push  the  point  of  the  probe  out  through  the  incision. 

Step  3. — Take  a  double  line  of  silk  more  than  twice  as  long  as  the  arm  and 
catch  its  mid-point  with  a  hemostat.  Protect  one  half  of  the  silk  by  wrapping 
it  in  a  towel  and  thread  the  other  half  through  the  eye  of  the  probe.  Pull  the 
probe  and  with  it  the  silk  out  through  incision  b.  The  hemostat  attached  to  the 
silk  prevents  too  much  being  pulled  out.  A  double  line  of  silk  now  lies  in 
the  subcutaneous  tunnel  a-b  made  by  the  probe. 

Step  4. — Reintroduce  the  probe  through  the  incision  b  and  bring  it  and  the 
silk  out  through  incision  c  made  near  the  insertion  of  the  deltoid. 

Step  5. — Pass  a  second  probe  through  incision  a,  upwards  and  inwards  and 
make  it  emerge  through  incision  d.  The  half  of  the  silk  line  which  was  wrapped 
in  a  towel  is  now  unwrapped  and  threaded  through  the  eye  of  the  probe.  Pull 
the  probe  arid  with  it  the  silk  out  through  incision  d.  Remove  the  hemostat 
from  the  middle  of  the  silk  so  that  the  loop  of  silk  becomes  buried  under  the  skin 
at  a. 

Step  6. — In  the  same  fashion  pass  the  silk  under  the  skin  from  d  to  c. 

Step  7. — Reintroduce  both  probes  through  incision  c  and  pass  them  under 


874 


OPERATIONS    ON    VEINS 


the  skin  round  the  shoulder  to  emerge  through  incision  /  made  at  the  posterior 
border  of  the  deltoid  (Fig.  1022). 

Step  8. — In  the  same  manner  bury  a  double  line  of  silk  under  the  skin  of  the 
back  of  the  arm  along  the  lines  g  h  f  and  g  k  f.  There  are  now  eight  threads 
emerging  through  incision  /. 

Step  9. — Take  a  long  probe,  cut  oflf  the  ends  of  two  of  the  emerging  threads 
so  that  they  are  four  inches  shorter  than  the  probe  and  thread  them  into  the 
eye.  Thrust  the  probe,  eye  first,  through  incision/ and  make  it  penetrate  under 
the  skin  of  the  back.  The  probe  being  longer  than  the  silk,  unthreads  itself. 
Withdraw  the  probe  carefully  leaving  the  two  silk  threads  to  occupy  its  track. 


Fig.  io2r.  Fig.  io:; 

Figs.  1021  and  1022. — ^Lymphangioplasty. 


Repeat  this  manauvre  until  all  the  threads  which  emerge  at  /  have  been 
tucked  in  various  directions  into  subcutaneous  tissues  of  the  back. 

Step  10. — Close  all  the  incisions  with  sutures. 

Handley  writes  ("Brit.  Med.  Journ.,"  April  9,  1910. 

The  choice  of  cases  for  lymphangioplasty. 

"The  analysis  of  my  cases  shows  that  lymphangioplasty  is  contraindicated 
in  cases  where  a  general  anesthetic  cannot  be  borne,  and  in  cases  where  silk 
threads  would  have  to  pass  through  cancerous  tissue.  It  is  also  inadvisable  to 
operate  where  there  is  growth  present  about  the  shoulder,  if  the  pain  is  mainly 
an  axillary  one,  or  is  a  lancinating  pain  shooting  down  the  arm.  In  the  presence 
of  pleural  effusion  or  secondary  growths  the  benefits  of  the  operation  are  trans- 


ELEPHANTIASIS 


875 


ient,  but  the  shortest  period  of  relief  may,  under  the  circumstances,  be  consid- 
ered by  the  patient  as  worth  having. 

"  Minor  degrees  of  obstruction  to  the  return  of  lymph  from  the  arm  are  not 
infrequently  met  with  in  breast  cancer.  The  operation  of  lymphangioplasty 
should  not  be  applied  indiscriminately,  but  should  be  reserved  for  the  severer 
degrees  of  lymph-stasis  in  which  other  modes  of  treatment  are  powerless. 

"The  axillary  scarring  which  necessarily  follows  removal  of  glands  may  some- 
times lead  to  persistent  oedema  of  the  arm,  usually  slight  in  amount.  In  such 
cases  the  application  of  a  bandage  and  the  elevation  of  the  arm  on  an  inclined 
plane  for  one  or  two  hours  a  day  will  usually  suffice.  In 
other  cases,  which  ultimately  develop  into  the  true  brawny 
arm,  the  lymph  obstruction  is  partial  only.  In  such  cases, 
although  the  arm  may  attain  a  very  considerable  size,  the 
oedema  is  soft  and  pits  freely  on  pressure.  Postural  treat- 
ment by  elevation  will  sometimes  in  this  stage  reduce  the 
size  of  the  arm  considerably,  and  will,  to  some  extent, 
relieve  the  pain.  The  necessity  of  operation  is  thus  for  a 
time  deferred,  but  the  relief  obtained  is  not  to  be  com- 
pared with  that  resulting  from  lymphangioplasty.  It 
appears,  moreover,  to  be  very  transient,  and  in  many 
cases  even  before  the  oedema  has  become  solid,  postural 
treatment  is  intolerable  because  it  severely  aggravates  the 
pain.  This  fact  is  easily  explicable,  since  the  lymph  from 
the  forearm,  flowing  easily  upwards  into  the  arm  and 
meeting  obstruction  there,  distends  the  tissues  of  the  upper 
arm  to  an  unbearable  extent." 

Elephantiasis. — Handley  has  applied  lymphangioplasty 
to  the  treatment  of  various  oedemas  of  the  lower  extremity 
— elephantiasis,  Milroy's  disease  (congenital  oedema), 
etc. — but  finds  that  while  temporary  benefit  was  obtained 
the  condition  always  promptly  recurred. 

W.  Clark  ("St.  Bartholomew's  Hosp.  Reports,"  xlv,  1909,  Ref.  Zeut.  f. 
Chir!,  1 9 10,  No.  18)  reports  a  case  of  oedema  of  the  leg  of  uncertain  origin 
but  of  nine  years'  duration.  Implantation  of  a  thread  on  the  inner  side  from 
the  dorsum  of  the  foot  to  above  the  knee  gave  distinct  improvement. 

A.  B.  Mitchell  ("B.  M.  J.,"  No.  20,  1909)  reports  a  case  of  solid  oedema 
of  the  eyelids  on  both  sides  which  followed  a  severe  attack  of  erysipelas  and 
resisted  all  ordinary  treatment.     Handley 's  operation  was  performed  as  follows: 

1.  Make  the  very  small  curved  incision  a  (Fig.  1023)  on  the  upper  eyelid. 
Through  incision  a  pass  a  probe  under  the  skin  to  the  point  h  at  the  outer  margin 
of  che  orbit;  expose  the  point  of  the  probe  by  incising  the  skin  at  h.  Thread  a 
strand  of  coarse  silk  on  to  the  eye  of  the  probe  and  pull  it  through  the  subcu- 
taneous tunnel  made  by  the  probe  between  a  and  h. 

2.  Similarly  incise  the  lower  lid  at  c  and  pass  a  strand  of  silk  under  the  skin 
to  emerge  at  incision  h.  * 

3.  Pass  a  probe  through  incision  h  and  push  it  downwards  under  the  skin  to 
the  point  d  where  a  small  incision  permits  the  probe  to  emerge.     Thread  the  two 


Fig.  1023. — Lymphan- 
gioplasty. 


876  OPERATIONS    ON   VEINS 

Strands  of  silk  emerging  at  b  through  the  eye  of  the  probe  and  pull  them  through 
the  subcutaneous  tunnel  b  d. 

4.  With  a  probe  or  director  introduced  through  incision  d  make  a  small  pouch 
under  the  skin  below  d  and  into  this  tuck  the  ends  of  the  threads. 

5.  Close  all  skin  wounds. 

In  Mitchell's  case  one  of  the  threads  caused  irritation  and  had  to  be  removed; 
the  other  remained  in  situ;  the  result  was  good. 

In  the  case  of  a  young  soldier  who  suffered  from  solid  oedema  of  the  left  side 
of^the  face  and  lips  due  to  erysipelas  following  excision  of  enlarged  cervical 
glands  Mitchell  implanted  two  silk  threads  the  upper  ends  of  which  were 
fastened  to  the  fascia  covering  the  masseter,  the  lower  ends  being  tucked  into 
the  loose  tissue  behind  the  clavicle. 

"The  result  was  entirely  satisfactory;  the  threads  never  gave  the  slightest 
trouble;  the  face  resumed  the  natural  contour." 

Kondoleon  ("Zent.  fur  Chir.,"  No.  30,  191 2)  finds  that  in  most  cases  of  old 
elephantiasis  from  any  cause  "besides  the  well  known  alterations  in  the  skin 
and  subcutaneous  tissues,  the  fascia  is  always  much  thickened  (up  to  3  cm.), 
densely  infiltrated,  immobile,  and  adherent  especially  to  the  fat  lying  between 
it  and  the  skin.  The  outer  surface  of  the  fascia  is  irregular,  of  a  milky  hue;  the 
inner  surface  next  the  muscles  is  of  normal  color  and  consistence."  In  a  few 
cases  one  can  separate  the  fascia  from  a  sheet  of  connective  tissue  which  lies 
between  it  and  the  subcutaneous  fat,  in  other  cases  this  separation  is  impossible. 
Most  of  the  retained  lymph  lies  in  the  neighborhood  of  the  above-mentioned 
sheet  of  connective  tissue.  Kondoleon  finds  that  if  the  lymph  can  gain  access 
to  the  muscles  it  is  promptly  absorbed  and  he  has  had  apparent  good  results 
(though  his  cases  were  not  observed  sufficiently  long  to  permit  of  definite  con- 
clusions) from  the  following  operation: 

1.  The  disease  is  confined  to  the  leg.  On  the  outer  side  of  the  leg  make  a 
longitudinal  incision  through  the  skin  from  near  the  knee  to  near  the  ankle. 
Reflect  the  skin  on  each  side  of  the  incision  until  a  strip  of  fat  about  4  finger- 
breadths  wide  is  exposed.  Excise  this  fat.  Excise  the  thickened  deep  fascia 
to  an  equal  extent.  Attend  to  hemostasis.  Close  the  skin  wound  without 
drainage.     Do  the  same  on  the  inner  side  of  the  leg.     , 

2.  The  thigh  and  leg  are  both  involved.  After  operating  on  the  leg  as  above 
described,  perform  an  identical  operation  on  the  thigh. 

Royster  ("Journ.  A.  M.  A.,"  May  30,  1914),  Matas.  Sistrunk  (Trans. 
Surg.  Section,  A.  M.  A.,  191-8)  have  had  good  results  from  the  Kondoleon 
operation. 

A  similar  operation  may  be  used  for  elephantiasis  of  the  arm. 


SIMPLE    FRACTURES  877 


CHAPTER  LXV 

OPERATIVE  TREATMENT  OF  SIMPLE  FRACTURES,  EXCLUSIVE  OF 

THOSE  INVOLVING  ARTICULATIONS  AND   OF   SOME 

SPECIAL  FRACTURES 

Until  recently  all  closed  (simple)  fractures  were  treated  without  operation; 
to-day  most  of  them  are  and  ought  to  be  exempt  from  operation.  All  open 
(compound)  fractures  demand  operation. 

In  February,  191 1,  a  committee  was  appointed  by  the  Council  of  the  British 
Medical  Association  "  to  report  on  the  ultimate  results  obtained  in  the  treatment 
of  simple  fractures  with  and  without  operation." 

The  committee  limited  its  inquiry  to  simple  fractures  of  the  long  bones  which 
occurred  or  in  which  operations  were  performed  in  the  period  January,  1906,  to 
December,  1910.  Every  patient  reported  upon  was  examined  by  a  member  of 
the  committee.    The  following  are  the  conclusions  formulated  by  the  committee : 

I.  The  statistics  relative  to  the  non-operative  treatment  of  fractures  of  the 
shafts  of  the  long  bones  in  children  (under  the  age  of  15  years),  with  the  excep- 
tion of  fractures  of  both  bones  of  the  forearm,  show  as  a  rule  a  high  percentage 
of  good  results.  These  are  unlikely  to  be  improved  upon  materially  by  any 
other  method  of  treatment.  Operative  results  in  children,  expressed  in  percent- 
ages, are  approximately  the  same  as  the  non-operative.  The  relative  figures  are : 
Non-operative  cases  (cases  1017)  90.5  per  cent,  good  functional  results.  Opera- 
tive cases  (cases  64)  93.6  per  cent,  good  functional  results. 

II.  It  is  possible  either  by  non-operative  or  by  operative  treatment  to  obtain 
a  high  percentage  of  good  results  in  children. 

III.  In  comparison  with  the  non-operative  results  in  children,  the  aggregate 
results  of  non-operative  treatment  in  those  past  childhood  (i.e.,  over  the  age  of 
15  years)  are  not  satisfactory. 

IV.  From  the  analysis  of  the  age  groups  it  is  clear  that  there  is  a  progressive 
depreciation  of  the  functional  result  of  non-operative  treatment  as  age  advances, 
that  is  to  say,  the  older  the  patient  the  worse  the  result. 

V.  In  cases  treated  by  immediate  operation,  the  deleterious  influence  of  age 
upon  the  functional  result  is  less  marked. 

VI.  In  nearly  all  age  groups,  operative  cases  show  a  higher  percentage  of 
good  results  than  non-operative  cases. 

VII.  Although  the  functional  result  may  be  good  with  an  indifferent  ana- 
tomical result,  the  most  certain  way  to  obtain  a  good  functional  result  is  to 
secure  a  good  anatomical  result. 

VIII.  No  method,  whether  non-operative  or  operative,  which  does  not 
definitely  promise  a  good  anatomical  result,  should  be  accepted  as  the  method 
of  choice.  For  this  reason  mobilization  and  massage  by  themselves  have  not 
been  found  to  secure  a  high  percentage  of  good  results.     They  are,  however, 


878  OPERATIVE   TREATMENT    OF    SIMPLE    FRACTURES 

valuable  supplementary  methods  of  treatment.  Similarly,  of  operative  methods, 
those  which  secure  reposition  and  absolute  fixation  of  the  fragments  yield  better 
results  than  methods  which  fall  short  of  this;  imperfect  fixation  of  the  fragments 
by  wire  or  other  suture  has  been  found  to  be  an  unsatisfactory  procedure  in  the 
treatment  of  the  fractures  of  the  long  bones,  with  the  exception  of  the  olecranon 
process  of  the  ulna. 

IX.  Operative  treatment  should  not  be  regarded  as  a  method  to  be  employed 
in  consequence  of  the  failure  of  non-operative  measures,  as  the  results  of  second- 
ary operations  compare  very  unfavorably  with  those  of  immediate  operations. 
In  order  to  secure  the  most  satisfactory  results  from  operative  treatment,  it 
should  be  resorted  to  as  soon  after  the  accident  as  practicable. 

X.  It  is  necessary  to  insist  that  the  operative  treatment  of  fractures  requires 
special  skill  and  experience,  and  such  facilities  and  surroundings  as  will  ensure 
asepsis.  It  is,  therefore,  not  a  method  to  be  undertaken  except  by  those  who 
have  constant  practice  and  experience  in  such  surgical  procedures. 

XI.  A  considerable  proportion  of  the  failures  of  operative  treatment  are  due 
to  infection  of  the  wound,  a  possibility  which  may  occur  even  with  the  best 
technique. 

XII.  The  mortality  directly  due  to  the  operative  treatment  of  simple  frac- 
tures of  the  long  bones  has  been  found  to  be  so  small  that  it  cannot  be  urged  as  a 
sufficient  reason  against  operative  treatment. 

XIII.  For  surgeons  and  practitioners  who  are  unable  to  avail  themselves  of 
the  operative  method,  the  non-operative  procedures  are  likely  to  remain  for 
some  time  yet  the  more  safe  and  serviceable. 

(A)  Immediate  Operation. — Immediately  after  receipt  of  injury  the  tissues 
are  freshly  lacerated;  there  is  no  effusion  from  irritation;  the  lymphatics  are  not 
clogged  with  dead  material  being  removed.  Unfortunately,  from  the  trauma, 
much  tissue  is  so  injured  that  its  resisting  power  is  lowered  and  hence  an  amount 
of  accidental  infection,  which  would  be  harmless  in  a  wound  made  during  an 
ordinary  operation,  might  lead  to  serious  consequences.  Immediately  after 
injury  the  conditions  are  therefore  partly  favorable  and  partly  unfavorable 
for  operation.     Arbuthnot  Lane  favors  early  operation. 

(B)  Delayed  Operation. — Within  a  few  hours  of  the  receipt  of  injury  the 
extravasated  blood  clots  in  the  tissues;  coagulable  lymph  is  effused  throughout 
the  injured  area;  the  normal  lymphatic  drains  of  the  part  are  either  overworked 
or  clogged;  the  bruised  but  still  living  tissues  have  not  recovered  tone;  the  whole 
injured  area  is  in  the  least  favorable  condition  to  withstand  any  accidental 
infection.     This  unfavorable  condition  persists  for  about  seven  days. 

(C)  Late  Operation.— During  the  second  week  after  injury  the  injured 
tissues  have  recovered  tone;  much  of  the  extravasated  blood,  etc.,  has  been 
absorbed;  the  lymphatic  drainage  system  is  in  good  working  order;  the  ends  of 
the  broken  bones  have  gone  through  the  process  preparatory  to  repair.  All 
conditions  are  favorable  for  operation.  During  the  period  of  delay  the  usual 
means  of  reducing  and  treating  the  fracture  have  been  faithfully  tried  and  their 
failure  demonstrates  the  necessity  of  operation.     Some  time  during  the  second 


SIMPLE   FRACTURES 


879 


week  is  the  period  of  choice  for  operation — at  a  later  date,  nature's  efiforts  at 
repair  and  the  occurrence  of  contractures,  etc.,  would  seriously  interfere  with 
operative  reduction. 

PRINCIPLES   OF  OPERATION 

I.  Preparation  of  Patient. — If  necessary  expend  several  days  in  cleaning  the 
skin  of  the  part.  Scrub  repeatedly  with  soft  soap  and  hot  water,  using  the  nail- 
brush or,  better,  some  form  of  scrub-cloth.  On  the  evening  before  operation 
wash  with  benzene,  gasoline  or  alcohol.  On  the  morning  of  the  operation  repeat 
this  washing.     On  the  operating  table  paint  with  iodine. 


Fig.  1024. — Lane's  forceps  or  tongs. 

II.  Make  an  appropriate  incision  where  it  will  do  least  harm  and  give  the 
most  free  possible  access.  Make  the  incision  too  long  rather  than  too  short. 
As  soon  as  the  skin  is  completely  divided  exclude  it  from  the  rest  of  the  wound 
by  sterile  cloths  held  in  place  by  a  few  stitches  or  by  volsellae.  Complete  the 
exposure  of  the  fracture  by  blunt  and  sharp  dissection. 

Never  touch  the  wound  with  the  bare  hand;  make  all  necessary  manipulations 
with  instruments  (Konig's  rule).     Do  not  let  such  parts  of  instruments  as  have 


Fig.  1025. — Jacoel's  staples. 


Fig.   1026. — Int.  splint. 


touched  the  skin  of  the  patient  or  the  bare  hand  of  the  surgeon  enter  the  wound. 
Lane  in  fact,  does  not  permit  even  the  gloved  hand  to  enter  the  wound. 

III.  Having  thoroughly  exposed  the  ends  of  the  bone,  remove  all  blood- 
clot  and  materials  intervening  between  them.  Fritz  K5nig  advises  against 
a  too  thorough  removal  of  all  material  between  the  fractured  surfaces,  as  nature 
will  attend  to  this  and  much  of  the  material  here  present  is  of  value  in  the  forma- 
tion of  callus;  it  is  only  necessary  to  remove  such  structures  as  will  probably 
interfere  with  union.  Konig  writes  ("Archiv  fur  klin.  Chir.,"  Ixxvi,  725): 
"except  in  resections  (when  union  has  been  despaired  of)  or  when  there  is  ab- 
normal effusion  into  involved  joints,  we  do  not  concern  ourselves  much  with 
blood-clots." 


88o 


OPERATIVE    TREATMENT    OF    SIMPLE    FRACTURES 


Lane,  however,  thinks  thai  bones  ought  to  unite  witli  practically  no  callus. 

Now  attend  to  hemostasis  and  bring  the  fragments  into  apposition  by  means 
of  traction  combined  with  the  leverage  action  of  powerful  long-handled  forceps. 
Lane's  forceps  are  shown  in  Fig.  1024.  They  are  so  constructed  as  to  grasp  the 
bones  firmly  and  yet  not  exert  injurious  pressure.  Different  sizes  of  forceps 
are  required  for  large  bones,  as  the  femur,  and  small  bones,  like  the  ulna. 
The  forceps  hold  the  fragments  in  place  admirably  while  screw  nails,  staples. 


Fig.  1027. — {Gerster,  Annals  of  Surgery.) 


or  metal  splints  are  being  applied.  Lowman's  bone  and  plate  holder  (Fig.  1039) 
is  also  a  useful  aid.  John  Gerster's  turnbuckles  (Fig.  1027)  applied  to  Lowman's 
clamps  are  of  service  in  obtaining  and  maintaining  reduction.  If  the  fragments 
tend  to  remain  in  apposition,  close  the  wound  with  or  without  drainage  and 
treat  as  a  simple  fracture.  If  there  is  any  doubt  as  to  the  maintenance  of  appo- 
sition it  is  necessary  to  insure  it  by  means  of  sutures  (wire  or  chromic  gut),  pegs, 
screw  nails  (Lane),  ordinary  wire  nails,  intramedullary  bone  plates  or  tubes,* 
staples  (Jacoel)  (Fig.  io25),buriedsteelsplints (Fig.  1026), Freeman'sapparatus, 


*  Carleton  Flint  used  pegs  made  from  fresh  ox  bone.     These  pegs,  at  first  square  in  section, 
are  roughly  rounded  with  a  file  and  sterilized  bv  boiling. 


SIMPLE    FRACTURES 


88i 


Fig.  io2S.—{Lane.) 


Fig.  io2g.—{Latie.) 


Fig.  1030. — (Lane.) 


Fig.  103 1. — (Lane.) 


882 


OPERATIVE    TREATMENT    OF    SIMPLE    FRACTURES* 


Fig.  1032. — (Lane.) 


SIMPLE   FRACTURES 


88^ 


Fig.  1033. — (Lane.) 


884 


OPERATIVE   TREATMENT   OF   SIMPLE    FRACTURES 


Fig.  1034. — (Lane.) 


SIMPLE    FRACTURES 


88s 


Fig.  1034  A. — {Lane.) 


886 


OPERATIVE    TREATMENT    OF    SIMPLE    FRACTURES 


Fig.  1035. — {Lane.) 


Fig.  103s  A. — {Lane.)  ^ 


lane's  plates 


887 


etc.,  etc.   (see  p.  902).     When  steel  plates  are  used  see  that  they  are  strong. 
Sherman  used  plates  of  vanadium  spring  steel  with  screws  or  the  same  metal, 

Fig.  1037. 

IV.  Close    the    wound    with    or    preferably    without    drainage.       'Dress. 

Immobilize. 


Fig.  1036. — (Lane.) 


Fig.  1037. — Sherman's  vanadium  steel  bone  plates. 


3/8  IN. 


'/2   IN- 


Fig.  1038. — Sherman  vanadium  steel  tap  screws. 


Fig.  1039. — Lowman's  bone 
and  plate  holder. 


Figures  1027,  1028,  1029,  1030,  1031,  1032,  1033,  1034^  io35»  ^°S^' 
kindly  put  at  the  author's  disposal  by  Sir  Arbuthnot  Lane,  explain  better 
than  words  the  uses  of  buried  metal  splints. 


888 


COMPOUND    OR    OPEN   FRACTURES 


CHAPTER  LXVI 

COMPOUND   OR   OPEN   FRACTURES 

Practically  every  fracture  communicating  with  the  open  air  through  a  wound, 
no  matter  how  trivial  the  wound  may  appear,  ought  to  be  subjected  to  opera- 
tion.    The  object  of  the  operation  is  the  treatment  of  the  deep  wound;  treat- 


FiG.  1040. — Extension  arm  splint  applied.     [Robert  Jones,  LSniisii  Med.  Journ.) 

ment  of  the  fracture  is  a  secondary  consideration  and  may  be  carried  out 
either  at  this  time  or  later,  as  may  seem  best.  The  method  of  treatment  varies 
according  to  the  severity  of  the  injury,  the  amount  of  dirt  ingrained  into  the 
wound,  and  the  conditions  surrounding  the  patient.     An  elaborate  method  of 

operating  with  fixation  of  the  fractured  bones 
is  very  proper  when  a  good  operating-room 
and  good  assistance  are  available  and  yet 
may  be  quite  improper  under  less  favorable 
circumstances. 

Example. — Compound  fracture  middle  of 
humerus;  small  wound  through  skin;  much 
laceration  muscles.  Unfavorable  surround- 
ings. Treatment  adopted:  Free  enlargement 
skin  wound;  loose  packing  with  gauze;  im- 
mobilization in  comfortable  position,  but  no 
attempt  at  exact  reposition  of  bones.  Re- 
moval of  pack  in  about  48  hours.  Applica- 
tion of  dressings  and  immobilization  as 
before.  Reduction  of  fracture  on  eighth  day. 
Careful  immobihzation.  If  it  had  been  easy 
to  reduce  the  fracture  and  keep  it  reduced 
during  the  days  when  the  wound  required 
attention,  immediate  reduction  would  have 
been  eflFected,  but  as  it  was  the  patient  was 
comfortable,  the  wound  healed  well,  and  no 
time  was  lost.  Thomas"  splint  or  Jones' 
modification  thereof  (Figs.  1C40  and  1041)  give  admirable  immobilization  and 
extension  as  well  as  permit  easy  access  to  the  wound. 

When  it  is  evident  that  injury  to  the  vessels,  etc.,  of  the  part  has  destroyed 
all  hope  of  maintaining  the  nutrition  of  the  parts  distal  to  the  fracture,  ampu- 


FiG.  X041. — Modified  Thomas' 
humerus  extension  splint  applied. 
{Robert  Jones,  British  Med.  Journ.) 


OPEN    FRACTURES  889 

tation  must  be  done;  under  other   circumstances  conservative  operation  is 
imperative. 

An  operation  for  open  fracture  of  the  tibia  may  be  taken  as  typical. 

OPERATION  FOR  OPEN  FRACTURE  OF  THE   TIBIA 

Step  I. — Anesthetize.  Scrub  the  whole  leg  with  soap  and  hot  water,  using 
a  wash  cloth.  Shave  the  leg.  Scrub  the  whole  leg  with  turpentine,  gasoline, 
or  ether  to  remove  grease.  Scrub  once  more  with  soap  and  water.  Scrub  with 
alcohol.  Scrub  with  some  rehable  antiseptic  solution,  preferably  Harrington's 
solution  (commercial  alcohol  (94  per  cent.),  640  c.c;  hydrochloric  acid,  60  c.c; 
water  300  c.c;  corrosive  sublimate,  0.8  gram).  Instead  of  the  above  elaborate 
classical  preparation  one  may  use  Grossich's  plan,  viz.,  avoid  the  use  of  water, 
shave  off  the  hair  (dry),  paint  with  tincture  of  iodine.  The  English  favor 
washing  with  alcohol  then  with  3  per  cent,  alcoholic  solution  of  picric  acid. 
Apply  an  elastic  constrictor. 

Step  2. — Enlarge  the  skin  wound  freely  so  that  every  nook  and  cranny  of 
the  deep  wound  becomes  accessible.  With  gauze  sponges,  gloved  finger,  and 
instruments  remove  all  foreign  material,  blood-clots,  etc.  Dissect  away  the 
ragged  skin  around  the  wound,  also  all  portions  of  tissue  so  injured  that  they 
cannot  live.*  Remove  completely  all  detached  fragments  of  bone.  These 
fragments  Macewen  scrubs  thoroughly,  lays  aside  in  a  warm  aseptic  solution 
and  reimplants  with  good  efifect,  when  necessary.  Too  few  surgeons  follow 
Macewen's  lead  in  this. 

Fragments  of  bone  still  attached  to  the  shaft  by  periosteum  may  be  cleansed 
and  retained.  Remove  all  tissues  which  will  interfere  with  union  by  becoming 
interposed  between  the  fractured  surfaces.  With  retractors  open  all  torn 
tissue  planes  and  spaces;  clean  such  thoroughly  with  douche  and  mop. 
Provide  free  drainage  for  every  part  of  the  wound  through  counter-punctures 
when  necessary.  Reduce  the  fracture.  If  necessary  for  fixation,  unite  the 
fractured  surfaces  by  sutures  of  wire  or  catgut  or  by  means  of  the  pegs,  etc., 
described  elsewhere.  The  objection  to  the  use  of  wire,  pegs,  nails,  etc.,  is  the 
irritation  which  they  are  likely  to  keep  up  if  the  wound  is  or  becomes  infected. 
In  an  open  fracture  of  the  femur,  where  asepsis  was  evidently  unattainable, 

*In  wounds  from  projectiles  of  high  velocity  very  extensive  excision  of  tissue  (debridement) 
is  necessary,  much  greater  than  in  the  accidents  of  ci\dl  life  but  the  principles  are  the  same 
viz.,  removal  of  all  contaminated  tissue  and  all  tissue  so  injured  as  to  become  a  pabulum  for 
bacterial  growth. 

Martin  and  Petrie  (Brit.  Med.  J.,  Oct.  6,  191 7)  made  a  very  thorough  study  the  spread  of 
infection  in  the  open  bone.  Applying  the  results  of  their  investigation  to  the  treatment  of 
projectile  fractures  they  come  to  the  following  conclusions. 

1.  Soft  parts  killed  by  the  direct  effect  of  the  missile  require  removal. 

2.  An  infected  fracture  of  the  shaft  of  a  long  bone  requires  opening  to  the  full  extent  of 
the  solution  of  continuity. 

3.  In  infected  fracture  of  cancellous  bone  the  superficial  debris  of  smashed  trabeculae,  etc. 
requires  removal.     Solid  bruised  bone  is  able  to  resist  infection  and  may  be  left. 

4.  As  penetration  of  infection  is  at  its  maximum  in  the  first  few  days  early  operation  is 
essential,  especially  in  fractures  of  cancellous  bone  involving  joints. 

5.  Every  artery  directly  or  indirectly  supplying  a  fractured  bone  is  of  importance  in  the 
defence  against  infection. 

6.  In  the  presence  of  vascular  injury  proximal  to  the  fracture,  radical  measures,  such  as 
amputation  or  resection  of  a  joint,  may  be  adopted  with  less  hesitation. 


890 


COMPOUND    OR    OPEN   FRACTURES 


C.  H.  ^layo  mortised  the  bones  together  (Fig.  1042)  so  that  fixation  was  ob- 
tained without  employing  any  foreign  body.  Remove  the  elastic  constrictor. 
Attend  to  hemostasis  by  means  of  forceps,  ligatures,  and  hot  water.  See  that 
the  drainage-tubes  are  in  place  and  not  clogged. 

Step  3. — Partially  close  the  external  wound.  Dress.  Immobilize.  The 
Thomas  or  the  Hodgen  splints  are  excellent. 

Sinclair  informed  the  author  that  the  above  was  the  basis  of  the  very  success- 
ful treament  of  fractures  inaugurated  by  him  in  the  British  Service  during 
the  Great  War.  He  is  careful  to  operate  with  the  splint  (Thomas')  in  situ 
when  dealing  with  thigh  fractures. 

J.  Hogarth  Pringle  (Brit.  Journ.  Surg.,  II,  No.  5)  enunciates  the  following 
rules  which  he  follows  in  the  treatment  of  open  fractures  of  the  long  bones. 

Large  fragments  of  bone  ought  always  to  be 
saved  whether  they  have  or  have  not  been 
deprived  of  periosteum.  They  are  pre- 
served in  warm  salt  solution  until  required, 
and  if  soiled,  the  infected  surfaces  are  re- 
moved with  a  chisel.  The  preservation  of 
such  fragments  is  of  special  value  if  they 
represent  the  "third  fragment''  of  a  flexion 
or  spiral  fracture  because  if  they  are  not 
implanted,  two  pointed  and  often  narrow 
ends  of  bone  are  left,  a  pseudarthrosis  may 
result,  or,  if  union  takes  place,  there  is  much 
shortening.  Always  use  fixation  by  means 
of  wire,  screws,  nails,  plates,  etc.  Always 
excise  the  original  skin  wound.  When  con- 
fident of  asepsis  always  try  to  close  the  wound  even  if  relaxation  incisions 
are  required.  These  incisions  should  always  be  made  if  there  is  much 
undermining  of  the  skin  from  violence. 

Unless  very  confident  of  asepsis  leave  the  wound  open.  This  means  delay, 
but  without  harm  provided  the  exposed  bone  and  fascia  are  kept  moist.  If 
the  wound  is  open  the  fixing  agents  (plates,  etc.)  are  left  until  consolidation  is 
secure  and  are  then  removed. 

Lilienthal  (Trans.  Am.  Surg.  Assoc,  191 2)  fixes  the  bone  by  means  of 
Lane's  plates,  but  instead  of  the  ordinary  screws  he  uses  screws  with  the  head 
prolonged  into  a  steel  shaft  3  to  5  inches  long  with  a  square  pyramidal  head  to 
fit  a  key  which  is  to  be  used  instead  of  a  screw-driver.  To  simplify  extraction 
of  the  plate  he  threads  a  strand  of  silver-plated  piano  wire  into  the  terminal 
apertures  of  the  plate  and  lets  this  wire  protrude  from  the  wound  with  the 
elongated  screw  shanks. 

This  method  being  used  in  infected  fractures,  the  wound  is  packed.  The 
screws  and  plates  are  easily  removed  when  no  longer  required. 

In  very  complicated  cases  the  author  has  often  left  the  wound  wide  open, 
filling  it  loosely  wtih  gauze;  if  after  a  few  days  it  is  evident  that  asepsis  has 
been  attained  the  wound  may  be  closed  in  whole  or  in  part;  if  asepsis  has  not 
been  attained  the  openness  of  the  wound  is  a  great  element  of  safety.  Always 
remember  that  treatment  of  the  wound  is  of  incomparably  greater  importance 


Fig.  104: 


OPKN    FRACTURES 


891 


than  reduction  of  the  fracture.  If  reduction  of  the  fracture  does  not  interfere 
with  drainage  and  wound  treatment,  then  immediate  reduction  is  indicated; 
if  reduction  interferes  in  any  way  with  efBcient  drainage,  then  partial  reduction 
phis  as  thorough  as  possible  immobilization  is  the  treatment  of  choice  until  the 
drains  are  remo\cd  when  reduction  should  be  carried  out  The  Carrel-Dakin 
treatment  of  the  wound  gives  good  results  and  ought  to  permit  of  early  closure. 
During  the  after-treatment  some  form  of  interrupted  splint  is  a  great  boon,  as 
it  permits  the  dressings  to  be  changed  with  the  least  possible  disturbance  of 
the  parts.  Thomas'  splints  for  both  upper  and  lower  extremities  and  Hodgen's 
splint  are  of  inestimable  value. 


EXTENSfON  BY  CMIPERS 

WEIGHT  &.  PULLEY. COUNTER  -  EXTENSION 

AGAINST   TUBER-ISCHII. 

KNEE    FLEXION 

SECTIONAL  BED  LET  DOWN  AS  FOR 

RADIOGRAPHY 


Fig.  1043.— (r.  p.  Jones,  Am.  J.  Orlhop.  Surg.) 


To  obtain  the  best  results  in  the  treatment  of  compound  fractures  both 
ante-  and  post-operative  treatment  is  necessary  During  the  war  the  British 
were  able  to  lower  the  mortality  in  fractures  of  the  femur  from  80  to  20  per  cent, 
and  to  obtain  union  without  appreciable  shortening,  unless  there  had  been  very 
extensive  loss  of  bone  (Sir  Robert  Jones,  Surg.,  Gyn.  and  Obst.,  Jan.,  1920,  Sir 
Anthony  Bowlby,  Brit.  Med.  Journ.,  Jan.  3,  1920).  In  the  following  para- 
graphs the  principles  which  led  to  such  remarkable  results  will  be  outlined. 
They  are  as  pertinent  in  civil  as  in  military  practice.  Fractures  of  the  femur 
are  taken  as  typical,  but  similar  measures  have  similar  results  in  fractures  of 
other  bones. 

1.  On  the  battle  field  apply  the  Thomas'  splint  before  the  trouser  leg  is 
split  or  dressings  applied.  A  back  splint  is  often  necessary  also.  Leave  the 
shoe  on  the  foot.  Obtain  traction  by  steel  calipers  fixed  to  the  sole  below  the 
instep  or  by  a  steel  skewer  passed  through  the  leather.  This  permits  transpor- 
tation of  the  patient  with  a  minimum  of  pain  and  of  damage  from  the  fractured 
bone  traumatising  the  soft  parts.     All  factories  and  works  where  accidents  are 


892  COMPOUND    OR    OPEN    FRACTURES 

common  oughl  to  hiuc  a  su])])ly  ol  Thomas  Splints  both  lor  arm  and  leg  and 
some  of  the  employees  ought  to  be  trained  in  their  application. 

2.  As  soon  as  the  hospital  has  ])een  reached  operate  on  the  lines  already 
indicated  and  put  up  in  a  Thomas'  splint,  the  means  of  extension  being  now 
adhesive  plaster  or  bandages  fixed  to  the  limb  by  a  surgical  glue.  Direct  ex- 
tension by  calipers  is  often  l^est.  Instead  of  the  Thomas'  sjilint  various  others 
may  be  employed  but  none  should  be  chosen  which  do  not  permit  easy  access 
to  the  wound. 

3.  Regulate  the  amount  of  extension  by  means  of  a  portable  X-ray  appara- 
tus. The  best  results  in  the  B.  E.  F.  were  obtained  when  the  extension  was 
such  as  to  make  the  injured  limb  'definitely  longer  than  its  fellow.'  A  gap  of 
I  or  even  2  inches  between  the  main  fragments  of  ])one  can  be  completely 
filled  with  new  bone.     It  is  best  to  have  extension  with  the  knee  slightly  flexed. 

4.  Begin  moving  the  knee  early.  The  classical  Thomas'  splint  is  straight 
but  if  it  is  bent  just  above  the  knee  and  traction  is  maintained  by  Ransohoflf's 
calipers  or  such  like  means  any  amount  of  knee  flexion  and  extension  can  be 
secured  without  disturbing  the  fracture  of  the  femur  (Fig.  1043). 

5.  When  union  is  sufficiently  advanced  use  a  walking  caliper  sphnt,  which 
is  merely  a  Thomas'  knee  splint  in  which  the  end  is  fixed  into  the  heel  of  the 
shoe. 

The  following  tables  published  by  Bowlby  are  most  striking. 

Fractures  of  the  Femur  in  two  special  British  General  Hospitals  in  I'rance  in  1918: 

(o)  334  cases;  average  shortening  0.2  inches. 

(b)     60  cases;  average  shortening  0.2  inches.     (Of  these  60  cases,  36  had  no  shortening.) 

In  a  special  Hospital  in  England,  1918: 

68  cases.     No  shortening  in  39.     Average  shortening  in  the  remaining  29  cases  =  0.5  inch. 

z\n  open  fracture  at  the  articular  end  of  a  bone  may  involve  the  joint  in 
one  or  two  ways :  {a)  A  split  or  fissure  may  extend  from  the  main  site  of  frac- 
ture and  the  external  wound  into  the  joint.  If  such  a  fracture  is  seen  early  it  is 
very  improbable  that  infection  will  have  reached  the  joint  unless  the  fissure  or 
split  is  short,  i.e.,  unless  the  distance  from  the  point  of  articular  involvement  to 
the  external  wound  is  short.  Under  the  above  favorable  conditions,  treat 
the  case  as  a  compound  fracture  without  articular  involvement. 

{b)  There  is  free  communication  between  the  external  wound  and  the  joint. 
Treat  the  fracture  secundum  artem;  treat  the  joint  by  arthrotomy,  as  if  arthritis 
had  already  developed.  The  treatment  of  the  consequences  of  articular  infec- 
tion wfll  be  considered  elsewhere. 


UNUNITED    FRACTURE  893 


CHAPTER  LXVII 
UNUNITED  FRACTURE.    PSEUDARTHROSIS 

The  local  causes  of  non-union  of  fractures  are  usually  (a)  separation  of  the 
fragments,  (6)  insufficient  or  improper  immobilization,  and  (c)  most  important 
of  all,  interposition  of  muscle,  fascia,  or  fat  between  the  fragments.  The 
principles  of  operative  treatment  consist  in  (a)  removal  of  interposed  tissue; 
(b)  freshening  of  the  ends  of  the  bones;  (c)  obtaining  and  maintaining  apposition 
of  the  fragments.  If  these  principles  are  carried  out  with  cleanliness,  union 
is  sure,  provided  that  the  local  and  general  vitality,  i.e.,  the  recuperative  power, 
is  sufficient. 

Often  long-continued  non-union  results  in  contracture  or  shortening  of  the 
soft  parts  and  this,  unless  corrected,  may  prevent  either  the  obtaining  or  main- 
taining of  apposition  of  the  fragments.  Where  moderate  contracture  is  present 
Treves  very  wisely  recommends  that  extension  be  applied  to  the  hmb  for  a 
week  or  more  prior  to  operation.  Edward  Martin,  in  the  case  of  an  ununited 
fracture  of  the  femur  with  2)-^  inches  of  shortening,  having  failed  to  attain 
results  by  the  usual  means  of  traction,  devised  the  following  method:  "It 
consists  in  a  long,  strong  canvas  strip  pocketed  in  the  middle  and  looped  at 
the  ends.  The  bones  at  the  seat  of  fracture  are  freed,  the  pocket  is  slipped 
over  the  proximal  end  of  the  distal  fragment,  the  ends  of  the  canvas  strip  are 
carried  in  the  long  axis  of  the  limb  and  in  the  loops  is  fixed  a  cord  to  which  are 
attached  the  weights.  By  thumb  pressure  the  bone  is  kept  from  angling  out 
of  the  wound,  and  weights  up  to  100  pounds,  or  more,  are  attached  to  the  rope. 
In  from  three  to  five  minutes  the  shortening  is  overcome.  Only  those  struc- 
tures which  interfere  with  proper  placement  are  stretched,  and  this  is  done  so 
thoroughly  that  there  is  but  slight  tendency  to  the  reproduction  of  deformity" 
("Surg.,  Gyn.,  Obst.,"  Jan.,  1910). 

Ochsner  prefers  gradual  extension;  he  says  "  the  only  thing  that  is  peculiar 
about  the  method  is  the  apphcation  of  rubber  adhesive  strips  to  as  high  a  point 
above  the  seat  of  fracture  as  is  possible." 

"For  instance,  instead  of  applying  the  rubber  adhesive  up  to  the  fracture,  it 
should  be  applied  over  the  entire  length  of  the  thigh,  then,  with  no  more  than 
24  pounds  of  weight,  we  have,  in  every  fracture  where  there  has  not  been  a 
union,  been  able  to  stretch  the  muscles  sufficiently  to  replace  the  fractures  with- 
out making  a  resection  of  the  ends.  In  cases  where  there  is  a  union  in  malposi- 
tion, the  muscles  will  stretch  to  a  marked  extent.  Extension  may  be  supple- 
mented in  some  cases  by  preliminary  division  of  the  contracted  tissues,  al- 
though such  division  is  more  commonly  done  at  the  time  of  the  major  operation." 
The  aim  of  the  surgeon  must  be  to  so  operate  that  whatever  means  of  fixation 
and  immobilization  (pegs,  wire,  splints,  etc.)  is  used,  its  function  may  be  as 
nearly  as  possible  prophylactic,  i.e.,  the  fragments  of  bone  ought  to  be  so 
prepared  that  they  tend  to  remain  in  apposition. 


894 


UNUNITED   FRACTURE.      PSEUD  ARTHROSIS 


METHODS   OF  OPERATING 

Step  I. — Exposure  of  the  Bone. — Select  that  route  to  the  site  of  fracture 
which  is  shortest  and  which  will  necessitate  least  damage  to  the  tissues.  Re- 
member the  situation  of  important  structures  {e.g.,  the  musculo-spiral  nerve  in 
the  arm)  so  as  to  avoid  injuring  them.  If  possible  penetrate  to  the  bone  be- 
tween muscles  rather  than  through  a  muscle.  Usually  a  longitudinal  incision 
is  best,  J.  E.  Thompson's  article  on  'Anatomical  Methods  of  Approach  in 
Operations  on  the  Long  Bones  of  the  Extremities'  ("Annals  of  Surg.,"  Ixviii, 
309,  1 91 8)  is  well  worth  study. 

The  use  of  an  elastic  constrictor  is  optional,  though  it  is  preferable  to  avoid 
its  use  whenever  possible.     At  the  point  selected  make  a  vertical  cut  through 


Fig.  1044. 


Fig.  1045. 


the  skin  down  to  but  not  through  the  deep  fascia.  To  find  an  intermuscular 
septum  it  may  be  necessary  to  reflect  the  skin  from  the  fascia  for  a  short  distance 
on  one  or  both  sides  of  the  incision.  Divide  the  fascia  over  an  intermuscular 
septum  and  by  combined  sharp  and  blunt  dissection  penetrate  the  septum  to 
the  bone.  With  retractors  expose  the  bone.  The  length  of  the  wound  must  be 
sufficient  to  give  free  access  to  the  site  of  fracture.  A  small  incision  inevitably 
leads  to  much  bruising  and  damage  to  the  tissues  during  the  rest  of  the  operation. 
With  a  periosteal  elevator  or  rugine  separate  enough  of  the  periosteum  (if 
possible  en  masse  with  the  attached  muscles)  to  permit  of  a  thorough  appre- 
ciation of  the  conditions  to  be  dealt  with.  [Amount  of  fibrous  tissue  between 
the  fragments;  extent  of  separation;  amount  of  bone  atrophy;  obliquit>'  of  the 
ends  of  the  bone,  etc.,  etc.] 

Instead  of  exposing  the  fascia  by  a  vertical  incision  one  may  reflect  the  skin 
as  a  flap  by  means  of  I-,  or  U-,  fl-shaped  incision.  After  the  fascia  is  exposed 
the  rest  of  the  operation  is  as  described  above. 

Step  2. — Preparation  of  the  Ends  of  the  Bone  for  Their  Union.— The 
preparation  of  the  ends  of  the  bone  depends  on  the  conditions  found  at  the 
site  of  fracture.  The  bones  may  be  united  by  fibrous  tissue,  their  ends  may  be 
conical  from  atrophy,  there  may  be  a  wide  separation  between  them  or  one 


PSEUD  ARTHROSIS 


S95 


fragment  may  have  overridden  the  other,  causing  much  shortening.  The 
line  of  fracture  may  be  transverse,  obKque,  or  irregular,  (a)  Dissect  all 
foreign  material  (fibrous  tissue,  muscle,  etc.)  from  between  the  bones,  (b) 
If  possible,  make  each  fragment  of  bone  in  turn  protrude  from  the  wound 


Fig.  1046. 


Fig.  1047. 


and  vivify  it  by  sawing  off  thin  slices  of  the  bone  until  a  healthy  bleeding  surface 
is  obtained.  Sir  Robert  Jones  (Surg.  Gyn.,  &  Obst.,  Jan.,  1920)  in  case  of  mal- 
union  rarely  evacuates  the  ends  of  the  bone  through  the  wound  but  prefers  to 
follow  the  attached  surfaces  with  a  chisel  and  trust  to  extension  without  internal 
splinting,  (c)  If  it  is  impossible  to  make  the  ends  of  the  bone  protrude,  vivify 
them  in  situ  by  means  of  a  finger  or  a  Gigli  wire  saw  or  a  chisel. 

As  a  rule,  an  oblique  fracture  can  be  best  vivified  with  a  chisel;  a  transverse 
fracture  or  one  where  the  ends  have  become  conical,  with  a  saw.  {d)  When 
vivifying  the  ends  of  the  bone  it  is  often  possible  to  so  shape  them  that  the  one 
fragment  will  mortise  into  the  other  and  thus  tend  to  remain  in  position.     A 


Fig.  1048. 


Fig. 


1049. 


chisel  or  gouge  is  the  best  instrument  with  which  to  shape  the  ends  of  the  bone. 
Figures  1044  to  1049  show  various  methods  of  vivifying  and  modeling  the  ends 
of  the  bones. 

A.  G.  Wildey  (Brit.  J.  Surg.,  II,  No.  7,  p.  423)  operates  on  ununited  fractures 
as  follows:  Freely  expose  the  site  of  fracture.  Bring  the  ends  of  the  bone  out 
into  the  wound.     Vivify  their  terminal  surfaces  by  removing  a  very  thin  slice 


896 


UNUNITKD    FRACTURE.       PSEUDARTHROSIS 


Fig.  1050. 


Fig.  1051. 


Fig.  1050. — Improper  application  of  wire. 

Fig.  1051. — Proper  application  of  wire.     Note  the  wire  .is   at  rightajnglcs  to  the  line 
of  fracture. 


Fig.  1052. 


Fig.  1053. 


Fig.  1057.  Fig.  1058.  Fig.  1059. 

Figs.  1057,  1058  and  105;).— (.V/o.-Jji  ani  Vanvert.) 


Sl'TUKE    OF    BONE 


897 


from  each.  Remove  the  plugs  of  caUus  or  iibrous  tissue  from  each  end  by  a 
gouge  or  drill.  Drill  the  circle  of  indurated  bone  in  four  or  live  places  parallel 
to  the  long  axis  of  the  bone,  using  drills  Nos.  1  to  3.  The  drills  must  penetrate 
to  normal  bone  which  is  shown  by  lessened  resistance  to  the  advance  of  the  drill 
and  by  bleeding.  Usually  a  depth  of  from  i  to  2  inches  is  necessary  to  open  a 
vascular  area  of  bone.  The  deeper  the  perforation  required,  the  larger  should  be 
the  drill  and  the  more  numerous  the  holes  bored.     When  both  fragments  have 


Fig.   1060. — {Lejars.) 


been  treated,  place  them  in  apposition  and  secure  fixation  by  means  of  Lane's 
plates.  Wildey  finds  that  union  is  easily  secured,  is  very  firm,  but  that  there  is 
some  excess  of  callus. 

Step  3. — ^Union  of  the  Bones.— If  the  fragments  show  a  marked  tendency  to 
remain  in  apposition,  the  wound  may  be  closed  and  the  case  treated  by  splints, 
etc.,  like  any  ordinary  fractuYe.  Unfortunately,  the  above  is  not  commonly 
sufl&cient  and  it  becomes  necessary  to  hold  the  bones  together  by  some  means 
applied  directly  to  them.  The  methods  devised  for  attaining  direct  union  of 
the  fragments  are  legion — a  few  of  the  principal  ones  will  be  given  here. 

Method  A. — Suture  of  Wire  or  Catgut.— Figures  1050  to  106 1,  show  how 

transverse    or  oblique  fractures  may  be  fastened  together  with  stout  wire  or 

stout  chromicized  catgut.     If  wire  is  used,  the  ends,  after  twisting,  must  be 

cut  off  short  and  any  sharp  protruding  ends  must  be  hammered  flat  or  directed 

57 


898 


UNUNITED    FRACTURE.      PSEUDARTHROSIS 


into  the  bone  so  as  not  to  lacerate  the  soft  parts.     Most  surgeons  use  silver  or 
aluminum-bronze  wire. 

Method  B.— Fixation  by  Nails  or  Bone  Pegs.— Where  the  fractured  sur- 
faces are  oblique,  bore  a  hole  transversely  through  both  fragments — tem- 
porarily leave  the  drill  in  situ.  With  a  second  drill  bore  another  hole  through 
both  fragments;  remove  this  drill  and  replace  it  by  a  bone  peg.  Remove  the 
drill  first  introduced  and  replace  it  also  by  a  bone  peg.  The  drill  left  in  situ 
keeps  the  fragments  in  good  position  while  the  first  peg  is  being  introduced. 


Fig.  1061. — {Lejars.) 


Bone  pegs  are  easily  made  from  a  bone  knitting  needle  of  convenient  thickness 
and  are  sterilized  by  being  boiled.  When  the  pegs  have  been  driven  into  posi- 
tion, any  part  which  may  protrude  must  be  cut  oflf  flush  with  the  bone.  Instead 
of  bone  pegs  metal  nails  or  screws  may  be  used  in  the  same  way. 

Figures  1062  and  1063  show  the  application  of  pegs.  Jacoel  and  Dujarier 
have  devised  useful  metal  staples  to  take  the  place  of  nails  or  screws  (Fig.  1064). 

Depage  (Fig.  1065)  provides  a  long  screw  which  terminates  in  a  pliable 
wire.  After  boring  a  suitable  hole  he  passes  the  screw  through  both  fragments. 
Guided  by  the  pliable  wire  he  threads  a  nut  on  to  the  screw  and  thus  can  get 
very  firm  approximation.  The  excess  of  screw  is  cut  away.  The  objections 
to  this  procedure  are  the  wide  exposure  necessary  and  the  difficulty  of  removing 
the  plate  should  that  subsequently  be  necessary. 


SYNTHESIS   BONE 


899 


Fig.  1062. 


Fig.  1063. 


Fig.  1064. — Jacoel's  staples. 


Fig.  1065. — Depage's  screws. 


Fig.  1066. — {Cuthbert-Wallace,  The  Lancet.) 
Showing  the    essential  parts:  i.  A  bolt.     2.  A  nut  with  a  soft  wire  brazed  to  one  facet.    3.  A  flat  spanner. 

4.  A  clock-key  spanner. 


900 


UNUNITED    FRACTURE.      PSEUD  ARTHROSIS 


Cuthbert-Wallace  (Lancet,  May  15,  1915),  to  avoid  extensive  exposure  of 
the  bones  in  oblique  fractures,  uses  a  very  simple  bolt  as  follows:  Expose  the 
bone.  Reduce  the  fracture.  Drill  a  hole  through  the  central  point  of  the 
fracture.  If  the  fracture  is  not  very  oblique  the  hole  should  be  bored  more  or 
less  at  right  angles  to  the  line  of  fracture,  otherwise  it  should  be  at  right  angles 
to  the  axis  of  the  bone.  The  hole  ought  to  be  a  little  larger  than  the  bolt. 
Push  the  bolt  through  the  hole  till  its  end  just  emerges  on  the  opposite  side. 
Holding  the  nut  (Fig.  1066)  by  the  wire  attached  to  it,  place  it  in  position  on  the 
bolt  and  screw  the  bolt  home  with  the  clock-key  spanner.  Traction  on  the 
wire  prevents  the  nut  turning  with  the  bolt.  When  fixation  is  accomplished 
cut  off  the  end  of  the  bolt  protruding  from  the  nut  with  strong  pliers.  Bend 
the  wire  around  the  bone  to  the  head  of  the  bolt.  Cut  off  the  excess  of  wire. 
The  wire  left  in  situ  renders  removal  of  the  bolt  easy  if  this  is  necessary  at  any 
time.  If  the  bolt  is  introduced  obliquely  to  the  axis  of  the  bone  shaft  its  head 
can  easily  be  housed  by  cutting  a  small  hollow  in  the  bone. 

Method  C. — Fixation  by  Drills  or  Long  Metal  Nails.— ^This  method  is  the 
same  as  B,  except  that  the  drills  used  to  perforate  the  bone  are  left  in  situ  with 

their  proximal  ends  protruding  through  the  wound 
in  the  soft  parts.  After  two  or  three  weeks  the 
drills  become  loose  and  are  easily  removed.  Both 
methods  B  and  C  have  given  the  author  much 
satisfaction. 

Method  D.^ — Fixation  of  Intra-medullaiy  Pegs. 
Prepare  beforehand  several  bone  or  ivory  pegs 
of  different  sizes  so  as  to  be  sure  to  have  one 
about  the  calibre  of  the  central  cavity  of  the  bone. 
Bend  the  limb  so  that  the  end  of  the  lower  frag- 
ment of  bone  is  easily  accessible;  lightly  drive  a 
prepared  peg  into  the  medullary  cavity  for  a  dis- 
tance of  I  to  ij'2  inches.  Manipulate  the  limb  so 
that  the  end  of  the  peg  protruding  from  the  lower 
fragment  enters  the  medullary  canal  of  the  upper 
fragment  (Fig.  1067). 

Murphy  uses  a  transplant  from  the  same  pa- 
tient   as    an    intramedullary    peg.     The    tibia    is 
Pig.  1067.— (Lejars.)  usually  the  source  of  supply.     After  vivifying  the 

p.  Upper  fragment;  P',  lower  frag-  ends  of  the  bone  to  be  United,  enlarge  the  marrow 

ment;  F.  Peg;  .M.  Muscle;  G,  Fat.  '  ° 

cavity  of  both  the  upper  and  lower  fragments  with 
a  reamer  or  burr  for  a  distance  sufficient  to  form  a  good  firm  bed  for  the  im- 
plant. Thorough  reaming  is  an  insurance  against  fat  embolism.  Pack  the 
wound  and  protect  it  thoroughly.  Make  a  longitudinal  incision  over  and 
through  the  tibialis  anticus  and  divide  the  underlying  periosteum  of  the  tibia 
near  the  crest.  Retract  the  edges  of  the  wound.  Separate  the  periosteum  from 
the  crest  of  the  bone.  (The  object  in  making  the  incision  through  the  muscle  is 
to  have  a  good  covering  for  the  defect  which  will  be  left  in  the  bone.) 

Mark  the  upper  and  lower  limits  of  the  desired  transplant  by  boring  holes 
in  the  bone.     With  a  saw  make  a  transverse  cut  in  the  bone  at  each  end  of  the 


BONE    IMPLANTS 


go  I 


part  to  be  transplanted.  The  transplant  must  usually  be  as  thick  as  the 
surgeon's  little  finger  or  even  fore-finger,  and  the  transverse  cuts  must  therefore 
be  about  K  or  /4  inch  deep.  With  a  chisel  cut  a  groove  along  the  bone  from 
the  bottom  of  one  transverse  cut  to  the  bottom  of  the  other.  This  prevents 
splintering  of  the  fragment.  Apply  a  broad  chisel  or  osteotome  to  the  groove, 
cut  through  the  bone  and  remove  the  fragment.  Place  the  fragment  in  warm 
salt  solution  or  moist  gauze.  Close  the  wound  with  deep  and  superficial  sutures. 
Remove  the  pack  from  the  wound  exposing  the  bones  to  be  united.  Use  the 
fragment  of  bone  exactly  as  if  it  were  an  ivory  or  bone  peg.  It  is  of  prime  im- 
portance to  have  absolute  contact  maintained  between  the  implant  and  its 
upper  and  lower  bed,  viz.,  the  cavities  prepared  in  the  bones  to  be  united.  For 
this  purpose  it  may  be  necessary  to  drill  transversely  through  the  receiving  bone 
and  the  implant  and  insert  a  nail. 


Fig.  1068. — {Albee,  Surg.,  Gyn.  and  Obst.) 
I.  .4,  short  segment  bone  cut  out  from  above  fracture  by  double  circular  saw;  B,  long  segment  bone 
from  below  fracture.     2.  Segment  bone  B  put  partly  in  gutter  from  which  A  was  excised  and  partly  in  its 
own  gutter,  crosses  the  site  of  fracture  and  acts  as  splint.     3.  Section  of  splint  in  place  and  held  firmly  by 
pegs  made  out  of  segment  A. 


Even  if  apposition  between  the  fragments  of  the  fractured  bone  is  impossible, 
the  implant  will  live  if  asepsis  is  maintained  and  if  its  ends  are  kept  in  contact 
with  the  vivified  bone  above  and  below.  Union  cannot  be  firm  in  less  than  from 
forty  to  sixty  days. 

Albee  (Surg.,  Gyn.  and  Obst.,  June,  1914)  uses,  in  recent  fractures,  an  autog- 
enous graft  or  implant  obtained  from  the  fractured  bone.  Figure  1068  suffi- 
ciently describes  his  method.  In  cases  of  pseudarthrosis  the  bone  near  the 
site  of  fracture  is  usually  eburnated,  and  it  is  better  under  these  circumstances 
to  obtain  the  graft  from  some  other  bone,  usually  the  tibia,  of  the  patient 
himself. 

Magnuson  (Journ.  A.  M.  A.,  Oct.  25,  1913)  attains  fixation  in  transverse 
fractures  by  means  of  absorbable  ivory  plates.  The  plates  measure  2  inches  in 
length,  I  inch  deep,  ^^  inch  thick.  (A  larger  plate,  2^  X  iH  X  Me  inches, 
is  also  made.)  With  a  circular  saw  having  two  parallel  blades  at  proper  distance 
apart  to  cut  a  slot  exactly  the  width  of  the  ivory  plates  make  two  longitudinal 


go2 


UNUNITED    FRACTURE.      PSEUD  ARTHROSIS 


parallel  incisions  in  the  long  axis  of  the  bone  and  across  the  fracture.  These 
cuts  are  the  same  length  as  the  ivory  plate  and  penetrate  to  the  marrow  cavity. 
Drill  a  hole  at  each  end  of  the  parallel  cuts  so  as  to  mobilize  the  contained  bone 
and  permit  its  extraction.  The  result  is  a  slot  into  which  the  ivory  plate  is  now 
driven.  At  right  angles  to  the  plane  of  the  plate  drill  a  hole  on  each  side  of  the 
fracture  and  drive  into  these  holes  ivory  pegs  or  nails.  Close  the  wound  and 
treat  as  a  simple  fracture. 

H.  Piatt  (Lancet,  Feb.  i,  1919)  finds  that  there  are  two  causes  of  failure 
after  operations  by  bone  graft  for  ununited  gun  shot  fractures:  (i)  The  waking 
up  of  latent  infections,  (2)  the  bad  quality  of  the  skin  cicatrices  which  give  way 
because  of  malnutrition. 

Commonly  a  delay  of  six  months  is  prescribed  to  avoid  latent  infection, 
but  even  after  a  year  or  more  the  latent  infection  may  be  present.  It  is  better 
to  excise  all  the  scar  tissue,  vivify  the  ends  of  the  bone  and  close  the  wound. 


/ 


Fig.  1069. — {Freeman.) 


Fig.  1070. — (LamboUe.) 


This  can  be  done  two  months  after  healing  of  the  original  wound.  The  tissues 
are  removed  thoroughly  en  masse  and  are  put  in  a  sterile  receiver  for  bacterio- 
logic  examination.  In  two  or  three  weeks  physio-therapeutic  treatment  can 
be  begun.  Six  or  eight  weeks  after  this  preliminary  operation  bone  grafting 
can  be  safely  attempted. 

Method  E. — Fixation  by  Means  of  "Fish  Plates."  Internal  Splinting. — 
The  best  plates  are  those  of  Arbuthnot  Lane  made  of  stout  steel.  Such  may 
be  obtained  in  various  sizes.  W.  O.  Sherman  finds  plates  of  Vanadium  spring 
steel  stronger  and  less  bulky  than  Lane's  plates.  The  screws  are  of  metal  and 
should  be  a  trifle  over  ^^  inch  in  length.  Figures  1029  and  1033  show  clearly 
the  application  of  "fish  plates"  to  a  bone. 

Method  F. — ^Fixation  by  Means  of  Long  Screws  and  Extemed  Clamps. — 
This  method  has  been  recommended  by  Keetley,  Parkhill  and  Freeman.     The 


pakkiiu>l-frl:eman-lambotte  api'aratus  903 

application  of  Parkhill's  most  ingenious  apparatus  is  difiicult  because  of  its 
complexity. 

Freeman,  by  using  strips  of  hard  wood  backed  by  steel  plates  (Fig.  1069) 
has  rendered  the  method  exceedingly  simple.  The  attached  figures  sufficiently 
describe  the  procedure.  Figures  1070  and  107 1  show  an  exceedingly  complicated 
apparatus  on  the  same  principles  which  has  given  Lambotte  excellent  results. 

Lilienthars  Modification  of  the  Parkhill-Freeman  Device. — The  apparatus 
may  be  used  in  closed  or  open  fractures,  the  latter  will  alone  be  described  here. 


Fig.  1071. — (Lambotte.) 

Provide  four  gimlets  of  the  square-headed  variety  which  fit  in  a  brace  or  can 
be  put  in  with  a  key;  provide  two  rods  of  steel  about  the  size  of  small  telegraph 
wire.  Near  the  fracture,  bore  one  gimlet  into  the  bone  at  right  angles  to  the 
shaft,  deeply  enough  so  that  there  will  be  no  play  on  gentle  attempts  at  motion. 
Introduce  a  second  gimlet  an  inch  or  two  above  the  first.  In  the  same  manner 
introduce  two  gimlets  into  the  other  fragment.  Reduce  the  fracture  and  hold 
the  bones  in  place  either  by  external  manipulation  or  by  bone  clamps.  The 
gimlets  protruding  from  the  wound  are  not  in  alignment.  Apply  the  steel  rods 
"in  such  a  way  along  the  line  of  gimlets  and  roughly  parallel  to  the  bone  and 


904 


UNUNITED    FRACTURE.      PSEUD  ARTHROSIS 


that  the  rods  and  gimlets  shall  be  in  contact.  If  the  gimlets  were  in  a  perfectly 
straight  line  one  rod  would  be  sufficient,  for  it  would  touch  all  of  them;  but  the 
line  being  a  staggering  one,  two  rods  will  be  found  necessary."  The  steel  rods 
should  be  near  the  heads  of  the  gimlets,  i.e.,  remote  from  the  wound.  Bandage 
the  rods  and  gimlets  together  with  a  plaster-of -Paris  bandage  sterilized  by  bak- 
ing. Disinfect  the  wound  again  and  loosely  pack  with  gauze.  Apply  a  light 
rigid  dressing. 

Hey-Groves'  method  ("Lancet,"  Feb.  21,  1914)  combines  distraction  with 
fixation. 


Fig.  1072.  Fig.  1073. 

Fig.  1072. — Hey-Groves'   double  transfixion  apparatus  for  complicated  fractures  of  the  leg 

bones. 

A, A'  =  highly  tempered  steel  bars  which  transfix  the  tibia  above  and  both  bones  below.  They  are 
sufficiently  long  to  act  as  springs  when  their  ends  are  pushed  apart.  One  end  of  each  is  a  drill  point  and 
the  other  is  slotted  to  fit  a  drill  handle,  so  that  each  is  used  to  bore  its  own  hole.  B,B'  =  nuts  screwed  on 
to  A, A'  after  insertion.  C.C  =  screw  caps  which  protect  the  ends  of  A, A'  and  fix  the  apparatus  rigidly 
when  a  correct  position  has  been  attained.  D,D'  =  rods  with  eyes  which  slip  over  A, A'  and  opposite 
screw  threads  which  fit  into  cylinder  E. 

Fig.  1073. — Hey-Groves'  improved  apparatus  for  extension  and  fixation. 

A,  Pin  transfixing  upper  end  of  bone  B,  Lateral  rods  which  can  be  elongated  as  in  Pig.  1023.  C. 
Pin  transfixing  lower  end  of  bone;  this  need  not  be  parallel  to  pin  A.  D.  Perforated  iron  band  to  surround 
the  limb.  Pin  C  passes  through  holes  in  this  band.  E.  Clips  fixing  lateral  rods  to  any  part  of  the  band 
D  and  permitting  lateral  movement  through  30°. 


"Transfix  both  tibia  and  fibula  with  pin  A'  one  inch  above  the  tip  of  the  in- 
ternal malleolus.  Apply  strong  traction  to  the  leg  and  reduce  the  fracture  as 
accurately  as  possible.     Transfix  the  tibia  with  pin  A  opposite  the  tubercle. 

"The  two  pins  must  enter  the  bone  by  exactly  parallel  routes.  To  the 
pins  affix  the  rest  of  the  apparatus.  Fig.  1072.  By  rotating  the  cylinders  E  dis- 
traction is  obtained.  After  a  few  days  the  patient  can  leave  his  bed  and  walk 
with  crutches,  and  at  the  end  of  ten  days  he  can  put  his  foot  to  the  ground  and 


HEY-GROVES'    METHOD  905 

gradually  bear  his  weight  upon  his  injured  leg.  The  apparatus  is  removed  in 
three  weeks  in  the  comminuted  cases  when  union  is  rapid',  but  it  may  be  left  on 
for  six  weeks  in  a  case  where  union  is  slow." 

Exact  parallelism  of  the  two  pins  is  difficult  to  attain,  therefore  Hey- 
Groves  has  modified  his  apparatus,  as  follows:  "The  apparatus  consists  in 
two  transfixion  pins  ^f  g  inch  thick,  and  two  longitudinal  extension  bars  made 
of  a  tube  into  which  screw  rods  3-^  inch  thick  threaded  with  reversed  screws 
(Fig.  1073).  The  tube  is  perforated  at  its  centre  by  holes  for  a  lever,  and  when 
it  is  turned  in  one  direction  both  the  projecting  bars  are  forced  apart,  whilst 
the  reverse  movement  draws  them  together.  One  of  the  tansfixion  pins 
passes  through  two  holes  in  a  circular  hoop  of  steel  6  inches  in  diameter  3'^ 
inch  thick  and  i  inch  wide.  There  are  twelve  holes  in  the  hoop,  arranged  as 
six  opposite  pairs,  so  that  the  pin  can  lie  in  any  one  of  six  different  diameters 
of  the  hoop.  The  extension  bars  fit  by  an  eyelet-hole  over  the  ends  of  one  pin, 
and  by  the  other  they  take  a  bearing  on  the  steel  hoop  by  a  joint  which  allows 
of  a  lateral  movement  through  30°.  This  point  can  be  locked.  When  the 
apparatus  is  in  position  it  permits  of  the  following  movements: 

"  I.  Direct  Extension,  by  rotating  the  central  tubes  of  the  longitudinal  bars 
in  the  same  direction. 

"2.  Tilting  of  the  transfixion  pins  with  consequent  correction  of  angular 
deformity,  by  screwing  one  extension  bar  more  than  the  other,  or  by  screwing 
them  in  reverse  directions.  If  the  one  pin  which  pierces  the  hoop  lies  at  right 
angles  to  the  plane  of  the  extension  bars,  it  can  be  tilted  by  pulling  on  one 
end  in  a  distal  and  the  other  in  a  proximal  direction. 

"3.  Rotation  of  one  transfixion  pin  in  relation  to  the  other.  This  allows 
of  rotatory  displacement  being  corrected. 

"As  regards  the  technique  of  the  application  of  this  apparatus  to  the  thigh 
or  low^er  leg,  the  general  remarks  made  about  transfixion  apply  here,  but  in 
the  making  of  the  punctures  for  the  upper  or  counter  extension  pin,  the  skin 
must  be  drawn  downwards,  whereas  with  the  lower  it  is  drawn  upwards  for 
the  avoidance  of  tension. 

"In  applying  the  upper  pin  to  the  femur  a  point  is  taken  on  the  front  of 
the  thigh  vertically  below  the  anterior  superior  iliac  spine  and  on  a  level  with 
the  lower  border  of  the  symphysis  pubis.  This  is  over  the  base  of  the  great 
trochanter.  The  pin  is  inserted  backwards,  so  that  its  posterior  end  emerges 
behind  the  prominence  of  the  trochanter  and  not  at  the  back  of  the  thigh. 

"The  upper  pin  in  the  tibia  should  lie  between  the  level  of  the  lower  border 
of  the  patella  and  the  tuberosity  of  the  tibia,  in  a  transverse  direction.  In 
each  case  the  lower  pin  is  in  the  position  described  above  for  simple  transfixion. 

"The  apparatus  is  applied  under  general  anesthesia;  the  double  transfixion, 
only  occupying  about  23^  minutes,  can  be  done  under  gas,  but  unless  there 
is  any  contraindication  ether  is  better,  because  this  gives  a  fuUer  muscular 
relaxation  and  affords  time  for  the  adjustment  of  the  hoop  and  extension  bars. 

"Before  the  operation  it  is  known  by  measurement  or  better  by  the  X-rays 
exactly  how  much  shortening  exists.  The  longitudinal  bars  are  twisted  in 
their  central  tubular  portions  until  this  is  fully  corrected  or  until  the  trans- 
fixion pins  show  a  marked  bowing.     Being  made  of  higher  tempered  steel, 


9o6  UNUNITED    FRACTURE.      PSEUDARTHROSIS 

they  act  as  powerful  springs,  and  within  two  days  they  will  have  straight- 
ened themselves,  and  further  extension  can  be  given  by  a  few  turns  of  the 
tubular  screws,  and  so  on  at  two-day  intervals  until  the  correct  length  of  the 
bone  has  been  gained. 

"The  limb  is  slung  up  off  the  bed,  so  that  the  wounds  can  be  dressed  with 
the  least  disturbance.  At  the  end  of  a  week  the  patient  with  a  fracture  of 
the  tibia  and  fibula  can  get  up  and  the  one  with  the  fractured  femur  can  be 
moved." 

Method  G.-  Fixation  by  Ferrules  of  Decalcified  Bone.  TSenn.) — Figure 
1074  suflicienlly  sliows  this  method. 


Fig.  1074. — Decalcified  bone  ferrule  in  place. 

Step  4. — Closure  of  the  Wound. — Have  an  assistant  hold  the  limb  steady 
in  good  position.  Close  the  periosteal  wound  with  fine  catgut  sutures.  Close 
the  rest  of  the  wound  secundum  arteni,  with  or  without  drainage.  Apply  dress- 
ings Immobilize  by  plaster  of  Paris  or  preferably  by  proper  splints.  Treat 
as  an  ordinary  fracture. 

Early  in  this  chapter  it  was  stated  that  if  the  principles  of  treatment  here 
outlined  are  carried  out  with  cleanliness  union  is  sure,  provided  that  the  local 
and  general  vitality,  i.e.,  the  recuperative  power,  is  sufficient.  Where  the  general 
vitaHty  is  low  it  must  be  stimulated  by  proper  diet,  tonics,  and  especially  by  the 
open  air.  Where  the  local  vitality  is  low,  although  the  wound  may  heal  by 
primary  union,  yet  the  fracture  may  not  consolidate,  the  bone-forming  cells 
have  not  done  their  work.  To  stimulate  repair,  massage  is  of  value  and  the  use 
of  apparatus  which  permits  of  ambulatory  treatment  may  also  aid. 

V.  Biingner  ("Archiv  fiir  klin.  Chir.,"  xH,  185)  recommends  that  primary 
union  be  not  sought  in  cases  where  atrophy  of  the  fractured  ends  of  the  bone  is 
present,  but  that  after  these  structures  are  fixed  together  by  any  of  the  methods 
described,  the  wound  be  packed  with  gauze  and  allowed  to  heal  by  granula- 
tion.    There  is  something  to  be  said  in  favor  of  this  suggestion. 

When  one  bone  of  the  leg  or  forearm  is  the  site  of  pseudarthrosis  and  there 
is  much  loss  of  substance,  this  loss  must  either  be  made  good  or  apposition  of 
the  fragments  obtained  by  excising  a  portion  of,  and  so  proportionately  short- 
ening the  companion  bone.  For  example,  after  freshening  the  ends  of  the  bone 
in  pseudarthrosis  of  the  tibia,  direct  apposition  may  be  impossible  until  a  seg- 
ment of  the  fibula  is  excised.  Where  the  fracture  is  situated  in  the  lower  third 
of  the  radius  it  is  better  to  excise  a  portion  of  the  distal  end  of  the  ulna  rather 
than  a  segment  of  that  bone  opposite  the  radial  fracture.  By  doing  this  the 
necessity  of  obtaining  bony  union  of  a  new  fracture  is  avoided.  Such  methods 
are  easy  but  nece-^sarily  entail  considerable  shortening,  hence  whenever  possible 


PLASTIC    OPERATIONS 


907 


the  loss  of  substance  ought  to  be  made  good  by  some  plastic  operation.  The 
operative  treatment  of  certain  ununited  fractures,  such  as  those  of  the  patella, 
olecranon,  neck  of  femur,  etc.,  are  described  in  other  sections  of  this  work. 

PLASTIC   OPERATIONS   ON  BONE 

Plastic  operations  on  bone  are  required  to  stimulate  union  in  stubborn  cases 
of  pseudarthrosis;  to  fill  bony  defects  caused  by  the  destruction  or  excision  of 
segments  of  bone;  to  replace  bones  congenitally  absent  or  removed  by  operation 


ff\u/iiaa>^i/^  If 


Fig.  1075.  Fig.  1076. 

Figs.  1075  and  1076. — Ollier's  operation 
par  rejiversement. 


Fig.  1077. 
Fig.   1077. — Ollier's  operation /xir 
dissement. 


I.  Autoplasty  with  Pedunculated  Bone  Flaps. — i.  Ollier's  operation  par  ren- 
versement  may  be  taken  as  a  t^-pe  of  these  procedures.  Make  an  incision  through 
the  soft  parts  sufficient  to  expose  the  ends  of  the  bone  and  the  fibrous  tissue 
connecting  them.  Excise  the  fibrous  connection  between  the  fragments.  With 
a  fine  saw  cut  from  one  fragment  a  thin  slice  of  bone  along  the  line  a  b  (Fig. 
1075)  and  remove  it.     From  the  point  c  on  the  other  fragment  cut  through 


A 


(P 


C 


Fig.  1078. 
Figs.  1078  and  1079. 


Fig.  1079. 
-Ollier's  operation  par  implant al ion. 


the  bone  along  the  line  c  d,  leaving  the  periosteum  at  d  undivided.  The  wedge 
of  bone  d  c  f  can  now  be  turned  downwards  (using  the  periosteum  at  d  as  a  hinge) 
so  that  the  apex  of  the  wedge  can  be  wired  or  stitched  to  the  raw  bone  surface 
a  b  (Fig.  1076)  or  pushed  into  the  medulla.  In  young  and  vigorous  patients  the 
operation  has  proven  satisfactory.  As  much  as  two  inches  of  bone  may  be 
replaced  in  this  manner. 


9o8 


UNUNITED    FRACTURE.       PSEUDARTHROSIS 


2.  Ollier's  Operation  par  glissemcnt. — From  one  of  the  fragments  cut  the 
triangle  C  (Fig.  1077).  Be  careful  not  to  separate  this  portion  of  bone  (C)  from 
its  connections  with  the  soft  parts.  Slide  C  downwards  until  it  comes  in  contact 
with  the  fragment  D,  the  end  of  which  must  be  vivified.     Suture  C  to  D. 

3.  OUicr's  Implantation. — This  is  only  suitable  when  one  of  two  parallel 
bones  is  the  site  of  pseudarthrosis. 

From  the  bone  A  cut  the  fragment  D  (Fig.  1078)  preserving  its  connections 
with  the  soft  parts.  Vivify  the  fragments  B  and  C.  Implant  the  fragment 
D  between  B  and  C  (Fig.  1079). 


Fig.   ioSo. 


Fig.  1081. 


Figs.  1080  and  ioSi. — Miiller's  operation. 


4.  W.  Miiller's  Operation.— Step  i. — Expose  the  ends  of  the  bone  by  a  ver- 
tical incision,  A  B  (Fig.  1080).  Remove  the  interposed  old  scar  tissue. 
With  a  chisel  vivify  the  ends  of  the  bone  (xx). 

Step  2. — Outline  the  flap  D  C  E  (Fig.  1080).  With  a  chisel  introduced  at  C 
cut  a  slice  of  bone  from  the  upper  fragment,  thus  forming  a  flap  of  bone,  peri- 
osteum, and  skin,  which  has  a  pedicle  at  D  E. 

Step  3. — Rotate  the  flap  D  C  E  so  as  to  make  it  bridge  the  osseous  defect. 
Fix  the  osseous  surface  of  the  flap  to  the  vivified  ends  of  bone  fragments  at  xx 
(Fig.  1081);  this  may  be  done  with  sutures  or  pegs. 

Step  4. — Close  or  lessen  the  size  of  the  defect  left  by  the  transplantation  of 
D  E  C  by  undermining  and  sliding  the  skin  edges  together  or  by  Thiersch's 
grafts. 

5.  Miiller  has  devised  a  method  by  which  the  twisting  of  pedicle  of  the  flap 
is  avoided. 

Step  I.- — Make  the  U-shaped  incision  A  B  C  D  (Fig.  1082),  the  points  A  and 
B  being  an  inch  or  more  above  the  end  of  the  upper  fragments,  and  the  apex  of 
the  flap  (C  D)  a  similar  distance  below  the  end  of  the  lower  fragment. 

Step  2. — With  a  chisel  introduced  at  C  D,  cut  a  slice  of  bone  from  the  lower 


HUNTINGTON  S    OPERATION 


909 


fragment  and  raise  it  along  with  the  corresponding  periosteum  and  skin.  Con- 
tinue the  dissection  of  flap  A  B  C  D  upwards. 

Step  3. — Remove  the  fibrous  tissue  from  between  the  two  fragments  of  bone. 
With  the  chisel  vivify  the  end  of  the  upper  fragment  of  bone. 

Step  4. — With  the  part  of  flap  A  B  C  D  which  contains  bone,  bridge  the 
defect  between  the  upper  and  lower  fragments  (Fig.  1083). 

6.  Huntington's  Operation  ("Annals  Surg.,"  Feb.,  1905;  "California  State 
Journ.,"  Oct.,  1909). — Huntington's  operation  is  suitable  in  cases  where  there 
has  been  extensive  loss  of  the  tibia,  but  the  fibula  remains  intact.  It  is  pre- 
supposed that  any  infection  which  may  have  been  present  is  now  absent. 


I    ) 


Fig.  1082. 


Figs.  1082  and  1083. — ^Muller's  operation. 


Through  an  appropriate  incision  expose  and  divide  the  fibula  at  a  point 
opposite  the  lower  end  of  the  upper  tibial  fragment  and  fix  the  fibula  into  a  de- 
pression in  the  tibia.  Codman  ("Annals  Surg.,"  June,  1909)  carried  out  Hunt- 
ington's operation  as  follows  (Figs.  1084  and  1085):  Make  a  curved  incision 
five  inches  in  length  across  the  leg  exposing  the  upper  fragment  of  the  tibia. 
Chisel  away  the  tip  of  this  fragment.  Divide  the  fibula  at  a  slightly  higher  level. 
Bend  the  leg  outwards  and  so  force  the  fibula  into  the  place  prepared  for  it  in 
the  upper  fragment  of  tibia  and  push  it,  like  a  peg,  for  a  short  distance  into  the 
spongy  bone.  Straighten  the  leg.  Fill  the  dead  space  left  at  the  point  where 
the  fibula  was  transferred  with  a  portion  of  tibialis  anticus  muscle.  Close  the 
wound.  Dress.  Immobilize.  In  time  there  is  liable  to  be  a  bowing  of  the 
foot  on  the  fibula  causing  a  deformity. 

This  led  Huntington  after  the  lapse  of  six  months  to  perform  a  second 
operation  as  follows:  Expose  the  upper  end  of  the  lower  fragment  of  tibia. 
Vivify  it.  Divide  the  fibula  at  about  the  same  level.  Unite  the  fibula  to  the 
tibia.     Close  the  wound.     Dress.     Immobilize. 


QIO 


UNUNITED    FRACTURE.      PSEUDARTHROSIS 


Several  brilliant  results  have  been  obtained  by  Huntington's  operation. 
Huntington's  patient  walks  without  a  limp — runs  and  plays  foot-ball. 

7.  J .  S.  Stone  s  Operation  ("Annals  Surg.,"  Oct.,  1907). — Stone's  operation 
is  practically  identical  with  Huntington's  except  that  he  assures  stability  to 
the  foot  in  the  second  operation  by  having  both  malleoli  attached  to  the  new 
tibia  (Fig.  loSbj. 

First  Stage. — Implantation  of  the  upper  end  of  fibula  into  upper  tibial 
fragment.     Identical  with  Huntington's  operation. 


1 

1 

I 

i 

' 

Fig.  1084. — Before  operation.  Fig.  1085. — After  operation. 

Figs.  1084  and  1085.— Replacing  tibia  with  fibula.     (Codtnan,  Annals  of  Surgery.) 

Second  Stage. — Expose  and  vivify  the  upper  end  of  the  lower  tibial  fragment. 
Expose  (without  injuring  the  periosteum)  the  lower  3  inches  of  the  fibula.  Divide 
the  periosteum  with  a  knife.  With  fine  chisel  and  strong  knife  split  the  fibula 
longitudinally  into  two  equal  parts.  In  Stone's  case  "each  half  of  the  bone 
had  a  thickness  of  only  4  mm.,  scarcely  over  an  eighth  of  an  inch,  yet  in  separat- 
ing them  for  a  distance  of  about  3  inches,  8  cm.,  it  was  essential  that  the  peri- 
osteum remain  adherent  to  each  portion  and  that  an  equal  thickness  of  each 
part  be  maintained  throughout.  It  was  planned  to  spread  the  halves  without 
breaking  either.  This  proved  impossible.  Fortunately  the  outer  rather  than 
the  inner  half  gave  way  close  to  the  upper  end  of  the  split  between  them.  In 
another  case  it  would  seem  wise  to  insure  a  break  in  the  outer  half  at  this 


AUTOPLASTY 


911 


point  rather  than  run  the  risk  of  breaking  the  inner  half  or  the  outer  half  at 
a  lower  level.'' 

When  the  fibula  has  been  transformed  to  take  the  place  of  the  tibia  its 
growth  becomes  much  increased  so  that  the  thin  splint-like  bone  comes  to 
simulate  the  tibia  in  size. 


Fig.  1086.— Tibia  replaced  by  fibula.     {Stone,  Annals  of  Surgery.) 

8.  Autoplasty  by  means  of  periosteal  flaps  (Codivilla's  operation)  is  closely 
allied  to  the  transplantation  of  pedunculated  flaps  of  bone.  Codivilla,  after 
vivifying  the  ends  of  the  bone,  unites  them  with  a  wire  suture  and  envelopes 
this  suture  in  a  detached  flap  of  periosteum  taken  from  any  convenient  bone. 


912  UNUNITED   FRACTURE.      PSEUDARTHROSIS 

Codivilla  is  careful  to  remove  a  thin  shell  of  bone  with  the  periosteum,  but 
Brade  ("Beitriige  zur  klin.  Chir.,"  Ixi)  used  the  periosteum  alone  and  obtained 
a  good  result. 

Operation  for  Congenital  A  bsence  of  Tibia. 

Halstead  Myers  ("Med.  Record,"  July  15,  1905)  operated  for  the  above- 
named  condition  successfully  as  follows:  Incision  across  the  outer  half  of  the 
joint  opening  the  articulation  between  the  fibula  and  femur.  The  patellar 
ligament,  thin  and  long,  was  inserted  on  the  inner  side  of  the  fibula  well  below 
its  head.  The  capsular  ligament,  and  especially  the  external  lateral  ligament, 
were  very  strong  and  required  division  before  the  head  of  the  fibula  could  be 
drawn  downwards  and  inwards  to  a  position  between  the  condyles.  The  patellar 
ligament  was  shortened  and  attached  to  the  anterior  surface  of  the  fibula. 
With  sutures  the  articular  capsule  was  repaired  so  as  to  aid  in  holding  the 
head  of  the  fibula  in  its  new  position.  After  closure  of  the  wound  at  the  knee, 
the  ankle  was  opened  by  a  transverse  incision,  the  external  malleolus  was 
cut  off  and  the  cut  end  of  the  fibula  planted  on  to  the  surface  of  the  astragalus, 
which  was  denuded  for  that  purpose.  Apposition  of  the  bones  was  retained  by 
sutures.  The  after  treatment  consisted  in  immobilization.  A  year  after  opera- 
tion the  patient  could  flex  his  leg  to  90  degrees,  almost  fully  extend  it,  and 
walk  about  all  day. 

II.  Autoplasty  with  Non-pedimculated  Portions  of  Living  Bone. 

A.  Transplantation  of  portions  of  bone  covered  with  its  periosteum. 

Step  I. — Expose  the  ends  of  the  bone.  Remove  interposed  fibrous  tissue. 
Freshen  the  ends  of  the  fragments.     Temporarily  pack  the  wound. 

Step  2. — Select  the  bone  from  which  to  obtain  material  for  transplantation, 
the  favorite  ones  are  the  tibia,  the  ribs,  or  the  upper  third  of  the  ulna.  Make 
a  vertical  incision  down  to  the  bone  and,  without  disturbing  the  periosteum, 
expose  it  sufficiently.  With  a  chisel,  cut  away  a  slice  of  bone  with  its  periosteum 
large  enough  to  bridge  the  defect.     Pack  the  wound  temporarily. 

Step  3. — Remove  the  pack  from  the  wound  made  in  Step  i.  Bridge  the 
osseous  defect  by  means  of  the  "bone-periosteal"  flap.  Be  sure  that  the  raw 
surface  (cut  surface)  of  the  graft  lies  against  corresponding  raw  surfaces  in  its 
new  birth.  If  necessary  fix  the  graft  in  position  by  means  of  sutures.  Close 
the  wound.     Apply  dressings.     Immobilize. 

Step  4. — Remove  the  pack  from  the  wound  made  in  Step  2.  Close  the 
wound.     Apply  dressings. 

E.  Lexer  ("Archiv  fur  klin.  Chir.,"  Ixxxv,  939)  publishes  a  remarkable 
contribution  to  our  knowledge  of  bone  transplantation. 

In  his  clinic  amputation  for  dry  senile  gangrene  is  common  and  from  the 
limbs  so  amputated  he  obtains  his  material.  If  the  implant  is  to  be  covereid 
by  periosteum  still  existing  around  the  bony  defect,  that  covering  the  implant 
must  be  removed,  as  a  double  layer  of  periosteum  gives  rise  to  exuberant  and 
irregular  development  of  bone.  In  all  other  circumstances,  even  when  the 
implant  is  placed  in  the  medullary  cavity,  the  periosteum  on  the  implant  should 
be  preserved.  If  a  tubular  or  cylindrical  bone  is  used  as  an  implant  and  the 
marrow  is  left  intact,  local  and  constitutional  disturbances  commonly  give 
trouble  without  infection  or  interference  with  union.     To  avoid  these  disturb- 


TRANSPLANTATION  BONE  913 

ances  which  he  attributes  to  absorption  of  degenerated  medullary  substances, 
Lexer  removes  the  marrow  with  a  spoon  and  fills  the  resulting  cavity  with  an 
iodoform  plug  (like  Mosetig's). 

Lexer  has  successfully  implanted  segments  of  bone  (with  its  periosteum) 
8  to  12  inches  (20  to  30  cm.)  in  length.  The  bone  used  must  be  so  fresh  as  to 
be  still  warm.     See  p.  900,  Murphy  on  transplantation  of  bone. 

If  the  transplants  arc  homogenous  instead  of  autogenous  it  is  advisable  to 
choose  a  donor  whose  blood  belongs  to  the  same  class  as  that  of  the  recipient 

B.  Transplantation  of  part  of  the  whole  thickness  of  the  shaft  of  a  hone  plus  one 
of  its  articulating  ends. 

Transplantation  combined  with  arthroplasty. 

A  good  example  of  the  above  is  the  following:  In  a  case  of  sarcoma  of  the 
upper  end  of  the  humerus,  Rovsing  ("Hospitalstidende,"  iii,  No.  i.  Ref. 
"Journ.  de  Chir.,"  March,  1910)  excised  the  diseased  bone  and  implanted  a 
segment  of  fibula. 

Step  I.— Make  a  curved  incision  following  the  borders  of  the  acromion 
process  and  through  this  penetrate  the  shoulder-joint.  Beginning  at  this  in- 
cision make  a  longitudinal  cut  down  the  outer  surface  of  the  arm  to  a  point 
well  below  the  disease. 

Step  2. — Excise  the  desired  portion  of  the  humerus  plus  its  periosteum  and 
the  muscular  insertions  so  as  to  keep  away  from  the  disease.  If  the  long  head 
of  the  biceps  is  involved  in  the  disease  excise  it  also. 

Step  3. — Attend  to  hemostasis  and  pack  the  wound  temporarily  with  gauze. 

Step  4. — ^Expose  the  upper  end  of  the  fibula  through  a  longitudinal  incision, 
being  careful  to  retract  uninjured  the  external  popliteal  nerve.  Open  the 
superior  tibio-fibular  articulation. 

Step  5. — Mobilize  a  segment  of  the  fibula  about  3  cm.  longer  than  the  seg- 
ment of  humerus  which  was  removed  and  excise  it,  but  leave  "a  sort  of  muscular 
sheath  about  i  cm.  thick  attached  to  it." 

Step  6. — With  a  chisel  sharpen  the  lower  end  of  the  fragment  of  fibula  and 
force  it  into  the  medullary  cavity  of  the  diaphysis  of  the  humerus. 

Step  7. — With  sutures  fasten  the  remains  of  the  articular  capsule  of  the 
shoulder-joint  to  the  fibula  and  the  soft  parts  of  the  arm  to  the  muscular  tissue 
left  attached  to  the  implanted  fibula. 

Step  8. — Close  the  wound.     Apply  dressings. 

In  Rovsing's  case  free  passive  motion  was  possible  two  months  after  opera- 
tion and  the  patient  was  able  to  use  the  arm  in  carrying  food  to  his  mouth. 

Operations  similar  to  or  identical  with  Rovsing's  have  been  performed  by 
a  number  of  surgeons. 

CharlesDavison  (Surg.,  Gyn.  and  Obst.,  Aug.,  1919)  has  used  the  upper  end 
of  the  fibula  to  replace  the  head  of  the  femur  with  satisfaction.  The  head  of 
the  transplant  hypertrophied  until  its  size  and  strength  met  the  functional 
demands.  Immobilization  was  kept  up  for  seven  months.  Then  there  was 
'vigorous  passive  motion'  until  walking  was  permitted.  Walking  without  sup- 
port was  not  permitted  until  two  years  after  operation.  The  patient  (aged  50) 
became  able  to  walk  up  and  down  stairs  and  could  cross  her  knees  while 
sitting. 

58 


914  UNUNITED    FRACTURE.      PSEUDARTHROSIS 

Transplantation  of  Epiphysis. — In  a  boy,  ten  years  old,  the  lower  fourth  of 
the  k'f I  iibula  had  been  destroyed  two  years  previously.  Staigc  Davis  (Annals 
of  Surg.,  1916,  Vol.  LXIV,  520)  freshened  the  distal  end  of  the  bone  and  cut  a 
bed  in  the  scar  tissue  which  occupied  the  place  of  the  external  malleolus.  He 
then  exposed  the  upper  end  of  the  fibula,  split  it  longitudinally  and  removed 
a  fragment,  with  its  periosteum,  6  cm.  long  and  about  ^i  the  thickness  of  the 
shaft.  This  fragment  included  the  upper  epiphyseal  cartilage.  The  transplant 
was  placed  in  the  bed  prepared  for  it,  the  marrow  surface  was  next  the  tibia, 
the  epiphysial  end  was  used  as  malleolus.  Free  fascial  strips  were  used  to 
unite  the  transplant  to  the  stump  of  the  fibula  and  to  the  calcaneus  respectively. 
A  free  transplant  of  skin  was  required  to  close  the  wound  because  of  the  amount 
of  scar  tissue.  In  spite  of  these  handicaps  the  transplant  lived  and  after  five 
years  had  increased  in  length.  Before  operation  the  right  fibula  measured 
20  cm.,  the  left  22.  Five  years  later  the  measurements  were  right  36  cm., 
left  32.75. 

C.  Transplantation  of  fragmented  bone  with  or  without  periosteum.  (Mac- 
ewen's  method.) 

Step  I. — Expose  the  ends  of  the  bone.  Remove  interposed  fibrous  tissue. 
Freshen  the  ends  of  the  fragments.     Temporarily  pack  the  wound. 

Step  2. — Obtain  fragments  of  bone  as  in  method  A,  or  from  a  patient  on 
v/hom  cuneiform  osteotomy  is  necessary.  If  there  is  any  delay  between  obtain- 
ing the  fragments  and  their  implantation,  be  careful  to  keep  them  in  warm  salt 
solution  or  wrapped  in  warm,  moist  gauze.  With  a  chisel  cut  the  pieces  of 
bone  to  be  implanted  into  small  fragments. 

Step  3. — Fill  the  gap  between  the  freshened  ends  of  the  bone  to  be  united 
with  the  osseous  fragments  obtained  as  above. 

Step  4. — Close  the  wound  without  drainage.  Apply  dressings.  Immo- 
bilize.    The  implantation  of  fragmented  bone  has  given  some  brilliant  results. 

III.  Transplantation  of  Dead  Bone. 

A.  Decalcified  Bone  Chips. — On  the  theory  that  the  fragments  implanted 
according  to  the  preceding  method  do  not  grow,  but  merely  act  as  scaffolding, 
to  be  replaced  by  osseous  material  supplied  by  the  ends  of  the  fractured  bone, 
some  surgeons  have  used  in  their  place  chips  of  decalcified  bone.  The  prepara- 
tion and  use  of  decalcified  bone  chips  is  described  elsewhere. 

B.  Transplantation  of  Large  Fragments  of  Dead  Bone. — Kausch  ("Beitrage 
z.  klin.  Chir.,"  Ixviii,  p.  670)  after  removing  the  upper  end  of  the  tibia  for 
sarcoma  implanted  a  corresponding  portion  of  a  tibia  obtained  in  the  course  of 
an  amputation  some  days  previously.  The  implant  was  deprived  of  its  peri- 
osteum and  marrow,  was  carefully  boiled  and  soaked  in  ether  to  remove  its 
fat.  There  was  complete  operative  recovery,  but  recurrence  of  the  sarcoma 
necessitated  amputation  nine  months  later,  when  examination  showed  the 
implant  firmly  united  both  to  the  fermur  and  the  tibia  and  enveloped  in  a  new 
formed  periosteum.  Kiittner  ("Zentralblatt  fiir  Chir.,"  1910,  No.  31)  excised 
the  upper  third  of  the  femur  for  osteosarcoma,  and  at  once  implanted  a  similar 
portion  of  femur  obtained  from  a  man  who  had  been  operated  on  for  coma 
due  to  tumor  of  the  brain  and  died  without  regaining  consciousness.  The 
upper  end  of  the  femur  along  with  its  head  was  removed  under  aseptic  pre- 


MALUNION    FRACTURES 


915 


cautions  eleven  hours  after  death  and  was  preserved  for  twenty-four  hours  in 
salt  solution  to  which  some  chloroform  had  been  added.  Six  weeks  after 
operation  the  result  was  promising. 

IV.  After  removing  a  central  enchondroma  from  a  phalanx,  Primrose  im- 
planted an  ivory  peg  of  suitable  size  and  shape.  A  skiagram  taken  fourteen 
weeks  later  showed  the  peg  partially  absorbed  but  surrounded  by  a  satisfactory 
amount  of  good  bone.  Primrose's  operation,  as  well  as  those  in  which  joints  are 
transplanted  from  fresh  cadavera,  are  all  anticipated  in  Th.  Gluck's  almost 
prophetic  article  published  in  the  Archiv  fur  klin.  Chir.,  xli,  1890. 


CHAPTER  LXVIII 
FRACTURES.    MALUNION 

When  fractures  have  solidly  united  in  bad  position  or  with  an  excess  of 
permanent  callus,  deformity  results.     The  deformity  is  often  of  no  importance, 


Fig.  1087. — Badly  united  fracture. 
Line  of  section. 

but  when  it  is   disfiguring,   operation  may  be  proper;  when  it  is  disabling, 
operation  may  be  obligatory. 

(A)  When  excessive  callus  causes  injurious  pressure  on  important  nerves 
or  vessels,  cut  down  upon  the  callus  and  with  a  chisel  or  rongeur  forceps  remove 
as  much  of  it  as  may  be  necessary.     Sometimes  it  is  wise,  after  freeing  the  nerve 


9i6 


FRACTURES.      MALUNION 


or  vessel  from  injurious  pressure,  to  interpose  a  flap  of  fascia  or  muscle  between 
these  structures  and  the  bone. 

(B)  Malunion  without  much  shortening,  but  in  a  more  or  less  angular  posi- 
tion, requires  the  same  operative  treatment  as  similar  deformities  due  to  other 
causes.     See  Osteotomy. 


^l^Sl 


Fig.  1088. 

If  a  moderate  amount  of  shortening  is  present 
an  obHque  osteotomy  will  not  only  correct  the 
angular  deformity,  but  may  permit  the  desired 
amount  of  lengthening  to  be  obtained  (Fig.  1087). 

(C)  Malunion  with  Much  Shortening  Owing  to 
"Overriding"  of  the  Bones.— The  treatment  of 
this  condition  consists  in  osteotomy,  if  necessary 
plus  fixation  of  the  bones  as  in  pseudarthrosis. 
Figures  1088  and  1089  sufficiently  explain  the 
general  plan  of  operation.     It  must  be  remembered 


Fig.  1089. 


Fig.  1090. 


Fig.  1091.— (Pa^T.) 


Figs.  1091  and  1092. — Direct  traction  apparatus 

that  contraction  of  the  soft  parts  must  be  overcome  before  apposition  in  good 
position  can  be  obtained  or  maintained.  For  this  purpose  extension  by 
means  of  the  weight  and  pulley  or  suitable  apparatus  is  often  sufficient,  but 


DIRECT   EXTENSION 


917 


it  must  frequently  be  supplemented  by  tendon  lengthening,  by  tenotomies,  or 
by  fasciotomies. 

Direct  Application  of  Extension  Apparatus  to  Bones. — Codivilla  and  Stein- 
mann  have  each  recommended  that  extension  be  applied  directly  to  bones  and 
thus  better  results  be  obtained  than  where  the  extension  is  exerted  through 
adhesive  plaster  applied  to  the  skin.  The  application  of  the  principle  is  simple 
and  safe  provided  the  asepsis  is  perfect.  There  are  two  methods  by  which  direct 
extension  may  be  applied:  1.  Make  a  puncture  down  to  the  bone.  Drill  a 
hole  completely  through  the  bone.  Introduce  a  skewer  through  the  bone  and 
make  it  protrude  through  a  puncture  in  the  skin  on  the  opposite  side  of  the  limb. 


Fig.  iog2. — (Steinmann.) 


■  Fig.  1093. — Improved    ice-tong    calipers. 
(r.  P.  Jones,  Am.  J.  Orthop.  Surg.) 


Apply  dressings  to  the  punctures  around  the  protruding  ends  of  the  skewer. 
Attach  strings  to  the  end  of  the  skewer  and  a  weight  to  the  strings.  2.  On  one 
side  of  the  limb  make  a  puncture  down  to  the  bone  through  the  puncture 
fasten  a  nail  or  drill  securely  into  the  bone.  Do  the  same  on  the  opposite  side 
of  the  bone  and  attach  weights  to  the  nails  by  means  of  cords  or  cahpers  (Figs. 
1090,  1091  and  1092).     The  first  of  these  methods  is  by  far  the  better. 

Ransohoff  uses  an  appliance  like  ice-tongs  or  calipers  for  the  same  purpose. 
Robert  Jones,  Bowlby,  Sinclair  and  others  urge  that  the  Steinmann  apparatus 
is  dangerous  and  that  ice-tongs  calipers  such  as  devised  by  Ransohoff  and  modi- 
fied by  Pearson  be  so  guarded  that  they  grip  but  do  not  penetrate  the  bone 


91 8  FRACTURES.       MALUNION 

(Fig.  1093).     ^f  course  care  nnist  be  taken  to  a\oid  any  penetration  of  or  injury 
to  a  joint  in  using  the  calipers  or  pins. 

It  may  be  useful  to  describe  in  some  detail  the  operative  treatment  of  one 
or  two  well-known  exanij)les  of  malunion. 

I.  Malunion  in  Colles's  Fracture.— The  lower  fragment  of  the  radius  is 
tilted  dorsally  on  the  upper  fragment  and  has  become  united  there,  causing 
the  classic  "silver  fork"  deformity. 

Dawbarn's  Operation. — Step  i. — Expose  the  line  of  union  b\'  a  longitudinal 
incision  along  the  outer  side  of  the  bone.  Reflect  the  periosteum  along  with 
the  rest  of  the  soft  parts  from  the  outer  side  of  the  bone.  Avoid  injuring  the 
radial  nerve. 

Step  2. — With  a  fine  chisel  or  osteotome  divide  the  line  of  union  between 
the  two  fragments.  Correct  the  deformity  and  after  closing  the  wound  treat 
as  an  ordinary  Colles's  fracture.  After  correction  there  is  frequentl)'  a  gap 
left  between  the  two  fragments.     This  gap  may  be  filled  in  one  of  two  ways. 

Step  3. — (A)  At  a  point  midway  between  the  wrist  and  elbow,  make  an 
incision  down  to  the  ulna.  From  the  ulna  excise  a  segment  of  bone  equal  to 
the  gap  in  the  radius.  Unite  the  divided  ulna  secundum  arteni.  The  resultant 
shortening  of  the  ulna  permits  apposition  of  the  fragments  of  the  radius.  The 
whole  forearm  is  of  course  shortened. 

(B)  Remove  from  the  ulna  a  much  smaller  segment  of  bone.  With  the 
chisel  cut  this  segment  into  small  fragments  and  implant  them  between  the 
fractured  surfaces  of  the  radius.  The  advantage  of  method  B  is  that  there  is 
less  shortening  of  the  forearm  than  with  method  A. 

(C)  Possibly  the  gap  might  be  filled  by  a  modification  of  Oliier's  auto- 
plastic operation  (p.  907).  . 

Remarks. — H.  A.  Lothrop  ("Boston  Med.  and  Surg.  Journ.,"  Dec.  7,  1905) 
finds  that  the  deformity  from  unreduced  Colles's  fracture  can  usually  be  cor- 
rected by  manipulation,  under  an  anesthetic,  during  the  first  three  weeks 
after  injury;  that  after  two  to  six  months  an  operation  on  the  lines  of  Dawbarn's 
should  always  improve  the  position  and  frequently  the  function;  that  after  six 
months,  while  it  is  easy  to  correct  backward  and  upward  displacement,  lateral 
displacement  is  hard  to  overcome  and  usually  requires  osteotomy  of  the  ulna. 
The  late  operation,  according  to  Lothrop,  rarely  improves  function. 

II.  Malunion  after  Separation  of  Lower  Femoral  Epiphysis.^ — The  epiphysis 
is  usually  dislocated  forwards  and  upwards  and  remains  in  contact  with  the 
diaphysis.  There  may  be  much  callus.  Where  fair  mobility  of  the  knee 
is  retained  or  expected,  operative  reduction  is  positively  indicated;  where 
anchylosis  is  present  an  osteotomy  may  give  as  good  results  with  less  risk. 

(A)  Operative  Reduction. — Step  i . — Expose  the  line  of  union  by  a  longitud- 
inal incision  on  one  or  both  sides  of  the  limb. 

Step  2. — With  the  elevator  separate  the  periosteum  and  soft  structures 
together  from  the  sides  of  the  bone  at  the  line  of  union.  With  the  osteotome 
divide  the  line  of  union.  By  manipulation  reduce  the  fracture.  Before 
obtaining  reduction  it  may  be  necessary  to  pare  off  some  bony  prominences  or 
excrescences  and  to  divide  or  lengthen  the  hamstrings.     After  reduction  the 


SEPAKATI(3N    EPIPHYSIS 


919 


Fig.  1094. — Separation  of  lower  femoral  epiphysis,  before  operation. 


Fig.  IOQ5. — After  operation 


920 


SPECIAL    FRACTURES 


fragments  may  be  lield  in  apposition  by  sutures,  naile,  bone  pegs  or  buried 

metallic  splints. 

Step  3. — Close  the  wound  with  or  without  drainage.  If  a  tourniquet  (elastic 
constrictor)  has  been  used,  the  author  provides 
drainage,  applies  dressings  and  splint,  and  only 
removes  the  tourniquet  after  the  patient  has  been 
put  to  bed  with  the  limb  fixed  in  a  vertical  posi- 
tion. After  twenty-four  hours  the  limb  may  be 
gradually  lowered. 

Figures  1094  and  1095  show  a  case  before  and  after 
the  above  treatment  was  carried  out. 

(B)  Osteotomy .^ — When  from  any  cause  operative 
reduction  is  inappropriate,  the  deforming  flexion  may 
be  overcome  by  osteotomy. 

In  a  case  of  much  disability  due  to  malunion 
after  Pott's  fracture,  Feiss  ("Surg.,  Gyn.,  Obst.," 
June,  1909)  corrected  the  deformity  and  restored 
the  weight-bearing  line  by  making  a  linear  osteotomy 
on  the  tibia  and  a  cuneiform  osteotomy  on  the  fibula, 
Fig.  1096  is  self-explanatory.  The  result  was  very 
gratifying. 


( 

i 

i 
t 

V. 


Fig.  1096. — Correction 
of  deformity  after  Pott's 
fracture.  {Feiss,  Surgery, 
Gynecology  and  Obstetrics.) 


CHAPTER  LXIX 


SPECIAL  FRACTURES 


I.  Fractures  of  the  neck  of  the  femur,  whether  involving  the  neck  alone  or 
with  it  the  trochanter. 

(A)  Excision  of  the  Head  or  Fragments.^ — Expose  the  joint  by  Hueter's 
anterior  incision  and  remove  the  fragments.    No  special  description  is  necessary. 

(B)  Nailing  the  Fragments  (Langenbeck,  Konig,  Trendelenburg,  etc.). — 
Step  I. — Make  a  short  vertical  incision  over  the  outer  surface  of  the  trochanter 
major  and  expose  the  bone. 

Step  2. — By  traction  reduce  the  fracture. 

Step  3.— With  a  drill  bore  a  hole  through  the  trochanter  and  into  that  part 
of  the  neck  attached  to  the  head.  Replace  the  drill  by  a  screw  nail  or  bone 
peg  (Fig.  1097). 

Step  4. — Dress.  Apply  traction  and  immobilizing  apparatus.  (Note:  In- 
stead of  the  screw  nail  or  peg,  the  Parkhill-Freeman  device  may  be  used.) 

(C)  Systematized  Operation. — Step  i. — From  a  point  midway  between  the 
trochanter  major  and  the  anterior  superior  spine  make  an  incision,  4  to  6  inches 
long,  downwards,  parallel  to  the  outer  margin  of  the  sartorius  muscle  (Fig. 
1098)  Hueter's  incision).  By  blunt  and  sharp  dissection  penetrate  to  the 
hip-joint  between  the  sartorius  and  the  tensor  vaginae  femoris  muscles.  A  few 
fibres  of  the  vastus  externus  require  division.  Remember  the  external  cir- 
cumflex artery  which  runs  transversely  immediately  below  the  trochanter. 


FRACTURE    NECK    OF    FEMUR 


921 


Step  2. — Retract  the  soft  parts.  The  fracture  will  now  be  visible.  Note 
that  the  capsule  of  the  joint  and  its  reflection  over  the  femoral  neck  are  torn. 
Remove  blood,  etc.,  from  the  wound.  If  possible,  by  rotation  of  the  limb 
expose  the  capsule  posterior  to  the  joint  and  repair  the  tear  in  it  with  sutures 
(Fig.  1099).  Remember  that  the  most  important  portion  of  capsule  reflected 
on  the  femoral  neck  lies  below  the  neck. 

/ 


(  ..<'\ " 


Fig.  1097. 


Fig.  ioq8. — Hueter's  incision. 


Ligamentum  teres 


Glenoid  lip  ] 

Capsule 

Reflection  of  capsule 


Reflection  of  capsule 


Fig.  logg. — (Morris.) 

Bring  the  fractured  surfaces  of  bone  into  good  apposition  and  fix  them 
in  position  (a)  by  using  method  B  guided  by  the  finger  and  eye  through  the 
open  wound  (b)  by  means  of  wire  sutures. 

Repair  the  tear  in  the  capsule  reflected  on  to  the  neck  of  the  femur. 
Repair  the  main  rent  in  the  capsule.     Close  the  wound  in  the  soft  parts. 

Step  3. — Apply  dressings.     Immobilize. 


922 


SPECIAL   FRACTURES 


J.  E.  Moore  ("Northwestern  Lancet,"  March  i,  1904),  apropos  of  a  case 
of  ununited  fracture  on  which  he  operated,  remarks  that  the  nail  used  for 
fixation  might  have  been  omitted  with  advantage  and  the  Maxwell  method  of 
extension  used  alone.  This  suggestion  applies  equally  to  cases  of  recent  fracture 
of  the  femoral  neck  whether  operated  on  or  not.  The  method  consists  in 
applying  extension  by  weight  and  pulley  in  the  directions  shown  in  Fig.  iioo, 
the  resultant  force  being  in  the  long  axis  of  the  neck  of  the  femur. 


fiESULTA^T 


Fig.  iioo. 

Gurlt,  Fritz  Konig,  and  others  have  noted  that  in  true  intracapsular  fracture, 
the  head  of  the  femur  deprived  of  nourishment  soon  undergoes  degenerative 
changes  which  unfit  it  for  union  even  after  operation,  hence  F,  Konig  advises 
operation  at  the  end  of  eight  days.  Practures  of  the  neck  involving  the  tro- 
chanter rarely  require  operation.  Impacted  fractures  do  not  call  for  operation 
unless  they  cause  disabling  deformity.  Fred  Cotton  in  fractures  of  the  neck 
of  the  femur  produces  impaction.  Having  placed  the  bones  in  good  position  by 
traction  and  manipulation,  he  covers  the  region  of  the  trochanter  with  some 
layers  of  felt  and  then  with  a  large  wooden  mallet  delivers  a  swinging  blow 
to  the  trochanter  in  the  direction  of  the  neck  of  the  bone.  Impaction  having 
been  secured,  immobilization  for  six  or  eight  weeks  is  practised.  The  author 
believes  operation  to  be  rarely  indicated  in  fresh  fractures  of  the  femoral  neck 
in  the  aged.  Maxwell  and  Ruth's  results  of  conservative  treatment  are  most 
encouraging  ("Journal  Am.  Med,  Association,"  April  9,  1904),  but  considering 
how  badly  the  aged  bear  the  necessary  confinement  in  bed,  the  writer  prefers 
to  trust  to  massage,  and  almost  immediate  passive  and  active  motion,  the  re- 
sult being  of  course  pseudarthrosis,  but  almost  always  a  useful  limb. 

If  operation  is  chosen,  which  method  ofifers  most?  Method  B  means 
working  in  the  dark  and  entirely  neglects  restoration  of  the  joint  capsule  which 
has  a  most  important  influence  on  the  nutrition  of  the  head  of  the  bone.  Method 
C  is  no  more  dangerous  than  methods  A  and  B,  but  permits  repair  of  capsule. 
One  of  F.  Konig's  cases  ("Archiv  fiir  klin,  Chir.,"  Ixxv,  725)  demonstrates 
admirably  the  importance  of  this  step.  Of  course  if  the  head  of  the  bone  is 
too  severely  injured  it  ought  to  be  removed. 


SEPARATION    EIMI'llYSlS    FEMUR 


923 


II.  Fractures  of  the  Lower  End  of  the  Femur. 

(A)  Transverse  Fractures. — Operative  Ircatment  is  practically  the  same 
as  that  for  separated  epiphysis. 


Fig.  iioi. — {Morris.) 
a,  Fat;  b.  Opening  in  synovial  membrane  behind  crucial  ligament  leading  into  inner  half  of  joint;  c. 
Synovial  membrane  reflected  off  crucial  ligament;  d,  cut  end  anterior  crucial  ligament;  e,  post,  crucial 
ligament;  /,  oblique  popliteal;' ligament;  g,  quadriceps;  h,  synovial  sac;  i,  tendon  quadriceps;  j,  patella; 
k,  bursa;  /,  condyle  femur;  tn,  patellar  synovial  fold;  n,  fatty  cushion;  o,  bursa;  p,   tibia. 

(B)  Separation  of  Lower  Femoral  Epiphysis. — Step  i. — As  the  knee-joint 
is  usually  unopened  by  the  injury,  endeavor  to  avoid  penetrating  it.  Figure 
IIOI  shows  the  normal  extent  of  the  synovial  sac.     "The  obstacle  to  reduction 


Fig.  1102. — Separation  of  lower  femoral  epiphysis.     {Scudder.) 

is  no  single  band  or  obstruction,  it  is  the  retraction  and  tension  maintained 
by  the  fascia,  ligaments,  and  muscles  of  the  thigh  upon  the  tibia.  This  retrac- 
tion is  so  great  that  the  tibia  is  held  crowded  against  the  lower  end  of  the  upper 
fragment,  and  prevents  the  replacing  of  the  epiphysis"  (Scudder). 


924  SPECIAL   FRACTURES 

Step  2. — ^Make  an  external  longitudinal  incision  freely  exposing  injured 
shaft  and  epiphysis. 

Step  3. — With  strong  hooks  make  traction  on  the  diaphysis  and  epiphysis 
(Fig.  1 102)  or  attain  the  same  purpose  by  other  means.  During  the  above 
manoeuvre  slowly  flex  the  knee  and  so  reduce  the  displacement. 

Step  4.— If  the  fragments  tend  to  remain  in  good  position,  pass  on  to  Step  5. 
If  the  fragments  do  not  tend  to  remain  in  good  position  apply  periosteal  sutures 
(good  in  any  case)  or  bone  pegs  or  any  of  the  established  means  of  fixation. 
It  is  more  important  to  avoid  irritating  means  of  fixation  in  case  of  epiphyseal 
separation  than  in  other  fractures  because  of  their  possible  evil  effect  on  subse- 
quent growth. 

Step  5. — Close  the  wound.  Apply  dressings.  Immobilize  for  three  or  four 
weeks  in  the  flexed  position.  After  this  time  the  leg  may  be  extended,  but  the 
use  of  plaster  of  Paris  or  splints  ought  to  be  kept  up  for  about  six  weeks  from 
the  date  of  operation. 

Figures  1094  and  1095  show  separation  of  the  femoral  epiphysis  before 
and  after  operation. 

(C)  Fractures  of  the  Condyles  of  the  Femur. — A  small  amount  of  deformity 
after  fractures  involving  the  knee-joint  means  much  disability,  hence  operative 
reduction  and  fixation  are  often  indicated. 

Step  I.— Expose  the  site  of  fracture  by  an  internal  or  external  longitudinal 
incision.     This  opens  the  joint. 

Step  2. — Reduce  the  fracture  and  fix  it  in  proper  position  by  some  of  the 
means  already  described.     The  author  prefers  bone  pegs. 

Step  3. — Remove  any  blood  and  detritus  which  may  be  present  in  the 
knee-joint.     Close  the  wound  without  drainage. 

Step  4.— Dress.  Immobilize  in  the  extended  position.  Elevate  the  limb 
for  twenty-four  hours.  As  soon  as  possible  begin  massage  especially  of  the 
quadriceps  extensor  femoris.  .Such  was  the  only  recognized  after  treatment 
until  Willems  of  Ghent  gave  in  1918  his  dramatic  exhibition  in  Paris  of  patients 
treated  by  immediate  active  mobilization.  An  account  of  Willems  method  is 
given  on  page  1030.  Pierre  Duval  remarks  "The  most  important  result  to  be 
obtained  is  the  reestablishment,  as  far  as  possible,  of  a  normal  joint  outline. 
Experience  has  shown  that  good  functional  results  can  be  obtained  even  when 
there  is  a  partial  loss  of  joint  surface  if  the  general  outline  of  the  joint  surface 
has  been  preserved." 

Sampson  Handley  ("Brit.  Med.  Journ.,"  Oct.  5,  1912),  and  Alglave  ("La 
Presse  Med.,"  Nov.  19,  191 2)  both  recommend  transarticular  exposure  of  the 
bone  in  so-called  T  fractures  of  the  lower  end  of  the  femur.  The  parts  are 
exposed  as  in  excision  of  the  knee  by  Method  E,  p.  1055,  where  the  tendo 
patellae  is  divided  and  an  anterior  flap  including  the  patella  is  thrown  upwards 
(Fig.  1 103). '  Alglave  recommends  that  the  tuberosity  of  the  tibia  be  cut  from 
the  bone  by  a  chisel  instead  of  the  tendon  being  divided.  It  is  easy  to  replace 
the  tuberosity  and  fix  it  with  a  wire  nail.  Fig.  1 105  shows  the  exposure  ob- 
tained. A  lateral  incision  plus  division  of  the  tuberosity  may  give  sufficient 
excess  (Fig.  1104). 


FRACTURE    PATELLA 


925 


III.  Fracture  of  the  Patella. 

(A)  Subcutaneous  Methods  of  Fixation.  Barker's  Method. — Step  i. — Pass 
a  long,  strong,  curved  needle  with  an  eye  near  its  point  through  the  skin  and 
tendo  patellae  immediately  below  the  lower  fragment.     Guide  the  point  of  the 


Fig.   1 103. — {Ha-ndley.) 


Fig.  1104. — {Alglave. 


needle  upwards  through  the  knee-joint,  close  to  the  posterior  surface  of  the 
patella  and  make  it  emerge  immediately  above  the  upper  fragment  after  pass- 
ing through  the  quadriceps  tendon  (Fig.  1106). 


Fig.  1105. — {Alglave.) 


Step  2. — Thread  the  needle  with  a  strand  of  strong  soft  silver  wire.  With- 
draw and  unthread  the  needle. 

Step  3. — Through  the  same  opening  reintroduce  the  needle  and  pass  it 
upwards  close  to  but  in  front  of  the  patellar  fragments.  Make  it  emerge 
through  the  same  opening  above  (Fig.  1107). 


926 


SPECIAL   FRACTURES 


Fig.  I 106.  Fig.  1107. 

Figs.  1106  and  1107. — Barker's  operation. 


Fig.  1108. — Barker's  operation. 


SUTURE   PATELLA 


927 


Step  4. — Thread  the  needle  with  the  end  of  wire  protruding  through  the 
upper  opening  and  withdraw  it.     The  wire  now  surrounds  the  broken  bone. 

Step  5. — Approximate  the  fragments  of  bone.  Tighten  the  wire  and  twist 
its  two  ends  snugly.  Cut  off  the  excess  of  wire.  Bury  the  twisted  part  of  the 
wire  beneath  the  skin,  if  necessary  enlarging  the  original  needle  puncture  for 
this  purpose  with  a  knife. 

A  modification  of  Barker's  method  is  as  follows:  Steps  i  and  2  as  above. 
Step  3 . — Approximate  the  fragments  of  bone.  Apply  a  firm  pad  over  the  patella. 
Bring  the  ends  of  the  wire  over  the  pad  and  twist  them  tight  (Fig.  1108). 

(B)  Open  Operation. 

(i)  Classical  Operation. — Step  i. — Make  a  vertical  incision  in  the  middle 
line  from  a  point  about  one  inch  above  the  upper  fragment  to  a  similar  point 
below  the  lower  fragment.  Reflect  the  soft  parts  (exclusive  of  the  periosteum 
which  must  not  be  disturbed)  to  either  side  as  so  to  freely  expose  the  fractured 
surfaces. 


.',:^^ 


Fig.  H09. — Torn  fascia  impaled  on  spicules 
of  bone  preventing  apposition  of  fractured 
fragments.     {After  Helferich.) 


Fig.  mo. — Wiring  patella. 


Step  2. — Remove  effused  blood  from  the  knee-joint  by  douching  with  salt 
solution  and  by  gentle  mopping  with  moist  gauze. 

.  Macewen  noted  ("Annals  Surg.,"  v,  177)  that  the  principal  obstruction  to 
bony  union  was  tags  of  torn  fascia  and  periosteum  which  curl  in  between  the 
fragments  and  become  fixed  to  the  fractured  surfaces  by  becoming  impaled 
on  the  protruding  spiculae  of  bone  (Fig.  1109).  Remove  all  interposed  tissue; 
in  old  cases  of  non-union  this  requires  that  the  surfaces  of  the  bone  be 
pared  or  freshened  with  the  chisel  or  saw. 

Step  3. — With  a  drill  bore  two  sets  of  holes  through  corresponding  parts  of  the 
upper  and  lower  fragments  without  encroaching  on  the  articular  surface  (Fig. 
1 1 10),  and  through  these  pass  sutures  of  wire  or  chromicized  catgut.  It  is 
easy  to  pass  wire  through  the  holes  in  the  bone,  but  when  pliable  material  or 
catgut  is  used  it  is  well  to  use  a  drill  provided  with  an  eye  or  notch  near  the 


928 


SPECIAL   FRACTURES 


point  by  means  of  which  the  suture  may  be  pulled  into  place  as  the  instrument 
is  withdrawn. 

Step  4. — Reduce  the  fracture.  Tighten  and  fLx  the  sutures.  If  wire  is 
used  after  it  has  been  fixed  by  twisting,  cut  oflf  any  excess  of  material  and  by 
hammering  flatten  the  projecting  knot.  If  the  case  is  an  old  one,  contracture 
of  the  quadriceps  may  so  interfere  with  approximation  as  to  require  lengthen- 
ing of  the  muscle  or  tendon. 

Step  5. — Close  the  wound  in  the  soft  parts.  Apply  dressings.  Immobilize 
in  the  extended  position.     Elevate  the  limb  for  twenty-four  hours. 

(2)  Stimson's  Operation.  Mediate  Silk  Suture. — Steps  1  and  2  as  in  classi- 
cal operation. 


Fig.   nil. — {Stimson.) 


Fig.  hi; 


Step  3. — With  a  full  curved  needle  pass  a  stout  silk  ligature  transversely 
through  the  ligamentum  patellae  close  to  the  apex  of  the  patella,  then  trans- 
versely in  the  opposite  direction  through  the  quadriceps  tendon  close  to  its 
insertion.  Approximate  the  fragments  (Fig.  iiii).  Tighten  and  tie  the 
suture. 

Step  4. — Place  one  or  two  catgut  sutures  in  the  torn  capsule  on  either  side. 

Step  5. — Close  the  wound.     Dress.     Immobilize. 

(3)  Vallas's  Operation.  Suture  of  Capsule. — This  operation  is  based  on 
the  fact  that  when  the  patella  is  fractured  transversely  there  can  be  but  little 
separation  of  the  fragments  unless  the  fibrous  capsule  of  the  joint  (fibrous  ex- 
pansion of  the  quadriceps;  capsular  ligament)  is  also  torn  (Fig.  1112). 

Step  I. — Expose  the  fracture  as  in  the  classical  operation  by  a  vertical  in- 
cision. A  more  generous  exposure  may  be  obtained  through  a  crucial  or  a  trans- 
verse incision,  or  by  reflecting  a  U-shaped  flap  of  skin  having  its  base  directed 
either  upwards  or  downwards.  The  writer  has  usually  employed  a  transverse 
incision,  but  the  simple  vertical  one  is  probably  sufficient. 

Step  2. — As  in  classical  operation. 

Step  3. — Carefully  inspect  the  torn  fibrous  capsule  on  either  side  of  the 


VALLAS     OPERATION 


929 


patella.  If  necessary  trim  its  torn  edges.  With  catgut  close  the  wound  in  the 
fibrous  capsule  on  each  side  of  the  patella  (Fig.  11 13);  when  this  is  done  the 
fragments  of  bone  will  be  found  in  apposition  and  no  special  bone  sutures  will  be 
required.  Suture  the  torn  fascia  and 
periosteum  over  the  patella.  Vallas 
uses  the  transverse  incision  and  silver 
wire  U-sutures  for  the  capsule,  which 
are  removed  after  eight  days.     A  glance 


I'IG.    II 14. 


Fig.  1 1 13. — Suture  of  capsular  ligament. 


Fig.  Ill 5. — {Labey.) 


at  Fig,  1 1 14  shows  the  method  of  their  introduction  ("Rev.  de  Chir.,"  Oct., 
1899).  Murphy  after  suture  of  the  capsule  surrounds  the  patella  with  wire  in 
the  manner  shown  in  Fig.  11 17.     The  wire  neither  penetrates  the  bone  nor  the 


Fig.  I II 6. — (Labey.) 


Fig.  I II 7. — (Labey.) 


joint.  During  the  whole  operation  no  finger  should  touch  the  wound,  and 
Murphy  insists  that  the  synovialis  must  not  be  touched  even  by  instruments 
or  gauze  lest  its  endothelial  covering  be  impaired. 

Step  4. — Close  the  external  wound.     Apply  dressings.     Immobilize  in  a 
position  of  extension. 
59 


930 


SPECIAL    FRACTURES 


(4)  Purse-String  Suture  of  Patella. — Expose  the  bone  and  prepare  for 
union  as  already  described.  With  a  long  needle  {e.g.,  Reverdin's)  make  a  strong 
silver  wire  encircle  both  fragments  of  the  patella  (Figs.  1115,  1116,  H17). 
Approxmate  the  fragments.  Tighten  and  fix  the  wire  by  twisting.  With 
sutures  close  the  rent  in  the  fibrous  capsule  and  suture  the  fascia  and  periosteum 
over  the  patella.     Close  the  external  wound. 


Fig.  II 18. 


Fig.  I I 19. 


(s)  Modified  Purse-string  Suture  of  Patella.  Quenu's  Operation. — This 
is  suitable  when  one  of  the  fragments  is  much  small  than  the  other.  Figures 
1 118  and  1 119  sufficiently  describe  the  method. 

Fracture  of  the  Patella  with  Wide  Separation  of  the  Fragments.  Lister's 
Operation  in  Two  Stages. — Stage  i. — Make  a  short  longitudinal  incision  over 
each  of  the  fragments  (Fig.  11 20,  AB  and  CD). 


^Lc 


'-J- 


y/uc-^^ 


Fig.  II 20. — (Lister.) 


Fig.  II 21. — (Lister.) 


Step  2. — Drill  two  holes  in  the  upper  fragment  and  pass  the  ends  of  a  stout 
wire  through  them  from  without  inwards  (Fig.  11 21). 

Step  3. — By  blunt  dissection  make  a  tunnel  under  the  skin  from  the  lower 
incision  CD  to  the  upper  one  AB.  Pull  the  ends  of  the  wire  through  the  tunnel 
to  emerge  at  CD. 


rotter's  method  931 

Step  4.— Bore  two  holes  through  the  lower  fragment  of  the  patella  corre- 
sponding to  the  holes  bored  in  the  upper  fragment.  Pass  the  ends  of  the  wire 
through  these  holes  from  within  outwards  (Fig.  11 22). 

Step  5.— Flex  the  thigh;  extend  the  knee;  with  a  strong  sharp  hook  pull  the 
upper  fragment  of  the  bone  downwards;  tighten  the  wire  stitch  and  fix  it  by 
twisting.  Close  the  wounds.  Apply  a  posterior  splint.  Keep  the  limb  ele- 
vated (in  vertical  position  to  relax  the  quadriceps)  for  two  or  three  days. 
Gradually  lower  the  limb.  The  object  of  the  operation  is  to  bring  the  fragments 
moderately  close  together— if  this  is  done,  the  quadriceps  will  stretch  to  such  an 
extent  that  at  a  secondary  operation  the  broken  surfaces  of  the  patella  can  be 
freshened  and  brought  into  correct  apposition.  (The  diagrams  here  used  are 
reproductions  of  Lord  Lister's  rough  sketches  with  autograph  explanations 
("Brit.  Med.  Journ.,"  April  11,  1908.) 


Utx/t^  AVa^pi^u^      1  f    S      ^  f    1    ^^//^''  /'^^«^^V*^'-<'*V>^ 


Fig.  1 1 22. — {Lister.) 

Lynn  Thomas  attained  the  same  end  by  chiseling  the  tubercle  of  the  tibia 
from  its  seat,  being  careful  not  to  detach  the  tendinous  and  periosteal  attach- 
ments along  its  inner  edge.  Separation  of  the  tubercle  of  the  tibia  permits 
the  easy  approximation  of  the  fractured  surfaces  of  the  patella.  If  necessary 
the  tubercle  may  be  fixed  in  its  new  position  by  means  of  a  nail. 

Rotter's  Operations  (" Zentralblatt  fiir  Chir.,"  1908,  No.  17). — In  a  case  of 
old  patellar  fracture  where  there  was  much  separation  of  fragments  and  much 
disability,  Rotter  operated  as  follows: 

(i)  Exposure  of  the  parts  by  means  of  a  curved  incision. 

(2)  Excision  of  scar  tissue. 

(3)  Transverse  perforation  of  each  fragment  and  introduction  of  a  wire 
suture.     This  only  gave  a  slight  degree  of  approximation. 

(4)  Formation  of  a  flap  from  the  aponeurosis  of  the  rectus  femoris.  This 
flap  had  its  base  at  the  upper  edge  of  the  upper  fragment  of  the  patella  and  was 
long  enough  to  reach  to  the  ligamentum  patellae. 

(5)  Application  of  the  fascial  flap  over  both  fragments  of  patella  and  suture 
of  it  to  the  ligamentum  patellae  and  to  the  vivified  anterior  surfaces  of  the 
bone  fragments. 

(6)  Suture  of  the  wounds  in  the  capsule  of  the  joint.  (To  the  author  this 
seems  to  be  the  most  vital  step  in  the  operation.) 

Immobilization  for  seventeen  days.  After  eight  months  the  functional 
result  was  good.     The  silver  wire  was  found  to  have  broken. 

Occasionally  the  patella  will  be  so  comminuted  in  an  open  fracture  that  its 
repair  is  evidently  impossible.  Under  these  conditions  it  is  wise  to  remove 
all  the  fragments  and  detritus,  to  repair  all  injuries  sustained  by  the  fibrous 


932  SPECIAL   FRACTURES 

capsule  of  the  joint,  and  to  put  the  patellar  periosteum  and  the  patellar  and 
quadriceps  tendons  in  as  favorable  a  condition  for  repair  as  is  possible. 

Indications  and  Choice  of  Operation  in  Patellar  Fracture. — i.  When 
the  fragments  are  separated  as  much  as  one  finger-breadth  {•}'4  inch),  operate. 

2.  When  there  is  no  such  separation,  or  examination  is  difficult  because  of 
pain  and  swelling,  keep  the  patient  in  bed,  apply  a  posterior  splint,  treat  the 
knee  with  elastic  pressure  and  massage.  After  about  one  week,  proper  ex- 
amination will  be  possible.  Ask  the  patient  to  lift  his  heel  up  from  the  plane 
of  the  bed  to  the  slightest  extent  and  not  more.  If  he  can  do  this,  operation 
is  unnecessary;  if  he  cannot,  then  operate. 

3.  The  best  time  to  operate  is  during  the  second  week  after  injury. 
Murphy  thinks  that  the  knee  should  be  at  once  injected  with  about  15  c.c. 
(5  iv)  of  2  per  cent,  formalin  glycerine  and  Buck's  extension  applied  with 
a  weight  of  about  20  lbs.  After  the  lapse  of  from  5  days  to  a  week  operation 
is  safe.     Arbuthnot  Lane  operates  at  once. 

4.  None  of  the  subcutaneous  operations  permit  removal  of  fascia  from 
between  the  fragments,  nor  do  they  repair  the  injured  and  important  fibrous 
capsule,  hence  they  are  objectionable. 

5.  All  the  methods  in  which  material  which  might  prevent  union  is  removed, 
and  in  which  the  torn  fibrous  capsule  is  repaired,  are  satisfactory.  The  author 
prefers  Vallas'  operation. 

6.  When  the  bone  is  much  comminuted,  the  purse-string  suture  may  be 
the  most  suitable. 

After-treatment. — Vallas  and  Murphy  represent  two  extremes  in  the  matter 
of  after-treatment. 

1.  Vallas'  advice.  About  two  weeks  after  operation  begin  massage  of  the 
thigh.  Encourage  the  patient  to  contract  the  quadriceps  muscle,  without, 
however,  doing  it  to  such  an  extent  as  to  cause  pain  or  jeopardize  union.  About 
three  weeks  after  operation  begin  massage  of  the  whole  limb,  use  passive,  and, 
later,  active  motion. 

2.  Murphy's  advice.  Use  Buck's  extension  (15  to  25  lbs.)  and  a  posterior 
wire  trough  splint.  Begin  passive  motion  in  five  weeks.  Use  a  mechanical 
support  for  ten  weeks. 

IV.  Fracture  of  Tubercle  of  Tibia.  *^ — When  the  tubercle  of  the  tibia  is 
torn  from  the  bone  it  may  be  pulled  upwards  a  distance  of  four  inches;  but 
this  is  exceptional,  about  two  inches  being  the  usual  displacement.  With  the 
tubercle  a  portion  of  the  tibial  cortex  may  be  torn  off  and  this  may  remain 
more  or  less  attached  by  its  upper  end  to  the  articular  surface  of  the  bone. 
The  fractured  fragment  of  bone  may  become  wedged  into  the  knee-joint 
(Fig.  1 1 23). 

Operative  Treatment.— 5/e/>  i. — Freely  expose  the  site  of  injury  by  a  ver- 
tical or,  better,  by  a  horseshoe-shaped  incision  having  its  base  above.  If  the 
knee-joint  is  involved,  wash  all  blood-clots,  etc.,  out  of  it. 

Step  2. — Reduce  the  fracture.  To  do  this  satisfactorily  it  may  be  necessary 
to  pass  a  strong  suture  transversely  through  the  tendo  patellae  as  a  tractor. 

*  For  a  full  discussion  of  the  accident  and  its  treatment  see  Gaudier  and  Bouret,  "  Rev.  de 
Chir.,"  Sept.,  1905. 


FRACTURE   HEEL 


933 


The  suture  may  be  eventually  used  as  a  means  of  fixation  by  passing  it  through 
a  hole  bored  in  the  tibia. 

Step  3. — Unite  the  fractured  tubercle  to  the  tibia  by  means  of  periosteal 
sutures  or  of  bone  pegs,  nails,  or  a  wire  suture  (Fig.  11 24).  If  the  knee-joint 
is  open,  close  it  with  sutures. 

Step  4. — Close  the  external  wound  without  drainage.  Dress.  Treat  like 
fractured  patella. 


Fig.  1 1 23. — Fracture  of  tibial  tubercle. 


V.  Fractures  of  the  external  malleolus  often  lead  to  impairment  of  movement 
of  the  ankle-joint.  This  is  due  to  the  fact  that  the  fracture  opens  the  joint  and 
the  subsequent  callus  formation  leads  to  a  chronic  inflammation  of  the  joint. 
Bland-Sutton  ("Lancet,"  Feb.  7,  1914)  reports  three  cases  in  which  he  removed 
the  detached  malleolus  and  obtained  a  quick  convalescence  and  perfect 
function  in  each.  The  support  which  the  malleolus  normally  gives  the 
ankle-joint   is   restored   by   a    thick   fibrous   mass   of   tissue.     This  measure 


Fig.  1 1 24. — Fracture  of  tibial  tubercle. 


Fig.  II 2 ^. — Fracture  of  os  calcis. 


carries  out  a  principle  of  Bland-Sutton's  which  he  has  long  practised,  namely, 
the  removal  of  small  fragments  of  the  detached  bone  in  fractures  involving 
joints.     Willems  advocates  immediate  and  persistent  active  motion. 

VI.  Fracture  of  Tuberosity  of  Os  Calcis. — This  fracture  almost  always 
requires  fixation  by  operation. 

Method  A.- — Reduce  the  fracture  by  manipulation.  Make  a  very  small 
incision  (puncture)  down  to  the  middle  of  the  posterior  surface  of  the  fragment 
of  bone  attached  to  the  tendo  Achillis.  Drill  a  hole  through  the  fragment  and 
into  the  body  of  the  os  calcis.  Substitute  a  nail  or  a  bone  peg  for  the  drill 
(Fig.  1 125).  If  necessary,  close  the  skin  wound  with  a  stitch.  Immobilize 
in  a  position  of  plantar  flexion  with  the  knee  flexed. 


934  SPECIAL   FRACTURES 

Method  B. — Is  the  same  as  A  except  that  the  site  of  injury  is  exposed  by 
turning  down  a  flap  of  skin,  with  its  convexity  upward.  Cheyne  and 
Burghard  advise  that  "the  flap  should  reach  high  enough  up  the  back  of 
the  ankle  to  escape  friction  from  the  hard  part  of  the  boot."  In  old  cases 
it  may  be.  necessary  to  lengthen  the  tendo  Achillis  before  reduction  is  possible. 

VII.  Fractures  of  the  Upper  End  of  Humerus. — Non-impacted  fractures 
of  the  anatomical  neck  of  the  humerus  rarely  result  in  bone  union,  because  of 
malnutrition.  If  good  apposition  cannot  be  obtained  (as  shown  by  Skiagraphy) 
the  best  treatment  is  to  excise  the  head  of  the  bone  through  an  incision  along 
the  anterior  border  of  the  deltoid.  It  may  be  well  to  supplement  the  excision 
by  enveloping  the  fractured  surface  of  the  upper  end  of  the  humerus  in  a  flap 
of  fat  and  fascia  so  as  to  insure  as  much  as  possible  against  anchylosis.  Frac- 
tures of  the  surgical  neck  and  those  through  the  neck  and  the  tuberosities 
are  to  be  treated  by  operation  when  the  X-ray  demonstrates  the  futility  of 
conservative  measures. 

Occasionally  the  greater,  rarely  the  lesser,  tuberosity  is  in  whole  or  in  part 
detached  from  the  humerus.  Fritz  Konig  believes  the  accident  much  more 
common  than  is  usually  supposed  as  an  accompaniment  of  luxations  and  of 
fractures  through  the  tuberosities.  To  diagnose  it  accurately  necessitates  the 
taking  of  skiagraphs  before  reduction  of  the  dislocation  (Figs.  1126  and  11 27). 
Non-operative  treatment  Konig  finds  very  unsatisfactory. 

Methods  of  Operating. — (A)  Fracture  of  surgical  neck;  oblique  fracture 
through  tuberosities,  separation  of  epiphysis. 

Step  I. — Make  a  free  incision  in  the  interval  between  the  deltoid  and  pec- 
toral. Doubly  ligate  or  displace  the  cephalic  vein.  Penetrate  between  the  two 
muscles.  Retract  the  deltoid  strongly,  if  necessary  dividing  a  few  fibres  at  its 
insertion.     Expose  the  fracture. 

Step  2. — Inspect  the  fracture.  Remove  interposed  tissues.  Reduce  by 
traction  and  manipulation  .  If  the  head  is  dislocated,  it  may  be  necessary  to 
bore  a  hole  in  it  and  insert  McBurney's  hook  as  a  tractor. 

Step  3. — Fasten  the  fragments  together  by  means  of  sutures  (wire,  catgut, 
etc.),  pegs,  nails,  staples,  etc.,  as  may  be  convenient. 

Step  4. — Suture  the  torn  periosteum  with  fine  catgut.  Close  the  wound, 
obliterating  dead  spaces. 

Step  5. — Dress.  Treat  as  a  simple  fracture.  Begin  passive  motion  after 
about  two  and  one-half  weeks. 

(B)  Fracture  of  the  Tuberosity  of  the  Humerus. — Step  i. — Exposure  of  the 
fracture. 

(a)  Cheyne  and  Burghard  recommend  that  a  flap  containing  the  deltoid 
be  turned  up,  the  deltoid  being  divided  near  its  insertion. 

{b)  Make  the  incision  recommended  for  fracture  of  the  surgical  neck  and 
by  retracting  the  deltoid  expose  the  tuberosity. 

Step  2. — Fix  the  detached  tuberosity  in  place  by  suture  or  pegs.  If  it  is 
difiicult  to  insert  the  peg  through  the  incision  b,  guided  by  the  view  obtained 
through  that  incision,  make  a  puncture  through  the  soft  parts  directly  over  the 
replaced  tubercle  and  through  this  insert  a  peg  or  nail. 


FRACTURE   HUMERUS 


9.35 
Treat  as 


Step  3. — Suture  the  torn  periosteum.     Close  the  wound.     Dress 
a  simple  fracture. 

VIII.  Fractures  of  the  Lower  End  of  Humerus. — If  the  position  of  acute 
flexion  (Jones's  position)  be  adopted  for  all  fractures  of  the  lower  end  of  the 
humerus  operation  will  rarely  be  necessary.     The  fractures  which  very  com- 


FiG.   -112b. — Fracture  tuberosit}'  of  humerus.      [Konig.) 


Fig.  1 1 27. — Fracture  tuberosity  of  humerus.     {Konig.) 


monly  require  intervention  are  separation  of  the  capitellum  humeri  and  fracture 
of  the  internal  epicondyle  when  there  is  much  separation.  The  opinions  of 
surgeons  vary  much  as  to  operative  interference.  Cheyne  and  Burghard  recom- 
mend operation  almost  as  routine  in  T-fractures.  Of  course  when  there  is 
grave  injury  to  the  nerves  (usually  the  musculo-spiral  and  median)  or  to  the 
vessels  about  the  elbow  and  this  is  not  relieved  by  reposition  of  the  fragments 
of  bone,  operation  is  imperative. 


936 


SPECIAL   FRACTURES 


When  operating,  if  it  is  possible  to  avoid  opening  the  elbow-joint,  do  so. 
Figure  1128  shows  the  limits  of  the  joint.  The  time  of  choice  for  operation 
is  during  the  second  week  after  injury.  After  operation  passive  movements 
ought  to  be  begun  in  about  fourteen  days  or  even  less. 

Methods  of  Operating. — (A)  Fracture  of  one  condyle. 

Step  I. — Reflect  a  skin  flap,  convexity  forwards,  from  over  the  fractured 
condyle  (Cheyne  and  Burghard). 

Step  2. — Flex  the  elbow.  Separate  the  soft  parts  from  the  upper  part  of 
the  condyle  until  there  is  sufiicient  exposure.  Remove  interposed  tissues  and 
wash  the  joint  cavity  with  salt  solution. 


Radial  cul  de  sac. 
Fig.  1 1 28. — [Poirier  ei  Charpy.) 

Step  3. — Reduce  the  fracture  and  fix  it  in  position  by  peg,  nail,  or  suture. 
Suture  any  important  structures  which  may  have  been  torn  or  divided. 

Step  4. — Close  the  wound.  Dress.  Put  up  in  the  acutely  flexed  position. 
No  splint  is  necessary  or  desirable. 

(B)  Fracture  of  Both  Condyles.    T-shaped  Fracture. 

Step  I. — ^Method  A. — Make  a  longitudinal  lateral  incision  over  each  con- 
dyle and  exposg  the  fracture.  Do  not  jeopardize  the  nutrition  of  the  condyle 
by  unnecessary  separation  of  the  soft  parts. 

Method  B. — Make  a  vertical  median  incision  over  the  olecranon  process 
as  in  excision  of  the  elbow.  Split  the  triceps  tendon  vertically.  With  the 
periosteal  elevator  separate  the  tendon  from  the  ulna  and  so  reach  the  fracture 
without  peeling  the  condyle  out  of  its  attached  soft  parts. 

Step  2. — Reduce  the  fracture.  Peg  the  two  condyles  together  or  to  the 
shaft  of  the  humerus.  If  incision  B  has  been  used,  it  is  well  after  reducing  the 
fracture  to  make  a  puncture  directly  over  the  tip  of  the  condyle  and  introduce 
the  pegs  through  this  puncture. 

Step  3. — Close  both  deep  and  superficial  wounds.  Dress.  Put  in  acutely 
flexed  position  without  a  splint. 


FRACTURES   ELBOW 


937 


Method  C.^ — Sampson  Handley  thinks  that  the  lateral  incisions  (Method  A) 
should  always  be  employed,  because  if  they  suffice  they  do  little  harm,  and  if 
they  do  not  suffice  it  is  easy  to  join  them  by  a  transverse  posterior  cut  across 
the  olecranon,  and  by  sawing  through  the  olecranon  to  gain  perfect  access  to 
the  fracture. 

(C)  Separation  of  Capitellum  Humeri. — Open  the  joint  by  an  external 
longitudinal  incision.  Remove  the  fragment  of  bone.  Close  the  wound. 
Dress.     Begin  motion  within  a  few  days. 


Fig.  1129. — (Lambotle.)  Fig.  1130. — {LamhoUe.)  Fig.  1131. — {LamboUe.) 


Fig.  1132. — {LamboUe.)       Fig.  1133. — {LamboUe.)  Fig.  1134. — {Lambolte.) 


Fig.  1135. — {LamboUe.)  Fig.  1136. — {LamboUe.) 

a.  Point  of  insertion  of  screw  into  trochlea;  b,  point  for  nailing  epitrochlea. 

(D)  Fracture  of  Internal  (or  External)  Epicondyle. — (a)  Make  a  lateral 
longitudinal  incision  over  the  fragment  of  bone  without  opening  the  joint. 
Replace  the  fragment  and  suture  it  in  position.  The  suture  involves  the 
periosteal  covering  or  may  include  the  cartilaginous  epicondyle  itself. 

If  the  displaced  fragment  is  very  small,  or  if  (in  an  old  case)  it  has  become 


938 


SPECIAL    FRACTURES 


fixed  in  a  position  which  interferes  with  the  elbow,  excise  it  and  suture  the 
lateral  ligament  in  proper  position.     Dress.     Begin  motion  at  an  early  date. 

The  foregoing  figures  taken  from  Lambotte  (L'Intervention  Operatoire  dans 
le  Fractures)  show  the  application  of  screw  nails  to  several  varieties  of  fracture 
at  the  elbow  (Figs,  ii  29-1 136). 

IX.  Fracture  of  Olecranon  Process. — Most  cases  of  the  above  fracture 
call  for  operation. 

(A)  Subcutaneous  Operation.  Murphy's  Method. — Step  1. — Make  a  longi- 
tudinal incision  3'^  inch  long  on  the  outer  side  of  ulna  down  to  the  bone,  ^  inch 
from  the  articular  surface  (A,  Fig.  1137).  Make  a  corresponding  but  smaller 
incision  on  the  inner  side  (B).  Between  these  two  cuts  perforate  the  ulna 
and  pull  a  wire  through  the  drill  hole.  With  an  appropriate  needle  carry  the 
wire  under  the  skin  upwards  on  the  inner  side  of  the  elbow  and  draw  it  out 
through  a  puncture  wound  at  the  level  of  the  tip  of  the  olecranon  (C)  the 
tip  of  the  olecranon  having  been  brought  down  into  proper  position  by 
manipulation. 

Step  2. — With  an  appropriate  needle  pass  the  wire  through  the  same  (upper) 
puncture  transversely  through  the  triceps  tendon  immediately  above  the  frag- 
ment of  olecranon  and  make  it  emerge  through 
a  puncture  wound  (D)  on  the  outer  side.  Once 
more  reintroduce  the  wire  and  make  it  emerge 
at  the  original  incision  (A).  The  site  of  frac- 
ture is  now  encircled  by  the  wire. 

Step  3. — Tighten  and  twist  the  wire.     Cut 
off  the  ends  and  bury  the  knot.     Dress. 

Murphy  recommends  immobilization  in  the 
extended  position  for  4  weeks,  with  passive 
motion  from  the  third  day.  Cheyne  and  Burg- 
hard  recommend  that  the  elbow  be  kept  at  a 
right  angle  in  a  sling  and  that  early  motion  be 
attempted.  This  advice  seems  very  rational. 
(B)  Open  Operation. 

Step  I. — Method  of  Exposure. — (a)  Make  a 
median  longitudinal  incision  from  a  point  ^"i 
inch  above  the  tip  of  the  fractured  olecranon 
downwards  to  a  point  near  the  base  of  the  olecranon.  Divide  the  skin  and 
superficial  fascia  only.  Reflect  the  soft  parts  to  either  side  until  the  bone 
covered  by  deep  fascia,  etc.,  is  well  exposed. 

(6)  Make  a  horseshoe-shaped  incision  through  the  skin  and  superficial 
fascia  from  a  point  just  below  the  line  of  fracture  on  one  side  of  a  correspond- 
ing point  on  the  other  side.  The  cut  runs  upwards  to  a  point  about  i  inch  above 
the  tip  of  the  olecranon  (Fig.  1138).     Reflect  the  flap  thus  outlined. 

(c)  Same  as  [b)  except  that  the  base  of  the  flap  is  above  instead  of  below. 

Step  2. — Examine  the  fractured  surfaces.     Remove  interposed  tissues.     In 

old  cases  freshen  the  ends  of  the  bone.     If  necessary  cleanse  the  joint  cavity. 

Step  3, — Suture  of  the  Bone. — (a)  With  a  drill  make  one  or  two  oblique 

perforations  through  the  upper  and  lower  fragments  at  corresponding  points. 


Fig.  1 137. — Fracture  of  olecranon. 


FRACTURE    OLECRANON 


939 


Pull  wire  through  the  perforations  (Fig.  1 139).  Do  not  let  the  deep  part  of  the 
perforation  impinge  upon  the  articular  surface  of  the  bone.  While  boring 
the  holes  flexion  of  the  arm  permits  more  easy  access.     Now  extend  the  arm. 


Fig.  1138.  Fig.  1139. 

Figs.  1138  and  1139. — Fracture  of  olecranon. 

Approximate  the  fragments.  Tighten  the  wire  sutures  and  fix  them  by  twisting. 
Hammer  the  wire  knots  flat  or  into  the  bone  so  that  they  may  not  injure  the 
skin  subsequently.     Instead  of  wire,  chromicized  catgut  may  be  used. 


Fig.  1 140.  Fig.  1141. 

Figs.  1140  and  1141. — Fracture  of  olecranon.     {Schwartz.) 


(b)  Circular  Suture. — With  a  drill  make  a  perforation  transversely  through 
the  olecranon  about  j-i  i^^ch  from  the  fractured  surface  (Fig.  1140).  Pull  a 
wire  through  the  perforation.  In  the  same  manner  drill  a  transverse  hole 
through  the  detached  portion  of  the  olecranon  and  pull  one  end  of  wire  above 
mentioned  through  it.  Approximate  the  fragments.  Tighten  and  fix  the 
wire. 


940 


SPECIAL   FRACTURES 


(c)  Is  the  same  as  (b)  except  that  the  upper  loop  of  wire  perforates  the 
triceps  tendon  instead  of  the  bone.  Instead  of  wire,  chromicized  catgut  may 
be  employed. 

Step  4. — With  fine  catgut,  suture  the  joint  capsule  (Fig.  1141)  and  the  fascia 
covering  the  olecranon.  Close  the  skin  wound.  Dress.  The  limb  may  be 
immobilized  either  in  the  extended  or  semiflexed  position  or  may  be  put  in  a 
sling.  However  dressed,  passive  motion  must  be  begun  very  early  to  insure 
good  results. 

Any  of  the  methods  of  operating  described  give  good  results. 


Fig.  1 142. — Myositis  ossificans  traumatica.     (Keen.) 


X.  Fracture  of  Coronoid  Process  of  Ulna. — This  fracture  is  rare  and  when 
present  is  usually  associated  with  posterior  dislocation  of  the  elbow.  As  the 
brachialis  anticus  is  attached  near  the  base  of  the  coronoid,  there  is  not  much 
displacement  unless  this  part  of  the  bone  is  involved.  Operation  must  be 
very  rarely  indicated  except  in  old  cases  with  disability  due  to  interference 
with  flexion. 

Step  I. — ^Exposiire  of  Coronoid  Process.^ — Make  a  lateral  incision  on  one 
or  each  side  just  in  front  of  the  condyles  of  the  humerus.  With  a  periosteal 
elevator  separate  the  muscle  from  the  anterior  surface  of  the  condyles  until 
the  brachialis  anticus  and  with  it  the  coronoid  process  is  exposed.  Subsequent 
work  is  much  facilitated  if  the  process  is  exposed  from  both  sides. 


OSTEOMYELITIS 


941 


Step  2. — Repair  whatever  injury  is  found.  Usually  operation  is  performed 
late  because  of  disability  due  to  excessive  callus  or  to  the  formation  of  bone  in 
the  tendon  of  the  brachialis  anticus  (practically  myositis  ossificans  traumatica). 
When  this  is  the  case  remove  the  excess  of  bone. 

Step  3. — Close  the  wound.     Dress.     Apply  a  sling.     Begin  motion  early. 

N.  B. — The  above  description  is  based  on  that  of  Cheyne  and  Burghard. 
The  author  has  never  seen  a  case  of  fracture  of  the 
coronoid  process  requiring  operation.  He  has,  how- 
ever, seen  one  or  more  cases  of  myositis  ossificans 
traumatica  which  perhaps  might  have  been  mistaken 
for  such  a  condition,  and  in  which  the  neoplastic 
bone  was  removed  through  an  external  incision 
penetrating  the  muscle  (Fig.  1142). 

IX.  Separation  of  Head  of  Radius. — Operation 
is  required  when  the  head  of  the  radius  has  become 
separated  from  the  shaft  and  lies  in  the  elbow-joint 
impeding  motion. 

Step  I. — Make  a  three-inch  longitudinal  incision 
as  in  Fig.  11 43.  Separate  the  anconeus  and  extensor 
carpi  ulnaris  muscles.   This  exposes  the  head  of  radius. 

Step  2. — Incise  the  articular  capsule.  Remove  the 
fragment  of  bone.  Close  the  wound  with  deep  and 
superficial  sutures.  Dress.  Put  in  sling.  Begin 
motion  very  early. 


Fig.  1 143. — Exposure    of 
head  of  radius. 


CHAPTER  LXX 


OSTEOMYELITIS 


As  the  result  of  infection  acute  inflammation  develops  in  the  vascular  spongy 
bone  usually  near  an  epiphysis.  Pus  quickly  forms  and,  if  the  patient  sur- 
vives long  enough,  makes  its  way  to  the  periosteum  and  soft  parts.  When 
the  pus  escapes,  fistulae  are  formed  and  persist.  Early  death  of  portions  or 
even  the  whole  of  the  bone  is  a  prominent  feature  and  aids  in  keeping  up  the 
inflammation.  In  time  new  bone  is  formed  which  incloses  the  dead  portions 
(sequestra),  keeps  up  the  continuity  of  the  bone,  but  prevents  the  escape  of 
the  sequestra  when  they  become  separated  from  the  living  bone  by  the  activity 
of  granulation  tissue  growth. 

From  the  above  it  is  evident  that  different  methods  must  be  taken  to  combat 
the  disease  according  to  the  stage  to  which  it  has  developed.  When  operating 
for  osteomyelitis  of  one  of  the  bones  of  an  extremity,  it  is  wise  to  secure  a 
bloodless  field  by  using  an  elastic  constrictor,  as  it  is  very  important  to  see 
clearly  in  order  to  judge  how  much  it  is  necessary  to  do.  In  the  succeeding 
paragraphs  operations  for  osteomyelitis  of  the  lower  femoral  juxta-epiphyseal 
bone  will  be  taken  as  typical. 


942  OSTEOMYELITIS 

(A)  Early  Operation. — The  patient,  usually  young,  may  have  sustained  a 
slight  injury  or  been  exposed  to  cold;  or  the  patient  may  recently  havesufifered 
from  an  acute  disease;  there  is  much  prostration;  pain  near  the  knee,  often 
thought  to  be  in  the  knee;  there  has  been  a  chill  and  high  fever  often  mistaken 
for  typhoid;   there  is  evidently  a  serious  illness,  often  delirium  is  present. 


Gluteal  sulcus' 


•^v>  -Tensor  fasciae 

latae 


Ilio-tibial  band 


.— _  Popliteal  fascia 


Fig.  1144. — {SaboUa. 

Locally  the  only  symptoms  may  be  pain  and  tenderness;  this  last  is  our  only 
guide  to  the  seat  of  disease.  Commonly  at  this  period  there  is  some  swelling 
as  well  as  pain. 

The  Operation. — Before  anesthetizing  the  patient  locate  the  point  of  maxi- 
mum tenderness;  this  is  the  place  to  be  exposed  by  operation. 

Step  I. — Make  a  free  longitudinal  incision  down  to  the  bone  on  the  outer 


DRAINAGE 


943 


or  inner  side  of  the  thigh  as  may  be  convenient  so  as  to  avoid  injury  to  im- 
portant structures  and  yet  reach  the  point  of  maximum  tenderness  as  directly 
as  possible.  The  best  incision  is  one  on  the  outer  side  situated  in  the  furrow 
between  the  biceps  tendon  and  the  ilio-tibial  band  (Fig.  1144).  Note  the 
condition  of  the  divided  tissues  as  to  oedema,  etc.  Split  the  periosteum  over 
the  suspected  area  of  bone.  Note  the  condition  of  the  periosteum  as  to  thick- 
ness, softness,  oedema,  etc.,  and  as  to  the  firmness  or  looseness  of  its  attach- 
ment to  the  bone. 

Separate  the  periosteum  from  the  bone  over  an  area  about  3^  inch  in 
diameter.  Examine  the  surface  of  the  bone  for  evidences  of  disease.  Pass 
a  grooved  director  round  the  bone  to  the  popliteal  surface  of  the  bone  as  pus 
from  the  osteomyelitis  often  collects  here.  In  our  example,  no  such  evidence 
may  be  discovered. 


Fig.  1145. — Drills  and  Burrs.     {Stille.) 


Step  2. — With  a  Doyen  burr  (Fig.  1145),  a  small  trephine,  or  a  gouge  and 
mallet,  penetrate  the  bone  to  the  medulla  or  into  the  spongy  bone  near  the 
epiphyseal  line  (a  drill  or  gimlet  is  often  used  to  penetrate  the  bone,  but  the 
resulting  opening  is  too  small  to  permit  of  proper  investigation).  It  may 
not  be  necessary  to  penetrate  the  bone  very  deeply  as  the  focus  of  disease 
may  be  found  fairly  superficial.  The  diseased  area  may  be  recognized  by 
its  redness,  the  presence  of  granulation  tissue,  a  decrease  in  the  consistency 
of  the  tissue,  decrease  in  the  amount  of  fat,  and  by  the  presence  of  a  small 
amount  of  pus. 

Many  surgeons,  especially  in  Paris,  consider  that  it  is  not  possible  to  dis- 
tinguish clinically  in  all  cases,  acute  suppurative  osteomyelitis  from  periostitis 
and  hence  consider  it  harmful  to  systematically  attack  the  bone  since  simple 
periosteal  incision  may  sufl&ce.     S.  Rolando  (" Zentralblatt  fiir  Chir.,"  1908, 


944  OSTEOMYELITIS 

No.  20)  has  had  much  experience  in  hematogenous  osteomyeHtis  and  finds 
that  the  periostitis  is  always  secondary  to  the  osteomyeHtis.  To  avoid  un- 
necessarily extensive  opening  of  the  bone  Rolando  is  guided  by  radiography 
and  only  opens  the  bone  itself  at  places  where  clear  zones  indicate  the  presence 
of  lesions.  Rubritius  ("Zentralblatt  flir  Chir.,"  1908,  No.  9)  thinks  radiog- 
raphy valueless  in  recent  cases.  Multiple  openings  into  the  bone  may  be 
required.  It  is  unnecessary  to  expose  the  whole  of  the  medullary  cavity  as  is 
done  by  some.  All  that  is  requisite  is  to  penetrate  the  foci  at  the  most  de- 
pendent points  possible,  to  evacuate  their  contents  and  to  prevent  re- 
accumulation. 

Step  3. — Thoroughly  remove  all  the  diseased  material  with  a  sharp  spoon, 
aided,  if  necessary,  by  a  gouge.  Wash  or  douche  the  cavity.  Swab  with 
Harrington's  solution,  \\'ith  tincture  of  iodine,  or  with  liquid  carbolic  acid, 
subsequently  removed  by  swabbing  with  alcohol.  If  the  original  opening 
through  the  bone  does  not  provide  sufficiently  free  access  to  the  disease  or  a 
proper  amount  of  drainage,  enlarge  the  opening  with  the  gouge. 

Step  4. — Provide  for  drainage  by  means  of  a  rubber  tube  or,  better,  by  a 
loose  pack  of  iodoform  gauze.  The  Carrel-Dakin  method  or  Dichloramin  T. 
may  be  employed.  Partly  close  the  external  wound  with  sutures.  Apply 
abundant  dressings  and  a  splint.  During  the  operation  as  detailed,  no  focus 
of  disease  may  be  recognized.  This  does  not  by  any  means  signify  a  mistaken 
diagnosis,  it  means  either  that  operation  has  anticipated  the  gross  appearances 
of  disease  or  that  the  surgeon  has  failed  to  strike  the  focus.  It  is  proper  to 
make  a  further  search  for  the  focus  of  disease  by  drilUng  subsidiary-  holes  in 
various  directions.  If,  after  this  no  focus  is  found,  provide  for  drainage  as 
described.  If  the  operation  has  been  performed  before  gross  pathologic  changes 
have  arisen,  the  drainage  provided  may  well  lead  to  resolution  taking  place. 
If  gross  pathologic  changes  are  present,  but  have  not  been  discovered,  it  is 
almost  certain  that  the  pus  will  soon  evacuate  itself  into  the  bone  wound  made 
by  the  surgeon. 

Subperiosteal  Abscess. — If  in  Step  i  pus  is  found  situated  under  the  peri- 
osteum, or  if  instead  of  pus  inflammatory  exudate  is  there  present,  are  we 
to  content  ourselves  with  the  evacuation  of  this  focus  and  call  the  disease 
"periostitis"?  This  must  be  rarely  necessary.  Exceptionally  the  patient  may 
be  so  weakened  from  absorption  of  toxins  that  the  surgeon,  after  evacuating 
the  superiosteal  abscess  and  finding,  on  superficial  examination,  no  evident 
communication  with  the  inside  of  the  bone,  concludes  that  an  imperfect  opera- 
tion will  be  life-saving,  while  a  more  radical  operation  may  be  left  until  the 
drainage  has  permitted  recovery  from  the  more  urgent  symptoms.  Very  many 
cures  have  been  obtained  by  this  imperfect  operation,  but  it  is  so  uncertain, 
and  the  disease  is  so  grave  that  nothing  short  of  radical  intervention  is  justi- 
fiable in  the  large  majority  of  cases.  The  operation  ought  to  be  carried  out  on 
the  following  lines: 

Expose  and  divide  the  periosteum.  Evacuate  the  pus.  Scrape  away  all 
diseased  tissue.  Swab  wnth  Harrington's  solution  or  with  liquid  carbolic  acid 
followed  by  swabbing  with  alcohol.  Examine  the  exposed  bone  for  any  fistulae 
or  crevices  through  which  pus  escapes.     If  the  subperiosteal  pus  is  on  the 


ABSCESS   BONE 


945 


popliteal  surface  of  the  bone,  retract  the  soft  parts  and  examine  the  bone  care- 
fully with  a  probe.  If  a  fistula  leads  into  the  bone  enlarge  it,  and  follow  it 
into  the  focus  of  disease.  When  the  fistula  opens  on  the  popliteal  surface  of 
the  bone,  it  is  often  impossible  to  follow  it,  in  which  case  the  bone  must  be 
penetrated  from  the  side  (Fig.  1146).  If,  after  thorough  cleansing  of  the  sub- 
periosteal abscess  and  painstaking  examination,  no  disease  of  the  surface  of 
the  bone  is  discovered,  penetrate  into  the  bone  as  in  Step  2  (p.  943)  and  proceed 
as  there  advised. 

As  J.  C.  Warren  writes,  "No  operation  which  does  not  include  an  opening 
into  the  bone  should  be  regarded  as  a  completed  one." 


Fig.  1146. — Fistula  from  bone  leads  to  popliteal  space.     Penetrate  bone  from  the  side. 


WTien  pus  has  broken  through  the  periosteum  and  abscess  of  the  more 
superficial  structures  is  evident,  the  operative  treatment  must  be  carried  out 
on  the  lines  already  described. 

(B)  Abscess  of  Bone.  Late  Operation. — The  patient  has  survived  the 
early  and  most  acute  phases  of  the  osteomyelitis.  No  gross  masses  of  bone 
have  died,  or  if  so,  they  have  been  destroyed.  The  neighboring  bone  has 
reacted  against  the  inflammation  and  has  surrounded  the  focus  with  a  rampart 
of  thickened  and  sclerosed  bone  through  which  fistulae  lead  to  the  skin.  Drain- 
age is  imperfect,  but  the  main  impediment  to  recovery  consists  in  the  sclerosed 
bone  which  will  neither  provide  healthy  granulation  tissue  to  obliterate  the 
abscess  cavity,  nor  permit  its  walls  to  collapse.  The  objects  of  operation  are 
(a)  to  cleanse  the  abscess  cavity  thoroughly;  (6)  to  obliterate  it. 

These  objects  may  be  attained  in  more  than  one  way. 

Method  A. — Step  i. — After  applying  the  elastic  constrictor,  expose  the  bone 
freely  by  a  suitable  incision  as  in  an  acute  case. 

Step  2. — With  a  gouge  and  mallet  expose  the  abscess  cavity  freely  and 
clean  it  thoroughly.  Dissect  away  the  diseased  lining  of  all  fistulae.  Thoroughly 
disinfect  as  in  acute  cases.  After  the  thorough  cleansing,  temporarily  pack 
the  wound  with  gauze;  clean  the  skin  around  the  wound;  replace  all  soiled 

60 


946  OSTEOMYELITIS 

towels  by  clean  ones;  discard  all  instruments  which  have  been  in  contact  with 
the  wound  up  to  this  time;  let  the  surgeon  and  assistant  clean  their  hands  or 
change  their  gloves.  It  is  important  to  act  as  if  the  completion  of  Step  2 
was  the  completion  of  the  operation,  the  further  steps  being  considered  as  a 
new  operation  performed  on  a  clean  patient,  with  all  the  appliances  fresh  and 
clean. 

Step  3. — Remove  the  pack  from  the  wound.  With  gouge  and  mallet  cut 
away  the  sclerosed  bone  from  around  the  site  of  the  abscess,  until  healthy 
bone  is  reached.  The  object  of  this  is  to  leave  the  cavity  lined  with  bone 
from  which  it  is  reasonable  to  suppose  that  healthy  granulation  tissue  will 
grow  and  obliterate  it.  The  removal  of  the  sclerosed  bone  is  entirely  analogous 
to  the  removal  of  scar  tissue  from  around  a  vesico-vaginal  fistula  before  closing 
it  with  sutures. 

Step  4. — Loosely  pack  the  cavity  with  iodoform  gauze.  Apply  liberal 
dressings.  If  necessary,  apply  a  splint.  Put  the  patient  in  bed  with  the 
limb  elevated.  Remove  the  elastic  constrictor.  The  author  often  fills  the 
cavity  with  a  powder  consisting  of  iodoform  i,  crystalhne  boracic  acid  4, 
instead  of  employing  gauze  packing. 

Often  the  iodoform  is  omitted.  A  warning  is  necessary  regarding  the  liberal 
use  of  Boracic  acid.  Its  use  is  salutary  and  harmless  in  bone  cavities  whereas 
in  joints  or  large  cavities  in  the  soft  parts  absorption  may  cause  serious  or  fatal 
poisoning. 

The  subsequent  treatment  consists  in  keeping  the  wound  clean  and  encourag- 
ing the  formation  of  granulation  tissue.  Remember  that  the  open  air,  good 
food,  good  company  and  good  amusements  are  the  best  tonics  and  that  the 
patient  requires  such. 

Method  B. — Atkinson  Stoney's  Treatment  (Brit.  Med.  Journ.,  June  21, 
1919,  p.  700). 

Steps  I,  2  and  3  as  in  Method  A. 

Step  4. — Dry  and  swab  the  wound  with  ether  or  alcohol.  Plug  for  about 
two  minutes  with  gauze  soaked  in  ether  or  alcohol.  Rub  into  the  walls  of  the 
cavity  modified  Bipp  (iodoform  2,  bismuth  i,  vaseline  12).  Then  fill  the  cavity 
with  Bipp. 

(a)  If  the  cavity  is  small  and  regular,  if  its  original  walls  have  been  well 
removed,  if  there  is  a  good  depth  of  healthy  tissue  between  it  and  the  skin, 
close  the  wound  with  deep  sutures  of  catgut  and  superficial  of  silk  soaked  in 
Bipp.  Apply  thick  dressings  snugly  and  leave  them  undisturbed  if  possible 
for  ten  days. 

{b)  It  does  not  seem  wise  to  close  the  wound.  Plug  the  wound  tightly  with 
a  long  strip  of  gauze  impregnated  with  Bipp.  After  forty-eight  hours  remove 
the  gauze,  when  a  dry  clean  cavity  should  be  found.  Fill  the  cavity  with 
Bipp.  Apply  superficial  dressings  which  must  be  changed  every  four  or  five 
days,  fresh  Bipp  being  put  into  the  cavity  as  fast  as  it  disappears.  Never 
explore  the  cavity  after  the  operation.  Occasionally  the  cavity  may  be  closed 
by  operation  after  a  week  or  more. 

Stoney  treated  25  cases  of  chronic  bony  fistulae  which  had  lasted  for  periods 


MOSETIG  S   BONE   PLUGS  Q47 

ranging  from  two  months  to  over  four  years  (average  time  after  wound  received 
was  1 6  months).  In  22  cases  (88  per  cent.)  the  wound  was  healed  in  an  average 
of  one  month  and  two  days.  Only  three  patients  remained  in  hospital  more 
than  two  months.  A.  K.  and  Dorothy  K.  Milne  Henry  using  Sloney's  method 
in  15  consecutive  cases  found  only  two  which  did  not  heal  after  a  single  operation. 

Method  C— Use  of  Bone  Plugs.  Mosetig-Moorhof  s  Method  ("Zent. 
fur  Chir.,"  April  18,  1903). 

Steps  I,  2,  3,  as  in  Method  A.  To  remove  any  blood-clots  adhering  closely 
to  the  bone,  Mosetig  uses  peroxide  of  hydrogen.  After  every  particle  of  bone 
even  suspected  of  disease  has  been  removed  and  with  it  the  sclerosed  bone, 
the  cavity  must  be  thoroughly  dried.  For  this  purpose  a  douche  of  hot  air  is 
most  valuable.  The  simplest  hot-air  douche  is  shown  in  Fig.  11 47.  The 
cavity  is  now  ready  to  be  filled. 

Delbet,  to  test  the  above  method,  cleaned  osteomyelitic  cavities  carefully, 
insufflated  with  hot  air,  curretted  and  then  made  cultures  from  particles  re- 


FiG.  1 1 47. — Hot-air  douche. 

moved.  The  cultures  were  always  positive.  If  he  used  tincture  of  iodine 
instead  of  hot  air  the  cultures  were  negative.  The  hot  air  used  had  a  tempera- 
ture of  2oo°-30o°  but  the  temperature  of  the  bone  was  little  raised  by  it.  Quenu 
is  disappointed  with  hot-air  disinfection  and  doubts  the  efl&cacy  of  tincture  of 
iodine.  Sebileau  thinks  the  virtue  of  hot  air  consists  in  drying  the  cavity  and 
so  in  permitting  the  adhesion  of  any  antiseptic  material  to  its  wall.  Dentists 
are  well  aware  that  they  do  not  sterilize  pulp  cavities  by  using  hot  air  but  merely 
dry  them  ("Surg.  Soc,"  Paris,  Dec.  11,  191 1). 

Step  4. — The  following  prescription  has  been  prepared  before-hand:  Iodo- 
form, 60  parts;  spermaceti,  40  parts;  oil  of  sesame,  40  parts.  Heat  slowly 
to  100°  C.  When  the  mass  cools  it  forms  a  soft  solid  at  the  body  tempera- 
ture. Immediately  before  use  heat  the  iodoform  mixture  in  a  water-bath 
to  60°  C.  to  render  it  fluid.  Pour  it  into  the  bone  cavity  very  slowly  so  as  to 
avoid  the  formation  of  air-bubbles.  Fill  the  bone  cavity  completely.  As 
soon  as  the  mass  solidifies,  replace  and  suture  the  periosteum  and  soft  parts 
in  position.  If  one  or  more  fistulae  are  present,  these  act  as  drains;  if  such 
are  absent,  spaces  between  the  sutures,  or  a  strip  of  rubber  tissue  will  serve 
the  purpose.  Before  suturing,  ligate  any  divided  vessels  which  may  be  visible. 
Apply  dressings  and  if  necessary  a  splint.* 

*  A  splint  is  required  if  one  wishes  to  immobilize  a  neighboring  joint  or  if,  as  is  sometimes 
the  case,  a  mere  shell  of  bone  is  left  full  of  the  iodoform  wax  plug. 


g48  OSTEOMYELITIS 

Put  the  patient  in  bed  with  the  limb  elevated  and  only  then  remove  the 
elastic  constrictor.  The  iodoform  wax  plug  fills  the  cavity  until  such  time  as 
granulation  tissue  and  ultimately  bone  penetrates  and  replaces  it.  Elsberg, 
using  Mosetig's  plug,  has  modified  the  method  of  application  as  follows:  Re- 
move the  elastic  constrictor  before  pouring  in  the  plug.  Gain  the  necessary 
dryness  by  applying  adrenalin  gauze.  Permit  the  iodoform  wax  to  partially 
harden  outside  the  body  and  then  with  the  fingers  press  bits  of  it  into  the  walls 
of  the  cavity  until  the  whole  space  is  filled  in  the  manner  a  dentist  fills  a  cavity 
in  a  tooth. 

To  the  writer  Elsberg's  modifications  do  not  seem  to  be  improvements. 

Method  D. — Is  the  same  as  Method  A  except  that  in  Step  3  so  much  bone 
is  removed  that  the  soft  parts  can  readily  come  into  contact  with  the  whole  of 
the  wall  of  the  cavity  left.  The  particulars  of  this  method  will  be  more  fully 
described  under  Necrotomy.  Various  plastic  operations  devised  to  fill  bone 
cavities  will  be  found  described  elsewhere. 

(C)  Osteomyelitis  accompanied  by  death  of  bone.  Methods  of  operating. 
-  Sequestrotomy.  Necrotomy. — The  indications  for  operation  vary  with 
the  acuteness  of  the  disease  and  with  its  extent.  When  the  disease  does  not 
affect  the  whole  thickness  of  the  bone  and  the  sequestrum  is  of  but  moderate 
size,  no  matter  whether  the  disease  be  acute  or  chronic,  no  surgeon  would 
hesitate  to  do  a  radical  operation  and  do  it  promptly.  When  the  disease 
is  very  acute  immediate  operation  is  imperative  to  prevent  death  from  sepsis, 
but  if  the  whole  thickness  or  length  of  the  bone  is  necrosed  diflferences  of  opinion 
are  permissible  as  to  the  extent  of  the  operation.  If  under  the  above  circum- 
stances the  dead  bone  is  found  separated  from  the  living  bone,  in  case  the  whole 
bone  is  affected,  it  is  separated  from  the  surrounding  tissues,  no  good  but 
rather  much  evil  may  be  expected  from  its  retention,  hence  it  must  be  re- 
moved. If,  however,  the  dead  bone  is  not  entirely  free  it  is  often  the  best 
practice  to  drain  away  all  the  products  of  inflammation  but  leave  the  seques- 
trum in  situ  to  act  as  a  splint  until  new  bone  has  been  formed  sufficient  in  quan- 
tity to  preserve  continuity.  Should  the  irritation  from  the  presence  of  the 
dead  bone  keep  up  so  much  inflammation  as  to  endanger  life,  or  should  its 
presence  interfere  with  proper  drainage,  then  it  must  be  removed.  In  almost 
all  subacute  and  chronic  cases  of  extensive  necrosis,  it  is  possible  and  wise  to 
delay  removal  of  the  sequestrum  until  sufficient  new  bone  has  been  formed  to 
maintain  continuity.  During  this  period  of  waiting  efficient  drainage  must  of 
course  be  provided. 

In  the  succeeding  paragraphs  operations  on  the  tibia  will  be  generally  taken 
as  typical. 

(c)  The  extent  of  necrosis  is  not  great.  Operate  exactly  as  for  acute  or 
chronic  abscess  of  the  bone,  removing  sequestra — if  loose,  with  forceps;  if 
fixed,  with  the  chisel. 

{b)  The  necrosis  is  extensive  as  regards  length,  but  enough  healthy  bone 
remains  or  enough  involucrum  has  been  formed  to  insure  the  continuity  of 
the  bone.  The  old  method  of  treating  this  class  of  cases  was  to  enlarge  one 
of  the  fistulae  leading  through  the  involucrum  and  through  this  to  extract  the 


SEQUESTROTOMY 


949 


sequestrum  in  one  or  more  fragments,  provided  it  was  loose;  if  the  sequestrum 
was  found  still  attached  to  the  living  bone,  operation  was  given  up  until  separa- 
tion was  complete.  Such  a  procedure  gives  no  opportunity  to  clean  the  dirty 
cavity  which  contained  the  bone  and  has  been  entirely  discarded. 

Tjrpical  Sequestrotomy. — Step  i. — Make  a  longitudinal  incision  down 
to  the  bone  throughout  the  whole  length  of  the  disease.  This  incision  may 
pass  through  the  mouths  of  one  or  more  fistulae  or  may  be  independent  of 
such.  Denude  the  bone  of  periosteum  for  about  3-^  inch  on  each  side  of  the 
longitudinal  incision.     Retract  the  soft  parts. 

Step  2. — If  the  sequestrum  is  entirely  superficial  remove  it.     If,  as  is  the 
rule,  the  sequestrum  lies  inside  a  coffin  (involucrum)  of  new  bone,  perforated  by 
fistulae,  proceed  as  follows:  With  chisel  and  mallet  remove  enough  of  the  new 
bone  to  give  access  to  the  whole  of  the  se- 
questrum and  to  every  part  of  the  cavity  in 
which  it  lies.     Remove  the  sequestrum,  if 
necessary  cutting  it  from  the   living  bone 
with  the  chisel  or  other  appropriate  instru- 
ment. 

In  removing  a  portion  of  the  involucrum 
to  expose  the  dead  bone,  if  possible,  do  so 
in  such  a  manner  that  the  whole  of  one  wall 
of  the  cavity  is  removed,  the  whole  of  the 
other  side  or  wall  being  retained,  thus  after 
the  sequestrum  is  taken  away  and  the  cavity 
cleansed  the  overlying  soft  parts  may  natur- 
ally fall  into  and  obliterate  the  cavity  (Fig. 
1148). 

After  removing  the  dead  and  infected  portions  of  the  bone  there  may  be  a 
mere  splint  of  sound  bone  (cortical  bone)  left  maintaining  continuity.  This  is 
quite  sufficient  as  it  will  thicken  and  grow  rapidly.  As  the  extensive  removal 
of  bone  has  completely  done  away  with  the  bone  cavity,  the  soft  parts  can  be 
brought  together  and  healing  by  first  intention  sought.  Several  different 
methods  of  attacking  the  bone  with  a  view  to  obliterating  the  cavity  will  be 
described  later. 

While  working  on  the  bone  be  careful  to  avoid  fracturing  that  portion  of 
the  involucrum  which  is  to  be  retained  and  on  which  the  continuity  of  structure 
depends. 

Step  3. — With  the  curette,  aided  if  necessary  by  the  gouge,  remove  all 
diseased  granulation  tissue  and  bone  from  the  inside  of  the  involucrum  and 
from  any  existing  fistulae.  Swab  the  cavity  with  Harrington's  solution  or  with 
liquid  carbolic  acid  (95  per  cent.)  subsequently  swabbing  with  alcohol.  Ochsner 
follows  this  by  applying  tincture  of  iodine.  If  there  is  any  doubt  as  to  the  com- 
plete removal  of  all  infected  tissue,  pack  the  cavity  with  iodoform  gauze  and 
if  the  wound  is  found  aseptic,  after  a  few  days  close  it  with  sutures.  The 
Carrol-Dakin  treatment  may  be  used.  If  it  is  believed  that  all  disease  has 
been  removed  the  wound  may  be  closed  at  once,  any  non-obliterated  cavities 


Fig.  1 148. — Sequestrotomy. 

The  bone  is  divided  at  A  and  B  and  the 
(Shaded  area  removed.. 


950  OSTEOMYELITIS 

being  drained,  or  the  cavity  may  be  filled  with  Mosetig-Moorhof  iodoform 
and  wax  plug.  The  author  has  had  very  satisfactory  result  from  filling  the 
cavity  with  a  powder  consisting  of  iodoform  i,  boracic  acid  (in  crystals)  4. 
Even  when  the  cavity  was  not  above  suspicion  in  regard  to  cleanliness  rapid 
healing  has  ensued.  After  dressings  are  applied  fix  the  limb  in  a  splint.  Re- 
generation of  the  bone  is  usually  rapid. 

Methods  of  Obliterating  the  Bone  Cavity  after  Sequestrotomy. — It  is 
assumed  that  the  sequestrum  and  all  diseased  tissue  have  been  completely 
removed,  that  the  cavity  has  been  disinfected  and  packed  with  gauze,  that  the 
skin  around  the  wound  has  been  prepared  as  if  for  a  new  aseptic  operation, 
that  the  surgeon  and  assistants  have  prepared  themselves  and  the  instruments 
as  if  for  a  fresh  operation. 

I.  Schede's  Aseptic  Blood-clot. — Remove  the  pack  of  gauze  from  the  bone 
cavity.  Unite  the  divided  periosteum  and  soft  parts  with  fine  buried  sutures 
in  layers.  Close  the  skin  wound.  Provide  drainage  by  a  few  strands  of  cat- 
gut, a  chicken-bone  tube  or  a  strip  of  rubber  tissue.  Apply  abundant  dressings. 
Immobilize  the  limb  in  an  almost  vertical  position.  Remove  the  elastic  con- 
strictor. Enough  bleeding  takes  place  to  fill  the  cavity  with  blood.  Any  ex- 
cess of  blood  is  carried  into  the  dressings.  The  elevated  posture  prevents 
all  dangerous  or  inconvenient  hemorrhage  and  may  be  safely  discontinued 
after  twelve  to  twenty-four  hours.  If  everything  progresses  favorably  a  large 
cavity  may  heal  under  one  dressing  in  about  six  weeks.  Keep  a  very  sharp 
watch  for  signs  or  symptoms  of  decomposition  in  the  wound  as  this  is  liable 
to  occur  and  necessitates  immediate  evacuation  and  drainage. 

II.  Senn's  Decalcified  Bone  Chips.    Preparation  of  the  Chips. 

"Select  the  compact  layer  of  the  fresh  tibia  of  the  ox,  remove  all  periosteum  and  medullary 
tissue,  dix-ide  into  longitudinal  strips  about  J'g  of  an  inch  wide  and  immerse  in  a  relatively  large 
quantity  of  10  to  15  per  cent,  watery  solution  of  hydrochloric  acid  which  must  be  renewed  daily, 
for  from  one  to  two  weeks;  then  wash  thoroughly  in  water  or  a  weak  solution  of  caustic  potash, 
cut  into  small  chips,  soak  for  forty-eight  hours  in  i  :  1000  mercuric  bichloride  solution,  remove 
and  store  in  a  saturated  solution  of  iodoform  in  ether.  When  about  to  be  used,  wrap  in  asep- 
tic gauze,  dissolve  out  the  excess  of  ether  and  iodoform  with  alcohol  and  put  in  i  :  2000  mer- 
curic bichloride  solution  until  required,  when  careful  drying  with  iodoform  gauze  should  precede 
their  implantation."     (Senn.) 

Remove  the  gauze  pack  from  the  bone  cavity.  Fill  the  cavity  completely 
with  the  decalcified  bone  chips.  Treat  exactly  as  in  Schede's  method.  The 
interstices  between  the  chips  become  filled  with  blood.  The  bone  chips,  it 
is  claimed,  strengthen  the  frame-work  of  blood-clot  into  which  the  healthy 
granulation  tissue  penetrates,  while  being  impregnated  with  iodoform  they 
keep  that  drug  disseminated  throughout  the  blood-clot  where  it  inhibits  bacterial 
activity. 

Instead  of  decalcified  chips  such  foreign  material  as  paster  of  Paris,  amal- 
gam and  chips  of  fresh  bone  have  been  used  with  occasional  success.  Neuber 
believes  the  whole  value  of  Senn's  bone  chips  lies  in  the  fact  that  they  keep 
iodoform  diffused  through  the  blood-clot,  but  that  the  bone  chips  themselves 


OBLITERATION    BONE    CAVITIES 


951 


are  objectionable  as  they  are  too  slowly  absorbed.  Iodoform  glycerine  is 
valueless  as  a  substitute  because  the  iodoform  in  it  is  quickly  precipitated. 
Neuber's  method  is  as  follows: 

III.  Neuber's  Iodoform  Starch. — Preparation  of  the  starch.  Mix  10  grams 
of  wheat  starch  with  the  smallest  possible  amount  of  water  in  an  open  glass 
vessel,  pour  into  this,  constantly  stirring  the  mixture,  200  grams  of  boiling  2 
per  cent,  watery  carbolic  solution.  After  partial  cooling,  stir  in  10  grams  of 
powdered  iodoform.  Pour  into  a  sterile  glass  flask.  This  mixture  may  be 
kept  for  weeks  in  a  dark  room.  It  is  used  in  the  same  fashion  as  Mosetig- 
Moorhof's  iodoform  wax.  Neuber  considers  this  method  suitable:  (a)  after 
superficial  sequestrotomies  and  the  removal  of  superficial  tuberculous  foci;  (b) 
after  sequestrotomies  when  the  bone  cavity  is  deep  and  large  but  its  edges 
are  uniform  and  sloping  (not  overhanging). 

IV.  Mosetig-Moorhof's  iodoform  wax  plug  has  already  been  described. 


Fig.  I I 49. 


Fig. 


V.  Emil  Beck's  bismuth  paste  ("Journal  A.  M.  A.,"  March  14,  1908) 
may  be  used  in  a  manner  similar  to  Neuber's  starch.  The  formula  of  the 
paste  is  as  follows: 

Bismuth  subnitrate 30.0  grams.     (Carbonate?) 

White  wax .• 5.0  grams. 

Soft  paraffin  5.0  grams. 

Vaseline 60 . o  grams. 


Mix  while  boiling.  Do  not  spill  any  water  into  the  paste  while  boiimg. 
If  a  syringe  is  used  to  insert  the  paste  it  should  be  sterilized  by  the  dry  process 
and  the  plunger  dipped  in  sterile  vaseline  instead  of  water.  Soft  paraffin 
differs  from  hard  paraffin  in  being  absorbable.  Occasionally  Beck  adds  i  per 
cent,  of  formalin  to  the  paste. 

As  a  number  of  cases  of  nitrite  poisoning,  some  fatal,  have  been  observed 
after  the  use  of  subnitrate  of  bismuth,  it  is  recommended  that  the  carbonate 
of  bismuth  be  used  in  place  of  the  subnitrate. 

VI.  The  cavity  left  after  removal  of  the  sequestrum  has  walls  which  pre- 
vent obliteration  by  the  falling  in  of  the  overlying  soft  parts.  With  the  chisel 
cut  through  the  bone  at  the  base  of  one  of  the  walls  for  the  whole  length  of  the 
cavity,  but  carefully  avoid  cutting  the  periosteum.     Remove  a  wedge-shaped 


952 


OSTEOMYELITIS 


Strip  of  bone  A  B  C  D  along  this  line  of  section  to  permit  the  mobilized  bone 
to  fall  in  and  obliterate  the  cavity  (Figs.  1149  and  1150). 

VII.  Osteoplastic  method  of  M.  W.  af  Schulten  ("Archiv  fur  klin.  Chir.," 
lii,  145).  Of  this  method  there  are  several  varieties,  in  all  of  these  the  anterior 
wall  of  the  bone  cavity  (of  the  tibia)  is  removed,  sequestra,  etc.,  extracted,  the 
cavity  disinfected  and  packed  with  gauze  for  about  three  weeks  or  until  it  is 
covered  with  healthy  granulation  tissue,  .\fter  being  packed  with  gauze 
the  wound  should  be  partly  closed  with  sutures  to  prevent  too  much  retraction 
of  the  soft  parts. 

Variety  a  of  Method  (the  whole  shaft  of  the  tibia  is  affected). — Step  1. — 
Completely  remove  the  two  lateral  walls  of  the  bone  cavity  in  its  middle  third 
(Fig.  1 151),  leaving  the  posterior  wall  to  maintain  continuity. 


Fig.  iiiji. 


Fig.  1153. 


Figs.  1151,  1152  axd  1153. — Sequestrotomy. 


Step  2. — At  the  upper  and  lower  ends  of  the  primary  incision  (made  in  the 
previous  operation  and  now  reopened)  make  transverse  incisions  down  to  the 
bone  (Fig.  1151,  i,  i).  Through  these  cuts  divide  the  lateral  walls  of  the  cavaty 
transversely. 

Step  3. —  Introduce  a  chisel  into  the  bone  cavity  through  the  anterior  open- 
ing made  at  the  first  operation  and  cut  through  the  junction  of  the  lateral 
walls  (A,  B,  Fig.  115 2)  with  the  posterior  wall  (C,  Fig.  115 2)  of  the  cavity.  Be 
careful  to  leave  the  periosteum  intact. 

Step  4. — From  the  edge  of  the  posterior  wall  (C)  of  the  cavity  or  the  bases 
of  the  lateral  walls  shave  away  enough  bone  to  permit  the  lateral  walls  to 
slide  together  (Fig.  11 52). 

Step  5. — Approximate  the  lateral  walls  (Figs.  115  2-1 153  A,  B)  and  fix  them 
by  periosteal  or  bone  sutures  as  may  be  convenient.  Close  the  wound  in  the 
soft  parts.     Dress  and  apply  a  splint. 


NEUBER  S    OPERATIONS 


953 


N.  B. — The  object  in  treating  the  upper  and  lower  thirds  of  the  bone  diflFer- 
ently  from  the  middle  third  is  that  the  portions  of  the  cavity  situated  at 
the  ends  of  the  bone  are  more  difficult  to  obliterate  by  the  falling  in  of  the 
soft  parts  than  is  that  part  in  the  middle  of  the  shaft. 

Variety  b  of  Method. — Divide  the  lateral  walls  of  the  cavity  transversely 
at  both  its  extremities  and  also  at  its  middle  (Fig.  1154).  Mobilize  and  approxi- 
mate the  lateral  walls  as  in  variety  a.  Here  the  whole  cavity  is  obliterated  in 
the  method  used  in  the  previous  operation  for  the  upper  and  lower  ends.  Mobili- 
zation of  each  lateral  wall  in  two  segments  is  more  easily 
accomplished  than  in  one,  hence  the  transverse  incision  in 
the  middle. 

VIII.  Neuber's  Method  of  Invagination. — Sequestrotomy 
has  been  performed,  the  wound  has  been  disinfected,  and  all 
sclerosed  connective  tissue  has  been  dissected  away.  With 
the  chisel  remove  most  of  the  lateral  walls  of  the  bone  cavity, 
but  preserve  the  periosteum  unless  it  is  infected.  Invagi- 
nate  the  overlying  soft  parts  and  fix  them  in  position  by  su- 
ture, pegs,  or  strapping.  Figures  1155,  1156,  1157  explain 
the  method  more  clearly  than  words. 

IX.  M.  W.  af  Schulten's  method  for  obliteration  of  cavi- 
ties in  lower  end  of  femur. 

Ca\-ities  at  the  low^er  end  of  the  femur  are  not  so  amenable 
to  the  ordinary  means  of  obliteration  as  are  those  in  the  tibia 
or  the  shaft  of  the  femur.     Af  Schulten  ("Archiv  fur  klin. 
Chir.,"  liv,  328)  advises  filling   the   cavity  with   a  flap  of 
muscle  and  periosteum.     The  operation  is  done  in  two  stages. 

Stage  I. — This  is  the  same  as  for  old  abscess  plus  sequestrotomy  and  need 
not  be  described  again. 

Stage  2. — This  is  undertaken  two  to  three  weeks  after  Stage  i.  Apply  an 
elastic  constrictor. 

Step  I. — With  the  sharp  spoon  remove  all  the  granulation  tissue  from  the 
wound  and  the  bone  ca\dty.  Disinfect  the  cavity  as  thoroughly  as  possible. 
Pack  the  cavity  temporarily. 

Step  2. — Supplement  the  primary  longitudinal  incision  by  a  transverse 
one  involving  the  skin  alone.  Reflect  the  skin  as  in  Fig.  11 58,  exposing  the 
deep  fascia. 

Step  3. — Make  the  flap  ABC  (Figs.  11 58  and  11 59),  consisting  of  deep  fascia, 
muscle,  and  periosteum  and  ha\dng  its  pedicle  above.  The  flap  must  be 
long  enough  and  so  located  that  it  will  easily  fall  into  the  bone  cavity  after 
being  mobilized  (Fig.  1160).  (In  mobilizing  the  flap  it  may  perhaps  be  well 
to  use  a  chisel  instead  of  an  elevator  and  so  leave  a  thin  shell  of  bone  or  some 
fragments  of  bone  attached  to  the  periosteum.)  If  the  shape  of  the  upper  end 
of  the  bone  cavity  interferes  with,  the  pedicle  of  the  flap  when  it  is  implanted 
into  the  ca\'ity,  trim  the  bone  with  the  chisel  until  the  fault  is  eliminated. 

Step  4. — Remove  the  elastic  constrictor.  Attend  to  hemostasis.  Remove 
the  temporary  pack  from  the  bone  ca\'ity.  Fill  the  cavity  with  the  mobilized 
flap  (Fig.   1 160).     Fix  the  flap  with  a  few  catgut  sutures.     Close  the  skin 


Fig.     II54-— 
Sequestrotomy. 


954 


OSTEOMYELITIS 


/■ 


Fig.  1155. — Sequestrotomy. 


Fig.  1156. 

Figs.  1156  and  1157. — Sequestrotomy 


Fig.  \\i%.—{Aj  Schidlin) 


Fig.  II 59.— (^/ SchulUn.) 


AF    SCHULTEN  S   METHOD 


955 


(Fig.  1161)  wound  with  or  without  drainage.     Apply  dressings  and  a  splint. 
Keep  the  limb  elevated  for  twenty-four  hours. 

Af  Schulten  considers  that  any  pressure  exerted  upon  the  wound  may 
interfere  with  the  vitality  of  the  transplanted  flap,  hence  he  coveres  the  area 
of  the  wound  with  a  wire  cage  over  which  he  lays  a  few  layers  of  gauze.  By 
this  means  no  dressings  touch  the  wound  area  which  is  protected  completely 


Fig.  1 160. — {Af  Schulten.) 


Fig.  1161. — {Af  Schulten) 


Fig.  1 162. — {A f  Schulten.) 


Fig.  1163. — {Af  Schulten.) 


from  all  irritation  by  the  gauze  covering  the  wire  cage.  The  author  uses  a 
similar  method  for  the  protection  of  areas  covered  with  Thiersch's  skin  graft 
and  finds  it  excellent.  He  surrounds  the  area  with  a  cushion  of  sterile  gauze 
or..cotton,  like  a  bird's  nest  or  ring  cushion  and  covers  the  hole  in  the  centre 
of  the  cushion  with  a  few  layers  of  gauze.  This  permits  evaporation  of  dis- 
charges and  at  the  same  time  keeps  away  irritation.     When  the  bone  cavity 


956 


OSTEOMYELITIS 


is  very  deep,  two  muscle  and  periosteal  flaps  may  be  used  one  above  the  other 
(Figs.     1162,  1163). 

When  the  bone  cavity  is  very  long,  two  flaps  may  be  used  as  shown  in 
Figs.  1 164,  1 165.  Similar  procedures  may  be  applied  to  the  obliteration  of 
cavities  in  other  locations. 

(c)  The  whole  or  almost  the  whole  shaft  of  the  bone  is  necrosed,  the  perios- 
teum is  almost  entirely  separated  from  the  bone  and  between  these  two  struc- 
tures there  is  much  pus. 

As  already  mentioned,  if  efflcient  drainage  can  be  maintained,  it  is  wise  to 
retain  the  sequestrum  as  a  splint,  especially  as  many  cases  are  known  in  which 
partial  regeneration  of  the  apparently  dead  bone  has  taken  place.  If,  however, 
in  spite  of  free  drainage  symptoms  of  intoxication  persist  the  dead  bone  must  be 
removed.     If  a  disk  of  healthy  bone  is  left  between  the  shaft  and  epiphysis 


/  m^ 


/ 


Fig.  1 164. — (Af  Schulten.) 


Fig.  1165. — {Af  Schultin.) 


no  deformity  from  shortening  need  be  anticipated  (G.  B.  Johnston).  When  the 
tibia,  for  example,  is  removed  its  companion  bone,  the  fibula,  takes  on  com- 
pensatory hypertrophy.  G.  Ben  Johnston  ("Transactions  Am.  Surg.  Assoc," 
xxii)  thus  describes  the  operation: 

"  (a)  Free  incision  and  complete  removal  of  all  diseased  bone. 

"  (6)^Spare  all  periosteum  possible. 

"  (c)  Avoid  curette,  or  use  cautiously. 

"  {d)  Purify  the  wound  by  the  strictest  antiseptic  methods. 

"After-treatment. — (a)  Maintain  aseptic  methods. 

"  (b)  Avoid  too  frequent  and  rough  dressings. 

"  (c)  Treat  as  a  fracture  by  immobilization  in  a  fracture  box. 

"(d)  Carefully  shape  the  parts,  as  bone  tissue  develops,  by  bandages  or 
adhesive  straps. 

"  (e)  Protect  the  young  bone  by  means  of  plaster  of  Paris. 


DEFECTS   IN  TIBIA 


957 


"(/)  Abstain  from  the  use  of  the  limb  until  the  new  bone  is  capable  of 
sustaining  the  weight  of  the  body. 

"  ig)  Look  after  the  general  health." 

Le  Conte  ("Trans  Am.  Surg.  Assoc")  takes  up  a  very  similar  position  sup- 
porting it  by  the  experience  of  himself  and  his  colleagues  in  the  Pennsylvania 
Hospital  of  Philadelphia. 

X.  Von  Eiselsberg's  method.  Treatment  of  large  defects  in  tibia.  Von 
Eiselsberg  ("Archiv  flir  klin.  Chir.,"  Iv,  435)  extended  the  Konig-Miiller 
method  of  closing  cranial  defects  to  the  treatment  of  large  defects  in  the  tibia. 
While  the  method  was  devised  to  repair  the  damage  done  by  the  removal 
of  a  sarcoma,  it  may  be  employed  to  rectify  defects  from  other  causes,  e.g., 
from  total  necrosis  of  a  long  segment  of  the  bone. 

Step  I. — Apply  an  elastic  constrictor.  Clean  and  vivify  the  defect  to  be 
filled.  If  very  little  of  the  lower  end  of  the  tibia  remains  it  may  be  removed 
and  a  portion  of  the  astragalus  vivified  for  the  reception  of  the  flap. 


Fig.  1 166. — {v.  Eiselsberg.) 


Fig.  1 16 7. — {v.  Eiselsberg.) 


Step  2. — Divide  the  skin  so  as  to  make  the  flap  ABC,  Fig.  1166.  With 
a  chisel  make  an  incision  through  the  whole  thickness  of  the  cortical  bone 
along  the  dotted  line  in  Fig.  1166.  Do  not  in  any  way  separate  the  soft  parts 
from  the  bone  within  the  encircling  bone  incision.  With  the  chisel  separate 
the  divided  cortical  bone,  in  one  piece  with  the  periosteum  and  skin,  from  the 
medullary  bone.  This  gives  us  a  flap  of  skin,  periosteum,  and  cortical  bone 
provided  with  a  pedicle  at  A. 

Step  3. — Twist  the  flap  into  position  to  fill  the  tibial  defect  (Fig.  1167). 
Suture  it  in  position.  Do  not  apply  too  much  torsion  to  the  pedicle,  and 
when  applying  dressings  do  not  let  them  exert  much  pressure  either  on  the 
pedicle  or  on  the  flap. 

Step  4. — Close  the  wound  left  on  the  upper  part  of  the  leg  by  sliding  the 
skin  over  the  osseous  wound.  Complete  closure  will  often  be  impossible, 
but  the  resultant  space  may  be  subsequently  covered  by  Thiersch's  skin  grafts. 

Step  5. — Apply  dressings  and  a  splint.  Place  the  limb  in  a  vertical  position. 
Remove  the  elastic  constrictor. 


958  TUMORS  OF  BONE 


CHAPTER  LXXI 
TUMORS  OF  BONE 

I.  Benign. — Removal  of  the  neoplasm  itself  is  usually  all  that  is  necessary 
for  a  cure.  If  the  tumor  involves  so  much  bone  that,  after  its  removal,  restora- 
tion of  the  continuity  of  the  limb  becomes  impossible  or  inadvisable,  then 
amputation  may  be  necessary. 

Simple  cysts  of  the  long  bones  have  no  connective  tissue  capsule,  but 
islands  of  cartilage  may  exist  in  the  bony  capsule.  They  should  merely  be 
curetted  and  drained.  R.  C.  Elmslie  (Brit.  Journ.  Surg.,  II,  No.  5),  speaking  of 
benign  cysts  (osteitis  fibrosa)  of  the  humerus,  advocates  thorough  curettement, 
and  opening  of  the  medullary  cavity  above  and  below  so  as  to  admit  normal 
marrow  into  the  cavity.  "  If  there  is  any  deformity,  the  humerus  may  be  safely 
broker;  or  cut  through  at  the  site  of  the  cysts  in  order  that  the  bone  may  be 
straightened."  Ordinary  dentigerous  cysts  merely  require  evacuation  of  their 
contents,  removal  of  their  membranous  lining  and  excision  of  just  so  much  of 
their  bony  wall  as  will  correct  deformity.  Adamantine  epitheliomata  (Blood- 
good)  differ  from  dentigerous  cysts  in  containing  white  granular  tissue.  Such 
a  tumor  must  be  excised  with  its  bony  wall,  but  it  is  permissible  to  keep  close  to 
the  tumor.  This  tumor  is  included  among  the  benign  neoplasms  merely  be- 
cause it  is  indistinguishable  clinically  from  a  dentigerous  cyst  and  if  excised 
as  above  it  does  not  tend  to  recur.  Osteomata  should  be  removed  thoroughly 
along  with  considerable  of  their  bony  basis.  The  same  is  true  regarding 
enchondromata. 

II.  Tumors  of  a  Low  Grade  of  Malignancy. — ^Many  of  the  tumors  referred 
to  can  scarcely  be  recognized  before  being  exposed  or  incised. 

Giant-cell  Sarcoma.  Myelogenous  Sarcoma.  Myeloid  Sarcoma. — When 
cut  into,  the  tumor  presents  a  peculiar  brownish-red  color  like  liver  or  spleen. 
It  is  very  vascular,  hemorrhage  into  it  is  common,  it  is  friable  and  can  be  broken 
up  into  irregular  masses.  The  tumor  usually  grows  in  the  medullary  cavity  of 
the  long  bones  and  is  surrounded  by  a  shell  of  new-formed  bone.  It  is  only 
locally  malignant,  in  its  earlier  stages  at  least,  and  generally  grows  slowly 
without  much  pain,  causing  a  gradual  and  uniform  expansion  of  the  bone.  In 
time  the  tumor  extends  beyond  the  bone  and  invades  the  soft  parts  and  must 
then  be  considered  distinctly  malignant. 

In  its  early  stages  a  giant-cell  sarcoma  may  be  treated  by  excision  of  the 
tumor  and  the  surrounding  bone.  W.  Kramer  writes  ("Archiv  fiir  klin. 
Chir.,"  Ixvi):  "It  is  only  during  the  operation  that  the  surgeon  can  come 
to  a  conclusion  as  to  the  propriety  of  conservatism.  In  my  two  cases  I  have 
not  been  afraid  to  ascertain  the  condition  of  the  marrow  by  an  exploratory 
evidement  of  the  remaining  bone  and  have  only  proceeded  to  unite  the  ends 
of  the  bone  when  that  has  been  found  normal."  J.  C.  Bloodgood  ("Journal 
A.  M.  A.,"  Feb.  i,  1908)  writes  of  giant-cell  sarcoma:  "It  may  be  as  slow 


MYELOID    SARCOMA  BONE  959 

of  growth  as  the  cyst.  The  X-ray  shadow  does  not  distinguish  it  positively 
from  any  other  medullary  tumor  having  a  bone  shell.  This  tumor  has  been 
permanently  cured  by  simple  curetting.  Recurrences  have  followed  curet- 
ting, but  were  permanently  eradicated  by  a  second  operation  of  curetting 
resection,  or  amputation.  Of  over  one  hundred  cases  of  the  pure  tumor  none 
has  given  metastasis.  It  seems  justifiable  at  the  first  operation,  therefore, 
to  attempt  the  most  conservative  method,  even  with  the  risk  of  a  local  recurrence 
which,  if  it  does  occur,  apparently  is  not  associated  with  any  danger  of  metas- 
tasis. One  should  not  attempt  curetting  unless  there  is  a  thick  shell  of  bone,  so 
that  the  curette  or  chisel  removes  a  zone  of  bone  beyond  the  tumor.  When  the 
shell  of  bone  is  thin,  subperiosteal  resection  should  be  performed;  when  the 
periosteum  and  surrounding  muscles  have  become  infiltrated,  total  resection 
is  indicated.  In  one  of  my  recorded  cases  in  which  a  cure  was  effected  and 
in  which  there  was  infiltrated  muscle,  the  microscope  demonstrated  the  giant- 
cell  tumor  within  a  few  millimetres  of  the  plane  of  resection.  For  the  periosteal 
giant-cell  tumor  local  resection  with  chiseling  of  a  zone  of  bone  beneath  is 
sufficient." 

O.  Hildebrandt  believes  the  local  removal  of  myeloid  sarcomata  gives 
uncertain  results  and  is  not  advisable. 

Sir  H.  Morris  removed  the  radius  and  ulna  for  a  myeloid  sarcoma  originat- 
ing in  the  former  and  firmly  attaching  the  ulna  to  it.  After  four  years  there 
was  no  recurrence.  Glutton  operated  on  three  cases  of  endosteal  sarcoma 
of  the  radius.  In  one  of  these  the  sawed  end  of  the  bone  showed  a  small 
nodule  of  tumor  in  the  medullary  canal;  after  this  was  removed  by  scraping 
and  gouging  a  cure  seems  to  have  been  obtained.  In  another  case  where  the 
head,  neck,  and  upper  end  of  the  radius  was  excised  there  was  no  recurrence 
when  the  patient  died  from  renal  disease  after  eighteen  months. 

Herten  ("  Zentralblatt  fiir  Chir.,"  Feb.  5,  1910)  reviews  the  cases  (60  in 
all)  of  sarcoma  of  the  long  bones  operated  upon  in  the  Breslau  clinic  between 
1890  and  1909. 

Amputation  or  exarticulation  was  performed  in  advanced  cases  when  the 
sarcoma  did  not  seem  suited  for  resection.  (Twenty  cases  of  periosteal  sarcoma; 
six  of  myelogenous,  central  and  chondro-sarcomata.) 

None  of  the  periosteal  sarcomata  were  permanently  cured  while  there  was 
no  recurrence  in  two  cases  of  myelogenous  sarcoma,  in  one  of  central  round 
cell  sarcoma,  .and  in  one  of  unknown  variety.  Of  twenty-nine  resections 
five  were  too  recent  for  consideration;  of  the  remaining  twenty-four,  twelve 
were  periosteal,  twelve  myelogenous,  central  and  chondro-sarcomata.  One 
of  the  periosteal  remained  cured,  hut  only  after  amputation  because  of  poor 
nutrition  of  the  limb  and  reamputation  because  of  recurrence  one  year  later. 
In  the  group  of  myelogenous  and  central  sarcomata  nine  were  cured  and 
three  died. 

Among  the  nine  which  remained  well,  four  required  amputation  subse- 
quently, but  in  five  the  resection  sufl&ced. 

Among  the  twenty-nine  resections,  recurrence  was  recognizable  eight 
times  and  in  eight  cases  amputation  or  exarticulation  was  necessitated  owing 
to  recurrence  or  to  want  of  consolidation. 


960  TUMORS   OF   BONE 

Herten  concludes  that  a  high  amputation  or  exarticulation  is  always  indi- 
cated in  periosteal  sarcoma  of  the  long  bones,  while  in  myelogenous,  central 
and  chondro-sarcoma  resection  is  proper  in  favorable  cases.  In  one  case 
where  a  central  round  cell  sarcoma  of  the  humerus  was  resected  there  was  no 
recurrence  until  after  the  lapse  of  five  years  when  "suddenly  within  six  weeks 
there  was  a  recurrence  the  size  of  a  head." 

Kiittner  disapproves  of  conservative  operations  in  periosteal  sarcomata, 
prefers  amputation  even  in  myelogenous  sarcoma  and  thinks  resection  only 
justifiable  in  very  favorable  cases. 

On  the  whole,  one  may  conclude  that  a  conservative  operation  is  proper 
for  the  thorough  excision  of  giant-cell  tumors  affecting  bones  which  are  of 
prime  importance  for  the  efficiency  and  comfort  of  the  patient.  Examples 
of  such  bones  are  the  femur,  the  humerus,  the  radius  or  ulna,  the  jaws,  etc. 
When  a  toe,  finger,  foot,  or  perhaps  even  when  the  tibia  is  the  site  of  the  disease, 
amputation  may  leave  the  patient  as  capable  or  more  capable  of  pursuing 
work  or  pleasure  and  gives  a  better  assurance  of  real  cure.  The  amputation 
ought,  however,  to  be  conservative  and  not  such  as  is  described  later  in  this 
chapter. 

Pure  myxomata  of  bone  (endosteal  or  periosteal)  are  rare.  Treatment  is 
the  same  as  for  giant-cell  sarcomata. 

III.  Malignant  Tumors. — Sarcomata  (round  or  spindle  cell,  angio-sarcoma) 
are  the  malignant  neoplasms  which  occur  primarily  in  bone.  These  tumors 
(whether  central  or  subperiosteal)  early  pass  beyond  the  limits  of  the  bones 
and  infiltrate  the  muscles  and  tendons  attached  to  them.  The  muscles  act 
as  an  excellent  path  for  the  conduction  of  the  infiltrating  neoplastic  tissue  from 
one  bone  to  another,  e.g.,  the  deltoid  may  conduct  neoplastic  tissue  from  the 
humerus  to  the  scapula.  This  is  important  from  the  standpoint  of  treatment. 
Metastasis  is  very  common  in  spite  of  treatment.  A  classical  rule  in  the  treat- 
ment of  sarcoma  of  bone  was  to  amputate  at  or  above  the  joint  proximal  to  the 
disease,  i.e.,  to  remove  the  whole  of  the  bone  affected.  This  treatment  ought 
to  be  effective  if  the  tumor  is  still  confined  within  the  bone;  if,  however,  muscu- 
lar infiltration  has  taken  place,  even  if  it  is  not  apparent  to  the  naked  eye,  then 
the  only  hope  of  benefit  lies  in  more  extensive  work.  Theoretically  to  achieve 
the  best  permanent  results  one  should  remove  the  bone  primarily  diseased, 
the  muscles  inserted  into  it  and  the  bone  from  which  these  muscles  arise. 
This  theoretical  aim  is  nearly  attained  in  the  cases  of  tumors  of  the  humerus 
by  interscapulo-thoracic  amputation.  The  accompanying  statistics  speak  for 
themselves.  Berger.  Forty-six  cases.  Primary  mortality,  5  per  cent.  Free 
from  recurrence  after  one  year,  33  per  cent. 

Konitzer.  Primary  mortality,  4  per  cent.  Known  recurrence,  21  per  cent. 
Free  from  recurrence  in  less  than  one  year,  34  per  cent.  Free  from  recurrence 
longer  than  one  year,  21  per  cent.     Un traced,  24  per  cent. 

The  same  principle  may  be  easily  carried  out  in  sarcomata  of  the  foot  by 
amputating  above  the  knee.  Unfortunately,  in  many  or  most  instances  practi- 
cal considerations  (primary  danger,  unendurable  deformity,  etc.)  prevent  the 
attainment  of  the  ideal.     Under  these  circumstances  one  may  amputate  as 


SARCOMA   BONE  961 

high  as  possible  and  at  the  same  time  remove  as  thoroughly  as  possible  the 
muscles  inserted  into  the  diseased  bone,  especially  those  most  likely  to  be  in- 
volved. Example:  Periosteal  sarcoma  on  the  outer  side  of  the  head  of  the 
tibia.  Amputation  above  the  knee  is  necessary.  It  is  probable  that  any 
neoplastic  invasion  of  the  tendo  patellae  will  be  slow  to  spread  upwards  beyond 
the  patella;  hence  if  the  disease  is  tolerably  recent  the  quadriceps  extensor  may 
be  considered  reasonably  safe.  The  biceps  is  the  muscle  most  probably  in- 
volved, hence  as  soon  as  the  amputation  is  completed  and  the  main  vessels 
ligated  it  seems  to  the  writer  most  reasonable  to  expose  this  muscle  throughout 
its  whole  length  and  to  excise  it  completely. 

Carcinomata  and  hypernephromata  are  always  secondary  to  disease  else- 
where, and  any  operation  performed  on  them  must  be  considered  merely  pal- 
liative, except  when  the  primary  tumor  has  directly  invaded  the  affected 
bone  and  and  can  be  removed  with  it. 

Wengloski  (Lancet,  May  16,  1914)  in  sarcomata  which  involve  a  bone 
removes  the  disease  of  the  soft  parts,  scrapes  away  the  rest  of  the  tumor  upon 
the  bone  and  lays  bare  the  bone  as  if  for  resection.  He  then  covers  the  soft 
parts  with  three  or  four  thicknesses  of  gauze,  covers  the  gauze  with  asbestos 
paper  and  the  paper  with  sheets  of  metal.  The  metal  is  to  keep  condensed 
steam  from  the  asbestos. 

Steam  is  generated  in  an  autoclave  or  even  a  kettle  (the  steam  is  under  a 
pressure  of  from  3  to  5  atmospheres).  A  thick  rubber  tube  about  6  feet  long 
conducts  the  steam  from  the  spout  of  the  kettle  to  a  metal  nozzle.  For  the 
front  of  the  bone  a  straight  metal  tube  with  terminal  holes  (like  the  'rose'  of  a 
watering  pot)  is  good.  For  the  hinder  surface  of  the  bone  a  flattened  curved 
tube  with  holes  on  its  concave  face  is  requisite.  Through  one  or  both  of  these 
tubes  steam  is  appUed  to  the  exposed  and  diseased  bone  so  as  to  kill  but  leave 
it  in  situ  like  a  graft  of  dead  bone. 

Experiments  show  that  when  steam  is  applied  to  the  surface  of  the  femur  a 
thermometer  in  the  medullary  cavity  registers  from  75°  to  80°  C.  (167°  to  176°  F.) 
in  from  4  to  4}^^  minutes.  To  gain  the  same  result  in  the  condyles  of  the  femur 
takes  8  minutes;  in  the  tibia,  3  minutes;  lower  jaw,.  13^^  minutes.  The  effect  of 
the  steam  spreads  only  about  2  cm.  (^  in.)  upwards  or  downwards  along  the 
bone  from  the  site  of  application;  thus  if  much  of  the  length  of  the  bone  is  to  be 
sterilized  it  must  be  done  bit  by  bit,  the  nozzle  being  moved  along  the  bone. 
The  results  of  Percy's  operation  on  cancer  of  the  uterus  seem  to  show  that 
moderate  heat  is  fatal  to  malignant  cells  and  to  support  Wenglowski's  ideas. 


962  OSTEOTOMY 


CHAPTER  LXXII 
CHONDRECTOMY 

It  is  well  known  that  when  osteomyelitis  affects  an  active  (fertile)  epiphyseal 
cartilage  one  of  two  things  may  happen:  (a)  The  cartilage  may  be  destroyed  and 
as  a  consequence  growth  of  the  bone  cease,  (b)  The  cartilage  may  be  stimu- 
lated and  growth  of  the  bone  become  excessive.  Where  the  diseased  epiphyseal 
cartilage  is  that  of  one  of  the  bones  of  the  forearm  or  leg,  deformity  results 
because  of  the  unequal  growth  of  the  two  bones.  The  deformity  may  be 
treated  by  resecting  a  segment  of  the  longer  bone,  thus  shortening  it.  Oilier 
has  operated  in  a  more  scientific  fashion.  He  cuts  down  upon  the  epiphyseal 
cartilage  whose  active  growth  is  producing  the  deformity  and  destroys  it  in  part 
or  completely.  In  the  forearm  bones  the  fertile  epiphyseal  cartilages  are  at  the 
inferior  extremity  of  the  bones;  in  the  tibia  the  fertile  cartilage  is  superior. 


CHAPTER  LXXIII 

OSTEOTOMY 

SPECIAL  INSTRUMENTS  REQUIRED 

I.  Chisels. — Although  for  many  purposes  the  ordinary  carpenter  chisel, 
tempered  to  cut  hard  wood,  is  convenient  and  efficacious,  yet  most  surgeons 
prefer  an  instrument  fashioned  out  of  one  piece  of  metal;  of  these  there  are  in- 
numerable patterns.  All  chisels  ought  to  be  large  enough  to  afford  a  good 
grasp  to  the  surgeon's  hand;  such  as  are  so  small  as  to  require  handhng  by 


Fig.  1 16S.— Chisel. 

the  fingers  and  thumb  are  difficult  to  use  with  precision.     The  most  useful 
chisel  has  a  cutting  edge  3^^  inch  wide;  a  narrower  instrument  is  also  serviceable. 
Chisels  are  of  three  varieties : 

(A)  The  ordinary  chisel  with  beveled  edge.  This  is  suitable  for  paring  or 
shaving  bone  and  for  excising  wedges  of  bone.  Figures  11 68  and  11 69  show 
why  ordinary  chisels  are  not  fitted  to  make  linear  incisions  in  bone. 

(B)  Gouges  of  various  shapes  are  useful  especially  for  the  cutting  of  gutters 
or  grooves  in  bone.  Their  cutting-edge  should  be  beveled  on  the  convex  or 
outer  side  (Fig.  11 70). 


OSTEOTOMY 


963 


(C)  Osteotomes,  or  wedge-shaped  chisels,  are  the  only  chisels  suitable  for 
making  a  clean  cut  into  or  through  a  bone.  Macewen's  osteotomes,  in  three 
sizes  (Fig.  1171),  are  classical  and  efficient.  Various  surgeons  have  modified 
Macewen's  osteotomes,  but  only  in  non-essential  details. 


/■ 


Chisel. 


Osteotome. 
Fig.  1169. 


2.  Mallet.^ — A  mallet  is  a  necessary  adjunct  to  the  chisel.  Wooden  mallets 
are  excellent,  but  are  liable  to  split  after  having  been  boiled  frequently.  Figure 
1 1 72  shows  how  a  leaden  mallet  becomes  spoiled  by  use. 
A  heavy  wide-faced  bronze  mallet  is  efficient  and  dura- 
ble.    Many  surgeons  use   an   ordinary  steel  hammer. 


Fig.  1 1 70. — Gouge. 


In  an  emergency  any  block  of  wood  or  a  potato  masher  serves  every  purpose 
and  is  easily  sterilized  by  boiling.  Rawhide  mallets  are  usually  light  and 
do  not  withstand  boiling  satisfactorily. 


Fig.  1 17 1. — Osteotome. 


Fig.  1172. 

lead  mallet,  face  mushroomed  from  use;  b,  large  bronze  mallet;  c,  wooden  mallet:  d,  Mixter's  mallet  of 

vulcanized  fibre. 


964  OSTEOTOMY 

METHODS  OF  USING  CHISFXS 

In  osteotomy  the  old  saying  ''the  more  haste,  the  less  speed"  holds  true. 
One  should  work  systematically.  In  cutting  out  a  wedge-shaped  piece  from 
a  bone  one  is  tempted  to  insert  the  chisel  and  make  it  penetrate  to  the  full 
depth  of  the  cut  which  must  be  made.  If  one  does  this,  the  chisel  will  surely 
be  jammed  and  gripped  in  the  bone,  causing  trouble  and  loss  of  time.  One 
should  content  one's  self  by  merely  cutting  through  the  external  layer  of  hard 
bone  until  the  whole  wedge  is  outlined,  and  then  step  by  step  penetrate  more 
deeply.  Macewen,  who  is  a  past  master  in  the  use  of  the  chisel,  seizes  it  low 
down  in  the  palm  of  the  left  hand,  so  low,  in  fact,  that  the  ulnar  side  of  the  hand 
is  supported  by  the  patient's  body,  the  thumb  of  the  left  hand  being  extended 
up  the  chisel  with  its  tip  resting  against  the  under  surface  of  the  expanded  head 


Fig.  1 173. — ^Macewen's  method  of  holding  osteotome.     (Tubby.) 

of  the  handle  (Fig.  11 73).  The  object  of  this  is  to  prevent  any  too  sudden  and 
great  onward  movement  of  the  instrument,  e.g.,  when  passing  from  cortical 
to  cancellous  bone.  Whenever  a  few  taps  of  the  mallet  have  caused  the  in- 
strument to  penetrate  a  short  distance  into  the  bone  it  must  be  slightly  with- 
drawn so  as  to  avoid  jamming.  Slight  pressure  upward  with  the  left  thumb 
generally  suflEices;  often,  however,  a  little  lateral  motion  given  the  chisel  will  aid. 
Backward  and  forward  motion  of  the  instrument  is  not  permissible;  such  motion 
is  liable  to  break  it. 

In  preparing  for  an  osteotomy  the  part  to  be  operated  upon  must  rest  on  a 
sand-bag  and  should,  if  possible,  be  so  placed  that  the  chisel  cuts  away  from 
important  soft  parts  and  toward  the  surgeon.  The  surgeon  can  work  more 
accurately  cutting  toward  than  away  from  himself. 

The  size  of  the  wound  in  the  soft  parts  depends  on  the  work  to  be  done  and 
the  dexterity  of  the  surgeon.  The  educated  hand,  using  the  chisel  as  a  probe, 
is  independent  of  the  assistance  of  the  eye.  It  is  safer  for  those  who  have  not 
had  large  experience  to  make  an  external  wound  sufficiently  large  to  allow  of  the 
eye  supervising  the  work. 

When  section  of  a  large  and  strong  bone  is  contemplated,  three  sizes  of 
osteotome  should  be  provided.     The  thickest-bladed  instrument  is  used  first. 


OSTEOTOMY  965 

When  this  has  penetrated  the  bone  to  such  a  depth  that  its  thickness  causes 
It  to  become  jammed,  it  is  replaced  by  the  next  finer  instrument  which  suffers 
no  obstruction  from  the  sides  of  the  cut  made  by  the  previous  osteotome. 

3.  Saws.— Saws  are  frequently  used  instead  of  chisels  for  dividing  bone. 
The  ordinary  surgical  saws,  such  as  are  used  in  amputations,  are  unsuitable  for 


Fig.  1 1 74. — Adams'  saw. 


Fig.  1175.— Jones' saw.     Note  button  on  ooi 


point. 


^-  .^J|IHHii!|lli!;ilHi      .ir|i|H|||l|!||| 


*iin9ftm*nnhhtt*iHfwt*Hi 


Fig.  1 1 76. — Finger  saw. 


Fig.  1177. — Gigli  saw. 


osteotomy.  Undoubtedly  Adams'  saw  (Fig.  11 74),  or  Jones'  modification  of  it 
(Fig.  1 175),  is  the  best  pattern.  The  ordinary  "finger  saw"  is  also  useful 
(Fig.  1 1 76). 

Chain  saws  have  been  much  used  for  the  division  of  bone,  but  they  are 
expensive,  easily  broken,  difficult  to  handle  and  are  now  practically  displaced 
by  the  simpler  and  more  efficient  wire  saw  of  Gigli  (Fig.  11 77). 


966 


OSTEOTOMY 


:^IETHODS  OF  PERFORMING  OSTEOTOMY 

I.  Linear  Osteotomy.-  Macewen's  supra-condyloid  osteotomy  for  knock- 
knee  is  a  classical  example  of  linear  osleotomy  anrl  will  be  taken  as  the  type  of 
such  operations. 

I.  Administer  a  general  anesthetic.  Render  the  limb  bloodless  and  apply 
the  elastic  constrictor.  Place  the  patient  on  his  back,  arrange  the  limb  to  be 
operated  on  so  that  it  lies  with  the  outer  side  of  the  knee  and  lower  part  of  the 
femur  resting  on  a  sand-bag.     The  best  sand-bag  is  one  of  stout  cloth  about 


Fig.  1 1 78. — Incision  of  supracondyloid  osteotomy.     (Labey.) 

18  X  12  inches  in  size  and  moderately  (not  tightly)  tilled  with  sand  (Fig.  1178). 
The  surgeon  stands  on  the  affected  side  of  the  patient.  An  assistant  iixes  the 
limb  by  grasping  the  tibia  and  the  upper  part  of  the  femur. 

Step  1. — Draw  an  imaginary  line  transversely  one  finger's  breadth  above 
the  superior  tip  of  the  external  condyle.  Draw  an  imaginary  vertical  line 
longitudinally  }2   inch   in  front  of  the  adductor  magnus   tendon   (adductor 

tubercle).  Note  the  point  where  these 
lines  cross.  At  this  point  introduce  a  long- 
bladed  scalpel  or  bistoury  directly  to  the 
bone  and,  cutting  upward,  make  a  longi- 
tudinal incision  of  such  size  as  to  admit  the 
largest  osteotome.  Endeavor  not  to  wound 
the  periosteum. 

Step  2. — (A)  Hold  the  knife  in  situ. 
Pass  the  largest  osteotome  (of  Macewen's 
series)  alongside  the  knife,  down  to  the  bone.  Turn  the  blade  of  the  osteo- 
tome transversely  to  the  bone  (Fig.  1179).  Pass  the  edge  of  the  osteotome 
over  the  bone  until  it  reaches  the  posterior  internal  border  and  make  it  pene- 
trate the  bone  from  behind  forwards  and  towards  the  outer  side.  After 
the  cortical  bone  is  penetrated,  pass  a  finer  osteotome  along  the  face  of  the 


Fig.    II 79. — Osteotomy.     (Macewen.) 


CUNEIFORM    OSTEOTOMY 


967 


first  one  used  and  remove  the  latter.  The  wide  groove  left  by  the  passage 
of  the  coarser  gives  great  delicacy  and  precision  to  the  use  of  the  more  delicate 
instrument.  With  this  finer  instrument  complete  the  section  of  the  femur 
along  the  line  described,  to  a  point  near  the  outer  layer  of  cortical  bone.  It 
is  wise  not  to  divide  the  outer  layer  of  bone  with  the  osteotome. 

(B)  Partially  withdraw  the  osteotome.  Change  the  direction  of  its  cutting- 
edge  and  make  it  cut  through  the  whole  cortical  bone  on  the  inner  side  of  the 
femur  (Fig.  11 80). 

(C)  Once  more  change  the  direction  of  the  osteotome  and  with  it  cut  the 
bone  from  its  anterior  inner  toward  but  not  to  its  posterior  external  borders. 
Of  course  in  many  cases,  e.g.,  in  children,  the  first  line  of  bone  section  is  all 
that  is  required,  but  in  others  where  the  bone  is  large  the  above  systematic 
procedure  will  be  found  expeditious  and  safe.  The  osteotome  ought  not  to  be 
removed  from  contact  with  the  bone  until  the  bone  section  is  completed,  as  its 
reintroduction  through  the  small  incision  in  the  soft  parts  is  a  matter  of  much 
difficulty.  All  the  procedures  described  can  be  carried  out  through  a  small 
wound. 


Fig.   1 180. — Original  lines  of  section  of  the  femur  in  osteotomy. 

Step  3. — Remove  the  osteotome.  Cover  the  wound  with  an  aseptic  pad. 
With  one  hand  grasping  the  femur  at  the  site  of  operation  and  the  other  grasp- 
ing the  leg,  complete  the  rectification  of  the  deformity  by  breaking  or  bending 
the  partially  divided  femur. 

Step  4. — Apply  dressings.  Remove  the  elastic  constrictor.  Treat  as  a 
simple  fracture  of  the  femur.  Both  limbs  are  usually  operated  upon  at  the 
same  sitting. 

II.  Cuneiform  Osteotomy. — The  operation  as  performed  for  angular 
anterior  curvature  of  the  tibia  may  be  taken  as  typical  Render  the  limb 
bloodless.  Apply  an  elastic  constrictor  (some  surgeons  omit  this  precaution 
as  they  fear  increased  subsequent  oozing). 

Step  I. — Make  a  longitudinal  incision  down  to  the  bone  over  the  most 
prominent  part  of  the  tibia.  This  cut  need  not  be  much  longer  than  the  width 
of  the  chisel,  as  the  wound  in  the  soft  parts  can  easily  be  made  to  slide  in  various 
directions  to  expose  different  portions  of  the  bone.  Reflect  the  periosteum 
with  the  soft  parts.     Keep  the  wound  open  with  retractors. 

Step  2. — With  an  ordinary  chise  outline  the  base  of  a  wedge  by  cutting 
through  the  cortical  bone.     This  base  correspond    to  the  apex  of  the  angular 


968 


OSTEOTOMY 


deformity  (Fig.  1181)  and  should  be  smaller  than  that  which  it  is  believed  will 
be  necessary.  With  the  chisel  cut  through  the  cancellous  bone  and  remove  a 
wedge-shaped  portion  of  bone.  Do  not  cut  through  the  whole  thickness  of  the 
bone;  the  posterior  undivided  portion,  corresponding  to  the  apex  of  the  wedge, 
is  easily  fractured  by  manual  force.  Straighten  the  limb.  If  sufficient  bone 
has  not  been  removed,  it  is  easy  to  slice  off  more  with  the  chisel  until  the 
minimum  amount  which  permits  of  correction  has  been  removed.  If  the 
fibula  interferes  with  the  correction  it  must  be  bent  or  broken  by  manual  force 
or  divided  with  an  osteotome. 

Slep  3. — If  the  wound  tends  to  gape,  introduce  a 
few  sutures.  Apply  aseptic  dressings.  ImmobiHze. 
It  is  well  to  elevate  the  limb  for  twenty  four  hours 
or  longer.  The  subsequent  treatment  is  the  same  as 
for  simple  fracture. 

III.  Subcutaneous  Osteotomy  by  Means  of  a 
Saw. — A  good  type  of  this  operation  is  that  of  W. 
Adams  for  the  intra-capsular  division  of  the  neck  of 
the  femur  in  cases  of  anchylosis  in  bad  position. 

Step  I.- — ^Introduce  a  long,  narrow-bladed  knife 
(Fig.  1 182)  at  a  point  one  finger's  breadth  above  the 
top  of  the  trochanter  major,  and  push  it  on  until  it 
encounters  the  neck  of  the  femur,  over  which  it 
must  be  passed  in  a  direction  at  right  angles  to  the 
axis  of  the  neck.  The  route  taken  by  the  knife  is 
practically  one  parallel  to  Poupart's  ligament.  Leave 
the  knife  in  situ. 
Step  2. — ^Pass  an  Adams'  or  Jones'  saw  alongside  of  knife  until  the  teeth  of 
the  saw  are  in  contact  vnth.  the  femoral  neck  (Fig.  1183).  Remove  the  knife. 
With  the  saw  divide  the  bone.  While  sawing  one  is  liable  to  pull  Adams's 
saw  out  of  the  cut  in  the  bone  and  have  much  difficulty  in  reintroducing  it. 
The  hook  or  break  on  Jones'  saw  prevents  such  an  accident.  Before  obtaining 
complete  rectification  it  may  be  necessary  to  divide  the  tendons  of  the  adductor 
longus,  sartorius  and  perhaps  the  rectus  muscles. 


Fig.  ii8t. — Cuneiform 
osteotomy. 


Fig.  1 182. — Adams' knife. 


Step  3.— Apply  aseptic  dressings.  Immobilize  the  limb  in  a  position  of 
slight  flexion  and  abduction. 

Genu  Valgum.  Knock-knee. — There  are  three  bony  deformities  com- 
monly present  in  knock-knee. 

(i)  Difference  in  size  of  the  condyles,  i.e.,  elongation  of  the  internal  one. 

(2)  Bending  of  the  lower  end  of  the  diaphysis  of  the  femur.  Macewen  found 
this  in  120  out  of  166  affected  bones.  In  some  cases  the  same  effect  is  obtained 
without  true  bending  of  the  bone,  by  an  elongation  of  the  inner  side  of  the  femur 
which  naturally  pushes  down  the  inner  portion  of  the  epiphysis. 


KNOCK-KNEE 


969 


(3)  Bending  of  the  upper  end  of  the  tibial  diaphysis.  The  most  important 
deformity  in  knock-knee  is  the  bending  of  the  lower  end  of  the  femur,  but  all 
the  deformities  mentioned  have  had  operations  devised  for  their  correction. 

Osteotomy  for  the  correction  of  genu  valgum. 

{A)  Macewen's,  directed  against  the  bending  of  the  lower  end  of  the  femur 
(see  p.  966). 


Fig.  1 183. — Division  of  neck  of  femur. 

(B)  Supra-condyloid  osteotomy  as  done  in  the  New  York  Hospital  for 
Ruptured  and  Crippled  (Whitman,  ''Orthop.  Surg.,  '  421): 

Place  the  inner  surface  of  the  semiflexed  knee  on  a  sand-bag.  Grasp  the 
femur  above  the  condyles  and  pass  a  short  osteotome  about  the  size  of  a  lead- 
pencil  through  all  the  soft  structures  down  to  the  bone  at  a  point  13^^  inches 
above  the  external  tuberositv.     The  cutting  edge  of  the  osteotome  must  be 


Fig.  I 184. 
Figs.  1184,  1185  axd  1186. 


Fig.  1185.  Fig.  1186. 

-Macewen's  linear  supracondyloid  osteotomy, 


kept  parallel  to  the  long  axis  of  the  thigh  until  it  comes  in  contact  with  the  bone 
when  it  is  to  be  turned  transversely  to  the  bone.  Drive  the  osteotome  through 
the  cortical  bone  until  so  much  is  divided  that  the  remainder  is  easily  fractured. 
The  rest  of  the  treatment  is  the  same  as  in  Method  A. 

Inspection  of  Figs.  1184,  1185,  1186,  shows  that  theoretically  Macewen's 
operation  is  the  better,  but  it  must  be  admitted  that  a  clean  osteotomy  gives 
good  results  whether  performed  from  the  inner  or  the  outer  side. 


970 


OSTEOTOMY 


(C)  Ogston's  operation :  Osteo-arthrotomy.  J'his,  the  lirst  successful 
operation  for  knock-knee  (1876),  is  directed  against  the  real  or  supposed  length- 
ening of  the  internal  condyle. 

Step  I.— Flex  the  knee  as  fully  as  possible.  Introduce  a  narrow-bladed 
knife  or  elongated  tenotome  (Adams's  knife)  through  the  skin  at  a  point  2  or  3 
inches  above  the  tip  of  the  inner  condyle.     Push  the  knife  downwards,  forwards 


Fig.  1187.— {Hof a.) 

Annandale;   b,  Ogston;    c    Reeves;    d.  Macewen's   cuneiform  osteotomy;   e.   Chiene;    /   Macewen's 
supracondyloid;  g.  Reeves;  h.  Billroth;  ».  Mayer;  k,  Schede;  /,  Barwell. 

and  outwards  until  the  point  is  felt  in  the  intercondyloid  space.  Turn  the  edge 
of  the  knife  towards  the  bone  and  in  withdrawing  it  cut  the  soft  structures  to  the 
bone. 

Step  2.— Introduce  an  Adams's  saw  through  the  knife  wound  and  divide  the 
internal  condyle  from  above  downwards  for  three-fourths  of  its  thickness.  Com- 
plete the  fracture  by  straightening  the  limb,  when  the  loosened  condyle  will 
slip  upward  (Fig.  1187). 


OSTEOCLASIS  97 1 

Step  3. — Immobilize  and  treat  as  a  fracture. 

{D)  Reeves'  operation  is  similar  to  Ogston's  but  in  it  the  bone  section  is 
made  with  a  chisel  down  to  but  not  through  the  articular  cartilage,  thus  avoiding 
any  direct  opening  of  the  joint.  Fowler  and  Pilcher  long  ago  showed  that  this 
operation  has  nothing  to  recommend  it. 

(jE)  Chiene's  operation  differs  from  Ogston's  in  that  he  removes  with  the 
chisel  a  wedge  of  bone  from  the  base  of  the  condyle.  The  operation  is  un- 
necessarily difficult. 

(F)  Section  of  Tibia. — Step  i. — On  the  inner  surface  of  the  tibia,  midway 
between  its  anterior  and  posterior  borders  make  a  longitudinal  incision  down 
to  the  bone.     The  cut  should  be  only  large  enough  to  easily  admit  the  osteotome. 

Step  2. — Introduce  the  osteotome  and  turn  its  cutting  edge  transversely  to 
the  bone.  Divide  the  tibia  from  within  outwards,  "commencing  from  the 
posterior  border  and  raising  the  osteotome  gradually  up  until  it  comes  into 
contact  with  the  anterior  surface  of  the  lower  portion  of  the  tubercle,  which  is 
by  far  the  most  dense  portion"  (Macewen).  Next  divide  the  dense  bone  on 
the  outer  side  of  the  tibia  from  before  backwards.  Complete  the  fracture  by 
manualforce.     It  is  unnecessary  to  divide  the  fibula. 

Osteoclasis  in  Genu  Valgum 

(A)  Manual. — Administer  a  general  anesthetic.  Place  the  patient  on  his 
back.  Let  an  assistant  firmly  grasp  and  steady  the  upper  portion  of  the  thigh. 
With  one  hand  grasp  the  femur  immediately  above  the  deformity,  with  the  other 
hand  grasp  the  leg.  Fully  extend  the  knee  and  endeavor  forcibly  to  bring  the 
limb  into  a  straight  position.  When  correction  is  obtained  it  is  usually  due  to 
the  production  of  one  or  several  of  the  following  lesions:  Fracture,  green  stick 
or  complete,  of  the  lower  end  of  the  femur;  separation  of  the  femoral  or  tibial 
epiphysis  or  of  both;  fracture  of  the  internal  condyle  (as  produced  in  Ogston's 
operation) ;  rupture  of  the  external  lateral  ligament. 

(B)  Instrumental  Osteoclasis. — ^This  operation  as  applied  to  knock-knee 
is  carried  out  in  much  the  same  manner  as  in  the  case  of  bow-leg  and  hence 
requires  no  description  here. 

Indications  for  Operation  in  Knock-knee.— Mechanical  treatment  by  mas- 
sage and  apparatus  often  gives  good  results  in  moderate  degrees  of  deformity 
in  patients  under  Jour  years  of  age.  After  the  fourth  year  improvement  cannot 
be  expected  from  other  than  operative  treatment,  hence  operation  is  positively 
indicated  in  every  case  of  knock-knee  where  the  patient  is  over  four  years  of  age, 
where  disability  is  present,  provided  that  the  general  health  of  the  patient  is 
fairly  good.  The  operation,  being  practically  without  danger,  is  permissible  for 
aesthetic  reasons  in  patients  whose  health  is  good. 

Choice  of  Operation. — Osteoclasis. — Theoretically,  the  danger  of  epiphyseal 
separation  causing  subsequent  want  of  bone  development  is  a  serious  objection 
to  osteoclasis,  but  experience  seems  to  show  that  these  dangers  have  been 
much  exaggerated.  Osteoclasis  is  suitable  only  in  the  very  young  where 
the  bones  are  still  soft.  On  the  whole,  however,  osteoclasis  whether  manual 
or  instrumental  is  very  inferior  to  osteotomy  in  that  it  produces  more  injury 
than,  and  lacks  the  definiteness  of  the  latter  operation. 


972 


BOW-LEG.       GENU   VARUM 


Osteotomy. — Only  when  the  tibial  curvature  is  much  greater  than  the 
femoral  does  the  former  require  division.  This  is  a  rarity.  In  very  rare  and 
exaggerated  cases  osteotomy  both  of  the  tibia  and  of  the  femur  may  be  per- 
formed, although  in  these  circumstances  femoral  osteotomy  plus  division  of 
the  biceps  tendon  has  given  as  good  or  better  results  than  double  osteotomy. 
All  other  osteotomies  for  knock-knee  have  been  practically  superseded  by  the 
Macewen  supra-condyloid  operation  or  some  modification  of  it. 


CHAPTER  LXXIV 

BOW-LEG.     GENU  VARUM 

Typical  genu  varum  is  the  result  of  external  bowing  of  the  femur  and  of 
the  leg  bones.  The  maximum  curve  is  generally  near  the  knee.  Bow-leg  may 
be  the  result  of  lateral  bending  of  the  leg  bones  alone,  the  femur  being  unaltered. 
An  anterior  curvature  of  the  tibia  gives  another  form  of  bow-leg.  Operative 
correction  is  demanded  in  all  severe  cases.  Before  the  age  of  four  or  five  years 
mild  deformities  may  be  corrected  by  mechanical  appliances;  after  that  age, 
operation  affords  the  only  prospect  of  cure. 

Methods  of  Operating. — (I)  Linear  Osteotomy. — Note  which  bone  or 
bones  are  most  seriously  affected.  Usually  in  typical  genu  varum  both  the 
femur  and  tibia  are  badly  curved.  Note  which  part  of  the  individual  bone 
is  most  bent;  it  is  this  part  which  must  be  divided. 

(a)  If  osteotomy  of  the  middle  third  of  the  femur  is  indicated,  make  a  vertical 
incision  through  the  soft  parts  down  to  the  bone  on 
the  outer  or  antero-external  side  and  proceed  as  in 
supra-condylar  osteotomy,  in  this  case,  however,  cut- 
ting the  bone  from  without  inwards,  (b)  If  the  tibia 
is  most  affected,  incise  vertically  the  soft  parts  down 
to  the  bone  over  the  inner  surface  of  the  bone  at  the 
point  of  greatest  curvature.  Introduce  the  osteo- 
tome and  then  turn  it  transversely  to  the  bone  and 
divide  the  cortical  bone  of  the  inner  and  outer  sides 
of  the  tibia,  and  especially  that  of  the  anterior  margin. 
Be  careful  not  to  injure  the  anterior  tibial  vessels  and 
nerves  which  lie  close  to  the  outer  surface  of  the  bone. 
Fracture  the  posterior  layer  of  cortical  bone  by  manual 
force.  Forcibly  fracture  or  bend  the  fibula.  If  this 
is  impossible,  palpate  the  fibula  and  make  a  small 
incision  down  to  it  through  the  soft  structures  of  the 
outer  side  of  the  leg.  Introduce  a  very  narrow  osteo- 
tome and  divide  the  bone.  (c)  If  femur  and  tibia  are  both  markedly  curved 
operate  on  both  at  the  same  sitting. 

Note. — The  object  of  the  surgeon  is  to  correct  the  deformity.  If  division 
of  one  bone  is  not  sufl5cient,  then  divide  the  other  as  well;  if  this  is  insufficient 
repeat  the  operation  at  whatever  places  it  may  be  demanded.  ]Macewen  has 
performed  ten  osteotomies  on  the  same  patient  at  the  same  sitting  and  obtained 
a  good  result. 


Fig.  I i8S.— Oblique 
osteotomy. 


OSTEOCLASIS  973 

IT.  Cuneiform  osteotomy  is  particularly  suitable  in  cases  of  anterior  curva- 
ture of  the  tibia  (sec  p.  QO7). 

III.  Oblique  Osteotomy  (Oilier). — In  some  cases,  especially  of  anterior 
curvature  of  the  tibia  where  there  is  much  shortening,  oblique  division  of  the 
bone  (Fig.  1188)  permits  elongation.  To  attain  this  elongation  it  may  be 
necessary  to  lengthen  the  tendo  Achillis  by  means  of  any  one  of  the  well-known 
methods. 


Fig.  1 190. — Collin's  osteoclast. 

IV.  Osteoclasis. 

(A)  Manual. — Grasp  the  bone  affected  above  and  below  the  point  of  the 
greatest  curvature  and  bend  it  straight  or  produce  a  fracture.  In  the  very 
young  a  green-stick  fracture  is  a  desirable  lesion  to  produce.  It  is  often  neces- 
sary to  support  the  point  of  greatest  convexity  on  a  fulcrum  {e.g.,  a  padded 
wedge  of  wood)  before  sufficient  force  can  be  applied.  It  may  be  necessary  to 
produce  multiple  fractures. 

(B)  Instrumental. — The  necessary  fracture  or  bending  may  be  more  pre- 
cisely and  definitely  produced  by  means  of  an  osteoclast.     Probably  Grattan's 


974  OPERATIONS    ON    THE    PELVIC   BONES 

osteoclast  (Fig.  1189)  is  the  best.  Place  the  limb  in  the  instrument  in  such  a 
fashion  that  the  movable  arm  (a)  is  applied  to  the  point  of  greatest  convexity 
while  the  opposite  or  concave  side  of  the  limb  is  supported  by  the  two  parallel 
fixed  arms  of  the  osteoclast.  By  means  of  the  screw  (x)  make  a  movable  arm 
(a)  press  against  and  fracture  the  limb.  Fig.  11 90  shows  CoUin's  osteoclast. 
By  whichever  means  the  limb  is  straightened,  it  must  be  fixed  in  good  posi- 
tion by  plaster  of  Paris  or  apparatus  and  treated  as  an  ordinary  fracture.  In 
the  treatment  of  bow-legs  osteotomy  and  osteoclasis  seem  to  give  about  equally 
good  results. 

CHAPTER  LXXV 
OPERATIONS  ON  THE  PELVIC  BONES 

Operations  on  the  bones  of  the  pelvis  are  indicated  in  acute  osteomyelitis, 
tuberculosis;  sarcoma,  etc. 

1.  Acute  Osteomyelitis  and  Periostitis. — The  method  and  time  of  opera- 
tion must  vary  according  to  circumstances.  "In  the  severest  cases  with  high 
fever,  great  local  pain  and  swelling  an  incision  should  at  once  be  made  at  the 
point  of  greatest  tenderness  or  swelling"  (Tillmanns),  all  sequestra  and  diseased 
bone  removed  and  drainage  provided.  When  the  disease  is  on  the  outer  side 
of  the  ilium  the  above  advice  is  easily  carried  out;  when,  however,  the  disease 
is  principally  on  the  inner  side  of  the  bone  it  is  necessary  to  trephine  or  better 
to  excise  a  larger  or  smaller  amount  of  the  ilium  in  order  to  provide  proper 
drainage.  To  do  this  the  author  has  found  it  necessary  to  operate  several 
times,  in  an  individual  case.  When  there  is  extensive  disease,  extensive  ex- 
posure of  the  bone  is  necessary. 

When  the  inflammation  and  swelling  are  diffuse  and  fever  is  high  more  sys- 
tematized resection  of  bone  is  necessary  and  the  whole  affected  bone  should  be 
early  removed.  When  the  local  and  general  symptoms  of  the  disease  are  mild, 
non-operative  treatment  should  be  adopted  until  recovery  takes  place  or  the 
incidence  of  abscess  or  threatening  symptoms  indicate  operation. 

2.  Chronic  pyogenic  osteomyelitis  with  fistula  calls  for  operation. 

3.  Tuberculous  osteomyelitis  is  usually  situated  near  and  commonly  involves 
one  of  the  joints  so  that  the  treatment  is  generally  directed  primarily  against 
the  arthritis  (hip-joint  disease;  sacro-iliac  disease). 

4.  Neoplasms.  All  malignant  neoplasms  demand  excision  provided  there 
is  a  moderate  chance  of  success.  All  non-malignant  neoplasms  threatening 
life  from  pressure,  etc.,  similarly  demand  removal.  All  other  neoplasms 
demand  removal  provided  that  the  operation  is  not  one  of  much  gravity.  The 
usual  rule  of  very  wide  excision  prevails  in  operations  for  malignant  tumors; 
when  removing  such  neoplasms  as  osteomata  and  chondromata  a  portion  of  the 
pelvis  itself  ought  to  be  removed  to  make  sure  that  the  base  of  the  neoplasm  is 
not  left. 

Every  extensive  operation  on  the  ilium  requires  free  exposure  of  the  bone. 
This  may  be  obtained  in  various  but  similar  ways. 

A.  Sprengel's  Method. — Make  an  incision  from  the  anterior  superior 
spine  of  the  ilium,  downwards  along  the  anterior  border  of  the  tensor  vaginae 


KOCHER.   EXPOSURE  PELVIS 


975 


femoris  and  divide  the  deep  fascia  (Fig.  1191).  From  the  upper  end  of  the  in- 
cision cut  backwards  along  the  iUac  crest  dividing  the  fascia  and  the  origin  of 
the  gluteus  medius  and  minimus. 

Through  the  above  incision  separate  the  muscles  and  periosteum  from  the 
pelvis  and  retract  them  downwards  and  backwards.  This  gives  good  exposure 
of  the  ilium  and  of  part  of  the  acetabulum.  Though  this  incision  Kocher 
removed  an  exostosis  from  the  acetabulum.  When  the  active  operation  is 
finished,  the  flap  is  easily  replaced. 

B.  Larghi's  Method  (see  p.  987). 

C.  Kocher's  Method. — Kocher  excised  one- 
half  of  the  pelvis  for  sarcoma  as  follows: 

Step  I. — Make  an  incision  from  the  sacro- 
iliac synchondrosis  forwards  along  the  iliac  crest 
and  Poupart's  ligament. 

Step  2. — Divide  the  abdominal  muscles 
attached  to  the  iliac  crest  and  Poupart's  liga- 
ment; separate  the  transversalis  fascia  and 
peritoneum  from  the  tumor  until  the  iliac  ves- 
sels are  exposed.  Retract  the  iliac  vessels  and 
the  anterior  crural  nerve  inwards. 

Step  3. — Isolate  and  divide  the  muscles 
passing  under  Poupart's  ligament  external  to 
the  great  vessels.  Divide  the  rectus  femoris, 
sartorius,  tensor  vaginae  femoris.     Separate  the 


Fig.  1191. — Sprengel's  incision. 


Fig.  1 192. — Result  of  excision  of  pelvis. 
(Kulenkamff.) 


gluteus  medius  and  minimus  bluntly  from  the  ilium  until  the  sacro-iliac 
articulation  is  reached.  Anteriorly  divide  the  ilio-psoas  muscle  and  the  cap- 
sule of  the  hip-joint. 

Step  4. — Divide  the  horizontal  ramus  of  the  pubis  and  the  ascending  ramus 
of  the  ischium. 

Separate  the  sacro-iliac  articulation  and  dislocate  the  bone  downwards. 


976 


OPERATIONS  ON  THE  PELVIC  BONES 


Step  5. — Separate  the  rest  of  the  pelvic  attachments  by  l)lunt  and  sharp  dis- 
section. The  flexors  arising  from  the  tuber  ischii  and  the  sacro-sciatic  hgaments 
require  division.  Excise  the  head  of  the  femur.  Remove  the  mobilized  portion 
of  pelvis. 

Step  6. — Suture  the  abdominal  muscles  to  the  glutei.  Close  the  wound  by 
deep  and  superficial  sutures  after  providing  freely  for  drainage. 

Kocher  remarks  that  the  bleeding  is  only  moderate  as  no  large  vessels  are 
injured  but  that  it  might  be  well  to  ligate  the  internal  iliac  vessels  before  re- 
tracting them  in  Step  2. 

D.  Kulenkamff's  Meihod.— Step  i. — Secure  temporary  hemostasis  by 
Momberg's  method.  Make  an  incision  along  the  crest  of  the  iUum  and  Pou- 
part's  ligament.  Separate  the  iliacus  muscle  (if  it  is  not  involved  m  the  disease) 
and  retract  it  along  with  the  iliac  vessels  inwards. 

Step  2. — Perpendicularly  to  the  first  incision  make  a  cut  reaching  down  to  the 
trochanter  major.     Open  the  hip-joint  and  decapitate  the  femur. 

The  rest  of  the  operation  is  practically  the  same  as  Kocher's.  Figure  1192 
shows  the  result  obtained  by  Kulenkamff.     (Beitrage  z.  klin.  Chir.,  Ixviii,  768). 


Fig.  1 193. — Excision  of  pubis. 


Fig.  1194. — Excision  of  acetabulum. 


Excision  of  Symphysis  Pubis. — Tuberculous  osteomyelitis  affecting  the 
pubic  bones  and  the  symphysis  calls  for  early  operation.  The  disease  may  be 
exposed  by  an  incision  directly  over  it;  all  affected  bone  cut  away  with  chisel  and 
mallet  and  all  abscesses  opened  and  curetted.  If  no  distinct  and  separated 
sequestrum  is  present  v.  Bunger  recommends  that  a  transverse  incision  be  made 
immediately  above  the  pubis,  the  soft  parts  separated  and  the  bone  divided 
subperiosteally  beyond  the  disease  (Fig.  1193). 

The  results  of  the  operative  treatment  of  pubic  tuberculosis  are  good. 

Excision  of  the  Acetabulum. — Schmidt's  Method. — Step  i. — Open  the 
hip  joint  through  Langenbeck's  incision  (p.  982).  Dislocate  the  head  of  the 
femur  (if  necessary  excising  it). 

Step  2. — Adduct  and  rotate  the  limb  outwards.  From  the  middle  of  the 
wound  make  a  cut  at  right  angles  forwards  towards  the  anterior  inferior  iliac 
spine.  This  cut  penetrates  to  the  bone.  By  blunt  dissection  separate  the  peri- 
osteum and  overlying  soft  parts  from  the  ilium  above  the  acetabulum  from  the 
anterior  inferior  spine  to  the  sciatic  notch. 


SACRO-ILIAC    DISEASE  977 

Step  3.— With  chisel  and  mallet  divide  the  ilium  transversely  above  the  ace- 
tabulum (Fig.  1 1 94).     Be  careful  not  to  injure  the  pelvic  contents. 

Step  4. — Divide  the  horizontal  ramus  of  the  pubis  with  a  Gigli  wire  saw. 

Step  5. — With  a  periosteal  elevator  separate  the  soft  parts  from  the  ischium 
below  the  acetabulum.  Divide  the  ischium  with  a  Gigli  saw  or  a  chisel 
(Fig.  1 194). 

Step  6. — Seize  the  acetabulum  with  bone  forceps  and  remove  it,  dividing  any 
obstructing  connections  with  scissors. 

Step  7. — Provide  for  drainage.  Close  the  wound.  Dress.  Put  up  in  a 
position  of  marked  abduction. 


CHAPTER  LXXVI 
SACRO-ILIAC  DISEASE 

Jacobson  and  Rowlands  ("Operations  of  Surg.,"  ii,  874)  write  regarding 
tuberculosis  of  this  joint: 

"It  has  been  shown  that  the  prognosis  in  this  disease,  usually  looked  upon 
as  so  grave,  is  much  better  if  the  same  radical  methods  of  treatment,  which 
have  proved  so  satisfactory  in  other  joints,  are  applied  to  the  sacro-iliac 
synchondrosis." 

Mr.  Collier  first  drew  attention  to  the  above  fact  with  a  case  successfully 
treated  by  trephining  (Lancet,  1889,  vol.  ii,  p.  787),  and  Mr.  Makins  and 
Mr.  Golding  Bird  followed,  each  surgeon  publishing  three  successful  cases 
("Clin.  Soc.  Trans.,"  vol.  xxvi,  p.  127,  and  vol.  xxviii,  p.  186). 

The  following  points  are  taken  from  these  papers : 

Operation. — The  joint  is  exposed  by  a  crucial  incision  (Makins),  or  by  a 
flap  (Collier,  Golding  Bird).  In  the  words  of  the  last-named  surgeon,  "a 
semicircular  flap  of  skin  and  subcutaneous  tissue  over  the  iliac  area  of  the 
joint,  and  having  its  convexity  corresponding  to  the  posterior  edge  of  the  ilium, 
is  dissected  upwards  and  forwards,  and  the  underlying  glutaei  are  detached. 
The  bone  being  thus  freely  exposed,  a  large  trephine  is  applied  at  the  root  of 
the  posterior  inferior  iliac  spine,  and  in  a  line  drawn  from  the  top  of  that  spine 
to  the  junction  of  the  anterior  with  the  middle  third  of  the  ihac  crest.  .... 
The  ilium  at  the  seat  of  operation  is  very  thick,  but  the  disc  of  bone  removed 
should  reach  quite  down  to  the  joint."  The  trephine-opening  is  then  sufficiently 
enlarged,  the  articular  surfaces  cut  away  with  a  gouge  or  forceps  sufficiently 
to  enable  the  surgeon  to  explore  the  pelvis  surface  of  the  joint,  and  to  liberate 
any  pus  lying  on  this  aspect.  The  sharp  spoon,  or  Barker's  flushing  gouge, 
is  then  thoroughly  used,  all  fragments  of  bone,  granulation  tissue,  or  loosened 
cartilage  removed,  and  any  sinuses  present  laid  open.  Sterlized  iodoform 
having  been  next  applied,  the  soft  parts  are  lightly  drawn  together  with  a 
few  sutures.  A  long  outside,  or  a  Thomas's  hip-splint,  should  be  used  at 
first,  but  subsequently  all  that  is  needed  is  a  well-fitting  pelvic  belt,  as  advised 
by  Mr.  Hilton." 

Bardenheuer  and  Picque  ("Journ.  de  Chir.,"  Sept.,  1910)  have  each  de- 
scribed more  systematic  methods  of  excising  the  sacro-iliac  joint.  Picque's 
method  is  the  one  described  here. 

62 


978 


SACRO-ILIAC    DISEASE 


Step  I. — Make  a  curved  incision  penetrating  to  the  bone  along  the  posterior 
third  of  the  iliac  crest  and  continued  down  the  border  of  the  sacrum  to  the 
level  of  the  third  posterior-external  tubercle.  With  periosteal  elevator  reflect 
the  periosteum  and  superjacent  soft  parts  from  the  outer  surface  of  the  posterior 
portion  of  the  ilium. 

Step  2. — The  sacro-iliac  joint  is  so  situated  that  to  reach  it  a  portion  of  the 
ilium  must  be  removed  (Fig.  1195).  The  excision 
of  the  segment  of  bone  may  be  complete  or  partial. 

(a)  Complete. — With  an  osteotome  divide  the 
iliac  bone  vertically  from  the  crest  down  to  the 
outer  and  upper  corner  of  the  great  sciatic  notch 
(Fig.  1196). 

(b)  Partial. — Make  the  vertical  incision  shorter 
and    supplement    it    by    a    transverse  one   (Fig. 

1 196)  in  such  a  fashion  as  to  leave  the  sciatic  notch  intact. 

Having  divided  the  ilium  pry  up  the  fragment  of  bone  with  an  elevator, 
divide  its  ligamentous  attachments  and  remove  it.  This  removes  the  iliac 
portion  of  the  sacro-iliac  joint  and  freely  exposes  the  articular  and  adjacent 
portions  of  the  sacrum. 


Fig 


1 195. — Exposure  of  sacro- 
iliac joint. 


Fig.   1196. — Exposure  of  sacro-iliac  joint.     (Picque.) 


Step  3. — Systematically  with  scoop,  rongeur  forceps  and  chisel  remove  all 
disease  from  the  sacrum.  In  doing  this,  so  shave  away  bone  that  no  irregular 
pits  or  tunnels  are  left  which  would  interfere  with  proper  drainage.  If  the 
disease  extends  to  the  sacral  foramina,  working  in  the  above  systematic  fashion 
permits  the  exposure  and  isolation  of  the  nerve  trunks  which  would  be  ex- 
posed to  much  injury  if  the  curette  was  used  blindly.  The  amount  of  bone 
removed  must  vary  with  the  extent  of  the  disease.  In  one  case,  Picque  writes, 
"the  wound  will  have  a  bony  floor  formed  by  the  anterior  portion  of  the  wing 
of  the  sacrum  united  to  the  ilium  by  the  anterior  sacro-iliac  ligament,  in  another 


SNAPPING    HIP  979 

case  the  wound  will  penetrate  the  pelvis  exposing  the  sacral  nerve  trunks, 
the  iliac  vessels  and  the  ureter.  Thus  the  resection  of  the  sacrum  like  that  of 
the  ilium  may  be  partial  or  complete."  When  extensive  resection  of  the 
sacrum  is  necessary  it  will  usually  be  found  that  nature  has  already  protected 
the  pelvic  organs  by  a  deposit  of  strong  fibrous  tissue. 

Step  6. — Close  part  of  the  wound  with  sutures  and  pack  the  rest  with  gauze. 
Picque  writes,"  however  thorough  the  resection  has  been,  points  of  caries 
will  always  appear  on  the  surface  of  the  spongy  bone,  interfering  with  cicatri- 
zation, there  will  be  exuberant  granulations  from  the  superficial  soft  parts 
and  the  dressings  should  be  made  curette  in  hand."  The  duration  of  post- 
operative treatment  varies  much  (six  weeks  to  three  months — Bardenheuer; 
three  to  eight  months — Picque).  The  author  has  had  no  experience  with  the 
Bardenheuer-Picque  operation  but  it  strikes  him  that  the  use  of  Mosetig's 
iodoform  wax  plug  might  facilitate  healing. 

Results. — Bardenheuer  reports  a  series  of  sixteen  cases  with  69  per  cent, 
recoveries  and  a  second  series  of  four  cases  with  100  per  cent,  recoveries,  Picque 
reports  six  cases  with  66  per  cent,  recoveries. 


CHAPTER  LXXVII 
HIP 

Snapping  hip;  Hanche  a  ressort;  Schnellende  Hufte;  Schnappende  Hufte, 
are  names  given  to  the  same  affection.  On  very  slight  motion  of  the  hip  the 
patient  can  procure  a  palpable  and  audible  snapping  which  simulates  a  disloca- 
tion in  a  very  persuasive  manner.  The  trouble  is  due  to  a  prominent  sausage- 
shaped  mass  of  tissue  slipping  forwards  or  backwards  over  the  upper  part  of  the 
trochanter  major.  In  one  case  observed  by  the  author  fixation  of  this  mass  by 
the  operator's  fingers  prevented  snapping.  The  mass  consists  of  part  of  the 
gluteus  maximus.  (Heully,  "Rev.  de  Chir.,"  May,  June,  July,  191 1;  Bayer, 
"Archiv  fur  klin.  Chir.,"  Ixxxii,  266;  Voelcker,  "Beitrage  z.  klin.  Chir.,"  Ixxii, 
619;  The  author,  "Annals  Surg.,"  Iviii,  59;  Manon,  La  Pr.  Med.,  Oct.,  29,  1919, 
A.  Mariau,  La  Pr.  Med.  Dec.  27,  1919.) 

In  one  of  the  author's  cases  there  was  much  disability  and  a  good  result  was 
obtained  by  the  following  operation: 

From  about  3-^  inch  above  the  great  trochanter  make  a  cut  downwards 
along  the  middle  of  the  bone  for  about  3  inches.  Divide  the  fascia  lata  corre- 
sponding to  the  skin  wound.  Incise  the  periosteum  longitudinally  on  the  lower 
part  of  the  trochanter  and  elevate  a  small  periosteal  flap.  Suture  the  posterior 
edge  of  the  wound  in  the  fascia  lata  to  the  periosteal  flap  and  to  the  insertion  of 
the  vastus  externus.  Suture  the  anterior  edge  of  the  fascial  wound  so  as  to 
make  it  overlap  the  line  of  fixation  of  the  posterior  edge.  Close  the  skin  wound. 
Dress.     Immobilize  the  hip  for  several  weeks. 

In  one  case  Voelcker  exposed  the  fascia  lata  over  the  great  trochanter  and 
divided  it  longitudinally  behind  the  palpably  thickened  ilio-tibial  band. 
Underneath  the  fascia  the  gluteus  maximus  appeared  and  contained  a  strong 


980  HIP 

band  of  tendon  which  was  inserted  into  the  ilio-tibial  band.     Division  of  this 
band  without  suture  of  the  fascia  led  to  cure. 

Manon  made  an  incision  along  the  axis  of  the  trochanter  major  and  recog- 
nized that  the  aponeurosis  going  from  the  gluteus  maximus  to  the  fascia  lata 
was  the  culprit.  Division  of  this  aponeurosis  at  right  angles  to  its  fibres  gave 
complete  relief. 

A.  Mariau  finds  that  transverse  section  of  the  posterior  part  of  the  ilio-tibial 
band  is  sufficient  for  cure.  If  his  views  are  correct  and  they  probably  are, 
then  all  more  complicated  operations  may  be  discarded. 

Iodoform  Injection. — Krause  describes  the  introduction  of  the  trocar  and 
cannula  as  follows:  The  trocar  ought  to  be  from  2^  to  33^^  inches  in  length. 
The  patient  lies  flat  on  his  back.  Flexion  of  the  thigh  should  be  avoided  if 
possible,  while  abduction  and  external  rotation  must  be  avoided.  The  thigh 
should  be  in  a  position  of  adduction  and  slight  internal  rotation.  Introduce  the 
trocar  at  right  angles  to  the  axis  of  the  femur,  at  a  point  immediately  above  the 
tip  of  the  trochanter  major  and  midway  between  its  anterior  and  posterior 
borders.  Push  the  trocar  slowly  onward  until  its  point  strikes  bone  (the  head 
of  the  femur  or  the  neck  near  the  head).  Adduct  the  limb  strongly,  keeping  the 
point  of  the  trocar  constantly  in  touch  with  the  femoral  head,  push  the  instru- 
ment cautiously  upwards  and  inwards  until  bony  obstruction  is  again  en- 
countered. The  point  of  the  instrument  is  now  Ijdng  between  the  head  of  the 
femur  and  the  rim  of  the  acetabulum.  Withdraw  the  stylette  and  push  the 
cannula  still  further  into  the  joint.  The  method  of  injecting,  the  material 
to  be  used  and  the  after-treatment  are  the  same  as  have  been  described  in  the 
chapter  on  operation  upon  the  knee. 

Vaseline  Injections. — Rovsing  ("Annals  Surgery,"  Dec,  1909)  advises  the 
injection  of  sterile  vaseline  into  joints  affected  with  traumatic  dry  arthritis. 
If  any  turbid  fluid  escapes  through  the  cannula  no  injection  of  vaseline  should 
be  made,  a  little  clear  synovial  fluid  escaping  does  not  contraindicate  injection. 
In  the  adult  about  20  c.c.  of  vaseline  is  the  correct  quanity  to  throw  into  the 
hip-joint. 

A  trocar  and  cannula  is  the  proper  instrument  to  employ^ — a  cannula  with 
cutting-edge  but  no  trocar  is  too  dangerous. 

Rovsing  has  had  a  special  apparatus  made:  (Fig.  1197)  "a  tube  of  india 
rubber  10  cm.  long,  which  at  one  end  is  provided  with  a  brass  ring  which  can 
be  screwed  on  to  the  ordinary  vaseline  tubes,  while  the  other  end  can  be  partly 
screwed  into  the  cannula  and  partly  into  a  close  fitting  cover,  which  fits  the 
cannula  and  during  the  boiling  can  be  closed  with  a  little  cover;  provided  with 
this  cover  the  rubber  tube  is  screwed  on  to  the  vaseline  tube  and  is  now  boiled 
together  with  this  for  fifteen  minutes  before  the  injection.  Then  the  joint  is 
punctured,  the  poincon  is  removed,  and  the  presence  of  synovia  in  the  joint 
ascertained.  In  such  a  case  catch  the  synovia  in  sterile  glass  tubes  for  examina- 
tion. If  it  is  found  to  be  turbid  and  fluffy  the  injection  of  the  vaseline  is 
abandoned,  but  if  none  or  only  an  inferior  mass  of  clear  synovia  is  found,  the 
vaseline  tube  is  taken  direct  from  the  cooking  vessel  and  connected  with  the 
cannula  by  the  connection  tube,  which  after  the  cover  has  been  removed  can 
be  screwed  straight  on  to  the  cannula.     The  vaseline  is  now  driven  through 


ARTHRcrrOMV    HIP 


981 


the  tube  and  cannula  in  this  way;  the  vaseline  tube  is  rolled  up  from  the  bottom 
by  the  aid  of  a  tiny  little  handle  (Fig.  1198).  By  this  means  every  possibility  of 
infection  of  the  vaseline  passing  from  the  tube  to  the  joint  is  precluded,  and  the 
method  is  in  every  respect  practical." 

Rovsing  when  injecting  insures  against  missing  the  hip-joint  by  exposing 
the  capsule  through  a  small  incision  just  above  the  trochanter. 


Fig.   1197. — (Rovsing,  Annals  of  Surgery.) 


Fig.  lie 


-{Rovsing,  Annals  of  Surgery.) 


Arthrotomy. — There  are  several  routes  through  which  the  hip-joint  may 
be  opened. 

I.  Anterior  Arthrotomy. — Method  A. — Step  1. — From  a  point  about  i 
inch  below  and  a  finger's  breadth  internal  to  the  anterior  superior  iliac  spine 
make  an  incision  3  or  4  inches  in  length  downwards  along  the  inner  border  of  the 
sartorius  (Fig.  11 99).  Expose  the  inner  border  of  that  muscle  and  retract  it 


Fig.  1 199. — Incision  of  anterior  arthrotomy  of  hip. 

outwards;  this  exposes  the  tendon  of  the  rectus  femoris  which  must  be  retracted 
outwards,  exposing  the  ilio-psoas  muscle.  Retract  the  psoas  inwards.  The 
joint  capsule  is  now  exposed. 

Step  2. — Flex  and  abduct  the  thigh,  rotating  it  outwards.  This  permits 
more  free  access.  Incise  the  capsule.  Explore  the  joint.  If  drainage  is 
required,  provide  such  and  partly  close  the  wound. 


982 


IIIP 


Method  B. — Step  i. — From  a  point  about  I?  inch  below  and  external  to 
the  anterior  superior  iliac  spine  make  a  3-  or  4-inch  incision  downwards  and 
slightly  inwards.  The  upper  portion  of  the  cut  runs  along  the  outer  border 
of  the  sartorius,  lower  down  where  the  sartorius  and  tensor  vagina;  femoris 
separate,  the  cut  takes  a  course  midway  between  these  muscles.  Retract  the 
sartorius  and  rectus  femoris  muscles  inwards.     The  joint  capsule  is  now  exposed 

Step  2. — Same  as  in  Method  A. 

If  on  account  of  suppuration  it  seems  desirable  to  provide  further  drainage 
through  a  counter-opening,  Labey  advises  the  following  procedure:  Abduct 
the  thigh  so  as  to  make  the  adductor  muscles  prominent.  Locate  the  adductor 
longus.  Make  a  4-inch  incision  along  the  outer  border  of  this  muscle,  begin- 
ning about  one  finger's  breath  from  the  fold  of  the  groin  and  a  little  external 
to  the  root  of  the  scrotum.  Divide  the  skin  and  subcutaneous  tissue.  Retract 
the  long  saphenous  vein  outwards;  ligate  and  divide  any  of  its  branches  which 
cross  the  wound.  Divide  the  deep  fascia  along  the  outer  border  of  the  adductor 
longus.     Push  the  finger  between  the  adductor  longus  and  the  pectineus  which 


Fig.  1200. — Drainage  of  hip 
{Labey.) 


Fig.  1 20 1. — {Esmarch  and 
Kowahig.) 
Figs.  1201  and  1202.- 


FiG.   1202. — [Labey.) 
Langenbeck's  arthrotomy. 

lies  immediately  external  to  it.  The  thigh  being  now  flexed  as  well  as  abducted, 
hook  the  finger  under  the  pectineus.  Introduce  a  closed  forceps  through  the 
arthrotomy  wound,  make  the  forceps  traverse  the  joint  inwards  and  downwards 
so  as  to  make  the  inner  and  lower  part  of  the  capsule  prominent  and  to  come 
against  the  finger  pushed  into  the  secondary  wound  (Fig.  1 200).  Guided  by  the 
finger,  make  an  incision  through  the  capsule  on  to  the  forceps.  With  the  forceps 
pull  a  large  drainage-tube  through  from  one  wound  to  the  other. 

II.  Posterior  Arthrotomy. — Method  A,  Langenbeck's  Method.-  Place  the 
patient  on  his  healthy  side  (latero-ventral  position).  Flex  the  thigh  to  a 
position  midway  between  extension  and  flexion  at  a  right  angle  to  the  body  (45°). 

Step  I. — Beginning  at  a  point  about  two  fingers'  breadth  below  the  tip 
of  the  trochanter,  make  an  incision  along  the  mid-line  of  the  trochanter  in 
the  long  axis  of  the  femur,  upwards  for  about  4  to  4^'^  inches  towards 
the  posterior  superior  iliac  spine  (Fig.  1201).  Divide  the  skin  and  sub- 
cutaneous fat  so  as  to  expose  the  gluteus  maximus  and  the  trochanter 
which  is  covered  by   the  strong  flat  tendon  of  the  gluteus  ma.ximus. 


ARTHRECTOMY    HIP  983 

Step  2. — Divide  the  tendon  on  the  trochanter  in  the  line  of  wound  and 
continue  this  division  upwards  so  as  to  penetrate  the  gluteus  maximus 
by  separating  its  I'lbres.  Retract  the  edges  of  the  muscular  wound  exposing 
and  then  dividing  the  layer  of  fat  covering  the  deeper  structures.  Expose  the 
pyriformis  (posterior  and  inferior)  and  the  gluteus  medius  (anterior  and 
superior).  Note  and  penetrate  the  groove  between  these  two  muscles. 
Retract  the  edges  of  this  deep  wound  so  as  to  expose  the  posterior  surface 
of  the  capsule. 

Step  3.^ — -Incise  the  capsule  (Fig.  1202). 

Method  B. — ^Kocher's  Curved  Incision. — This  method  is  described  in  the 
chapter  on  arthrectomy. 

Arthrectomy.  Anterior  Incision. — Several  methods  have  been  devised 
for  approaching  the  joint  by  the  anterior  route  only  Barker's  plan  will  be 
described.     This  operation  is  enthusiastically  advocated  by  A.  E.  Barker. 

Step  I. — See  Anterior  Arthrotomy,  Method  B. 

Step  2. — Open  the  joint  capsule  by  an  incision  parallel  to  the  neck  of  the 
femur.  Explore.  Do  not  dislocate  the  head  of  the  bone  through  the  incision. 
Divide  the  neck  of  the  femur  with  a  fine  saw  (Adams's)  or  an  osteotome.  Re- 
move the  head  of  the  bone.  Removal  of  the  normal  femoral  head  is  exceed- 
ingly difficult,  but  when  tuberculous  disease  is  so  advanced  that  excision  is 
necessary,  the  tissues  are  so  altered  and  softened  that  extraction  of  the  head 
is  usually  easy;  to  this  rule  there  are  some  striking  exceptions,  when  the  head 
of  the  femur  may  require  to  be  chiseled  from  the  cotyloid  cavity. 

Step  3. —  With  the  irrigating  curette  scrape  away  all  soft  broken  down  tissues. 
With  long  forceps  and  scissors  dissect  away  all  evidently  diseased  synovialis, 
etc.  Examine  the  acetabulum  and  its  surroundings  and  if  found  diseased, 
remove  the  foci  with  the  curette,  chisel,  or  gouge.  Thoroughly  douche  the 
cavity  with  warm  water  tinged  to  a  dark  sherry  color  with  tincture  of  iodine. 

Step  4. — (a)  No  evidence  of  secondary  (pyogenic)  infection  is  present. 
Fill  the  wound  with  iodoform-glycerine  or  iodoform  and  formalin  in  glycerine. 
Close  the  wound  without  drainage. 

{b)  Sinuses  are  present  or  there  is  evident  pyogenic  infection.  Provide 
for  free  drainage.     Partly  close  the  wound. 

After-treatment.^ — Barker  writes  as  follows: 

"No  splint  is  required  immediately  after  the  operation,  the  limb  lying 
in  good  position,  as  a  rule,  if  left  to  itself,  no  muscles  having  been  divided. 
If  there  be  any  tendency  to  displacement  a  weight-extension  will  be  the  most 
suitable  means  of  correcting  it  in  the  first  instance.  As  the  wound  hes  in  front 
and  is  small,  there  is  no  difficulty  in  dressing  it  without  moving  the  patient 
in  the  least,  hence  another  reason  for  discarding  splints  at  first.  But  when 
the  wound  is  in  a  fair  way  to  heal,  the  author  is  in  the  habit  of  putting  the 
patient  upon  a  double  Thomas'  splint,  in  which  he  can  be  removed  from  bed 
and  be  carried  out  for  change  of  air  without  the  least  disturbance  of  the  limb 
or  of  the  dressing  on  the  wound." 

External  or  Langenbeck's  Incision. — Konig's  Method. — Place  the  patient 
on  his  sound  side  with  the  operating-table  so  arranged  that  a  good  light  falls 
on  the  hip.     Three  assistants  are  necessary.     One  stands  opposite  the  surgeon. 


984 


HIP 


one  at  the  patient's  back,  and  the  third  where  he  can  manipulate  the  patient's  limb. 
The  surgeon  stands  behind  the  hip.     The  thigh  is  in  a  position  of  semiflexion. 

Step  I. — Make  a  five  inch  incision  over  the  middle  of  the  trochanter  major 
in  hne  with  the  long  axis  of  the  femur.  Rather  more  than  half  of  this  incision 
lies  above  the  trochanter,  between  it  and  the  posterior  superior  spine  of  the 
ilium  (Langenbeck's  incision.  Fig.  1201).  The  knife  is  made  to  penetrate  to 
the  bone  in  the  first  cut. 

Step  2.- — ^With  long-bladed  retractors  separate  the  edges  of  the  wound,  ex- 
pose the  capsule  and  divide  it.  Divide  the  periosteum  of  the  trochanter  in  the 
line  of  the  wound.     Do  not  separate  the  trochanteric  muscular  insertions. 

Step  3.^ — ^With  a  broad  chisel  partially  cut  off  a  shell  of  bone  from  the  anterior 
and  from  the  posterior  margins  of  the  trochanter.  Complete  the  separa- 
tion of  the  shells  of  bone  by  blunt  force,  leaving  them  loosely  attached  to  the 
shaft  of  the  femur,  the  periosteum  and  soft  structures  acting  as  a  hinge  (Fig. 

1203,  c,  c).  The  separated  portions  of 
bone  bear  the  insertions  of  the  trochan- 
teric muscles.  The  remaining  portion  of 
trochanter  (b)  must  be  removed  flush  with 
the  femoral  neck  by  means  of  the  chisel  or 
bone  forceps. 

Step  4. — With  retractors  expose  the 
femoral  neck.  Choose  the  point  at  which 
the  neck  is  to  be  divided.  With  a  peri- 
osteal elevator  bare  the  bone  of  the  neck 
at  the  line  of  section.  Divide  the  bone. 
For  this  purpose  use  a  finger  saw,  or 
better,  the  Gigli  wire  saw. 

Step  5.— Removal  of  the  femoral  head. 
Konig  writes  as  follows:  "The  removal 
of  the  head  is  often  difficult.  Sometimes 
it  has  sunk  into  the  cotyloid  cavity  which 
has  been  widened  by  disease  and  whose 
inequalities  of  surface  have  hooked  them- 
selves on  to  similar  inequalities  of  the 
femoral  head;  sometimes  it  is  so  changed  in  form  that  it  has  become  firmly 
fixed  in  an  excavation  of  the  acetabulum;  occasionally  its  surface  is  partially  or 
entirely  united  to  the  bone  of  the  acetabulum.  In  other  cases,  especially 
when  acute  osteomyeHtis  has  been  present,  the  epiphysis  is  separated  and  the 
head  itself  is  anchvlosed  to  the  acetabulum. 


Fig.  1203. — Konig's  arthrectomy. 


Fig.  1204. — Konig's  lever. 


"iMi"'      't^SI 


"In  simple  cases  when  room  is  made  by  pulling  the  limb  downwards  one 
can  remove  the  head  with  a  periosteal  elevator.  In  difficult  cases  a  specially 
strong,  spoon-faced  lever  is  required."  (The  author  has  had  one  made  of 
the  following  dimensions,  i4X%X/'^  inches  (Fig.  1204).  It  reminds  one 
of  a  burglar's  "jimmy,"  but  is  thoroughly  efficient.) 


EXCISION    HIP  985 

"In  unusally  difficult  cases  one  may  chisel  away  a  portion  of  the  posterior 
superior  rim  of  the  acetabulum  (a,  Fig.  1203).  This  would  be  done  in  any 
event  after  the  removal  of  the  head." 

Examine  the  trochanter  and  the  remnant  of  the  neck.  If  disease  is  present 
in  these  structures  attack  it  with  chisel  and  sharp  spoon. 

Step  6. — Examine  the  cotyloid  cavity  both  by  touch  and  sight.  Remove 
sufficient  of  the  posterior  superior  cotyloid  rim  to  permit  of  free  inspection  of 
the  cavity.  If  disease  exists  in  the  pelvic  bones  remove  it  thoroughly  with 
chisel  and  spoon.  In  cases  where  the  disease  has  invaded  the  pelvis  and  caused 
iliac  abscess,  the  latter  must  be  independently  opened  anteriorly  above  Pou- 
part's  ligament,  its  contents  evacuated,  its  cavity  cleaned,  filled  with  iodoform- 
formalin  glycerine  and  sutured. 

Step  7. — ^Excision  of  the  Synovialis.— Separate  the  synovialis  from  the 
rim  of  the  acetabulum  and  from  its  inferior  insertions,  and  dissect  it  out. 
Long  stout  dissecting  forceps  and  scissors  curved  on  the  flat  are  convenient 
for  this  purpose.  Changes  in  the  position  of  the  limb  assist  in  giving  free 
exposure.  All  the  synovialis  may  be  excised  as  above,  except  sometimes  a 
pouch  which  runs  down  to  the  lesser  trochanter  and  must  be  thoroughly  cu- 
retted. The  sharp  spoon  so  often  recommended  for  the  removal  of  the  sy- 
novialis is  practically  useless  for  the  purpose. 

Step  8. — Irrigate  the  wound  with  hot  water.  The  addition  to  the  water 
of  sufficient  tincture  of  iodine  to  make  it  a  sherry  color  is  valuable.  Dry  the 
wound  with  sterile  gauze.  Introduce  a  cannula  or  tube  into  the  wound.  Close 
the  wound  with  deep  and  superficial  sutures.  Place  one  or  more  sutures 
(not  tied)  in  such  position  that  when  the  tube  is  removed  they  may  be  tied 
and  effectually  close  the  wound.  Through  the  tube  fill  the  wound  cavity 
with  iodoform-glycerine  or  iodoform-formalin-glycerine  or  Beck's  bismuth 
vaseHne.     Remove  the  tube.     Fasten  the  last  sutures.     Apply  ample  dressings. 

James  E.  Moore  recommends  filling  the  wound  cavity  with  Mosetig's  bone 
plug.  Mosetig  himself  originally  only  used  this  plug  to  fill  cavities  actually 
cut  in  the  bone  itself.  His  plan  in  articular  caries  was  to  cut  (not  scrape) 
away  the  focus,  thoroughly  dry  the  bone  cavity  left,  fill  the  cavity  with  the 
iodoform  wax,  cover  the  plug  with  rubber  tissue  and  gauze  until  the  rest  of 
the  operation  was  completed,  then  he  removed  the  rubber  tissue  and  gauze 
and  closed  the  wound  after  introducing  short  drainage-tubes.  Moore  in  one 
case  could  not  obtain  sufiiciently  perfect  hemostasis  to  permit  the  use  of  the 
"bone  plug,"  hence  he  packed  the  wound  with  gauze  for  some  days  and  intro- 
duced the  plug  secondarily  with  good  results. 

If  secondary  infection  is  a  feature  of  the  case  and  especially  if  sinuses 
exist,  then  the  above  treatment  is  improper;  the  sinuses  must  be  cleaned  by 
the  sharp  spoon,  rubbing  with  gauze  or  by  dissection.  Filling  the  cavity  and 
sinuses  with  Beck's  bismuth  paste  seems  to  be  efficacious,  also  the  Carrel-Dakin 
treatment. 

After-treatment. — Put  the  patient  in  bed.  Apply  extension  by  means 
of  weight  and  pulley  in  a  position  of  slight  abduction.  Keep  up  for  from  six  to 
eight  weeks  or  longer.     Use  nocturnal  extension  for  a  period  of  one  or  two  years. 

Within  three  weeks,  if  all  goes  well,  begin  gentle  passive  motion.     After 


986 


HIP 


the  wound  is  satisfactorily  healed  massage  combined  with  passive  movements 
is  indicated,  and  active  movements  may  be  begun.  After  the  lapse  of  eight 
weeks  the  patient  may  be  encouraged  to  walk  with  crutches.  Huntington 
believes  that  in  most  cases  of  hip-joint  disease,  whether  tuberculous  or  of 
acute  infective  origin,  the  primary  focus  is  situated  in  the  neck  or  the  head 
of  the  femur.  Guided  by  X-ray  findings,  he  therefore  trephines  on  the  outer 
surface  of  the  trochanter  major  near  its  base  and  through  the  trephine  opening 
tunnels  the  neck  of  the  femur  until  he  reaches  the  disease  (Fig.  1205).  If 
sufficient  disease  to  account  for  the  symptoms  is  found  before  the  epiphyseal 
cartilage  is  reached,  do  not  penetrate  that  structure;  if  sufficient  disease  is  not 


Fig.   1205. — Tuberculosis  of  the  hip.     {Hunlington.) 


found  in  the  neck,  then  the  epiphyseal  cartilage  must  be  penetrated  and  the 
head  entered.  The  time  when  this  operation  may  promise  most  is  the  time 
when  non-operative  treatment  is  usually  considered  indicated,  viz.,  early.  The 
treatment  is  the  same  as  was  advocated  by  Macnamara  (Huntington,  "Surg., 
Gyn.,  and  Obstet.,"  ii,  p.  406). 

Angular  Incision.  Kocher's  Operation.- — This  incision  may  be  used  for 
arthrotomy  as  well  as  for  arthrectomy.  Place  the  patient  on  his  sound  side  in 
the  latero-ventral  posture.  Slightly  flex  the  hip.  Let  an  assistant  grasp  the 
leg  so  as  to  change  the  position  of  the  thigh  according  to  directions. 

Step  I. — Beginning  at  the  posterior  margin  of  the  base  of  the  trochanter 
major,  make  a  cut  upwards  to  the  posterior  angle  of  the  summit  of  the  tro- 
chanter-(Fig.  1206);  at  this  point  change  the  direction  of  the  incision  and  cut 
upwards  and  backwards  towards  the  posterior  superior  iliac  spine,  i.e.,  cut 


EXCISION    nil' 


987 


parallel  to  the  fibres  of  the  (gluteus  maximums  and  expose  that  muscle.  Split 
the  tendon  of  the  gluteus  maximus  in  the  direction  of  its  fibres,  and  enlarge 
the  deep  wound  upwards  and  backwards  by  splitting  the  muscle  itself  in  a 
space  between  its  fibres  (Fig.  1207). 

Retract  the  edges  of  the  deep  wound,  exposing  the  gluteus  medius  at  its 
insertion  into  the  trochanter. 

Step  2. — Rotate  the  hip  slightly  inwards  so  as  to  make  prominent  the  poste- 
rior angle  of  the  summit  of  the  trochanter.  Find  the  groove  between  the  gluteus 
medius  and  minimus  above  and  the  pyriformis  below.  Beginning  at  this 
point,  separate  with  elevator  or  knife  the  insertions  of  the  gluteus  medius 
and  minimus  along  with  the  corresponding 
periosteum  from  the  trochanter  until  the  in- 
tertrochanteric line  is  reached  anteriorly.  At 
this  point  separate  the  insertion  of  the  ilio- 
femoral ligament.  While  doing  this  flex  the 
thigh  and  rotate  it  outwards. 

Step  3. — Divide  the  articular  capsule  along 
the  lower  edge  of  the  pyriformis  tendon;  flex 
the  thigh  and  rotate  it  inwards  so  as  to  gain 
access  to  and  divide  the  insertion  of  the  pyri- 
formis. With  elevator  or  chisel  (removing  a 
thin  shell  of  bone  if  desired)  separate  the  in- 
sertions of  the  obturators  and  gemelli. 

The  rest  of  the  operation  requires  no  special 
description. 

Larghi's  High  Curved  Incision.— A.  Von 
Bergmann  ("Archiv  fiir  klin.  Chir.,''  Ixix,  592) 
strongly  recommends  the  above  incision  in 
cases  where  there  is  considerable  involvement 

of  the  pelvic  bones.  The  cut  skirts  the  iliac  crest  and  permits  reflection 
downwards  of  the  gluteal  muscle.  The  operation  was  originally  devised  for 
excision  of  the  ilium,  but  it  has  been  used  in  tuberculous  coxitis  and  especially 
in  dislocation  of  the  hip  {q.  v.). 

Ollier's  Snuff-box  Method. — Place  the  patient  on  his  sound  side.  Flex 
the  thigh  to  an  angle  of  45°  and  adduct  so  as  to  make  the  trochanter  prominent. 

Step  I.— Make  the  semilunar  incision  A,  B,  C  (Fig.  1208),  the  lowest  point 
(B)  being  about  2  inches  below  the  tip  of  the  trochanter,  the  pits  A  and  B  being 
about  the  same  distance  in  front  of  and  behind  the  posterior  and  anterior  edges 
of  the  trochanter,  respectively.     Divide  the  skin  and  deep  fascia. 

Step  2. — By  means  of  a  curved  incision  corresponding  exactly  to  the  skin 
incision,  expose  the  base  of  the  great  trochanter.  Continue  this  incision  for- 
wards in  a  curve  so  as  to  penetrate  between  the  anterior  fibres  of  the  gluteus 
medius  or  between  the  gluteus  medius  and  the  tensor  vaginae  femoris.  Con- 
tinue the  incision  backwards  in  a  curve  so  as  to  penetrate  between  the  fibres  of 
the  gluteus  maximus. 

Step  3. — ^Method  A. — Pass  a  Gigli  wire  saw  round  the  trochanter  major  and 
cut  through  the  base  of  the  trochanter  from  within  outwards  and  downwards. 


Fig.  1206.— Kocher's  incision. 


988 


HIP 


Method  B.— With  a  saw  cut  through  the  base  of  the  trochanter  from 
without  inwards  and  upwards  (Fig.  1209). 

Method  C. — Make  the  same  division  with  an  osteotome.  Whichever 
method  is  used,  divide  the  bone  obhquely  so  as  to  insure  easy  union. 


Fig.  1207. — Kocher's  operation.     {Kocher.) 

Step  4. — Reflect  upwards  the  separated  trochanter  with  its  muscles.     This 
exposes  the  joint  thoroughly  (Fig.  12 10). 

Step  5. — Treat  the  disease  as  already  described. 

Step  6. — If  the  trochanter  is  diseased,  remove  the 
disease  or  the  trochanter  itself,  as  may  be  indicated. 
If  the  trochanter  is  healthy,  return  it  to  its  normal 
position  and  fix  it  there  by  sutures  (wire,  chromicized 
catgut),  pegs,  or  screws.  Provide  drainage  if  neces- 
sary. Close  the  wounds.  Some  surgeons  fill  the 
joint  cavity  with  iodoform  emulsion,  Mosetig's  plug 
or  iodoform  starch  and  close  without  drainage. 

Rutherford  Morison  operates  as  follows:  Make  a 
convex   incision  immediately   above   the   trochanter 
major.     Divide   all    the   muscles   inserted   into    the 
trochanter.     Dislocate  the  head  of  the  femur  through 
the  wound.     Remove  all  the  capsule,  synovial  mem- 
brane, and  cartilage  from  the  head  and  the  acetabulum.     Close  the  wound 
completely.     Immobilize.     Do  not  remove  the  head  of  the  femur  unless  it 
has  become  a  sequestrum. 

Remarks. — When  coxitis  results  from   osteo-myelitis  the   treatment  ought 
to  be  by  excision.     While  arthrotomy  has  given  good  results,  yet  excision 


Fig.  1208. — Ollier's  opera 
tion.     (Labey.) 


ARTHRITIS    DEFORMANS 


989 


leads  to  a  quicker  recovery  and  so  avoids  the  more  remote  dangers  of  long- 
lasting  suppuration  (Hoffa).  When  there  is  hydrops  or  pyarthros,  puncture 
and  injection  with  some  fluid  such  as  formalin-glycerine  is  advisable  unless 
there  is  too  much  absorption  of  toxins,  in  which  case  arthrotomy  or  arthrec- 
tomy  is  indicated.  The  hydrops  of  typhoidal  coxitis  demands  puncture. 
In   tuberculous   coxitis   when  fistulas  are  absent   and   there   is   no   dislocation, 


Fig.  1209.  Fig.  12 10. 

Figs.  1209  and  1210. — OUier's  operation.     {Labey.) 

conservative  measures  ought  to  be  thoroughly  tried,  especially  in  the  young. 
When  sequestra  are  demonstrated  they  must  be  removed  by  operation  after 
the  failure  of  conservative  measures. 

The  presence  of  fistulae  is  not  per  se  an  indication  for  radical  measures, 
conservative  means  (suction  hyperaemia,  Beck's  paste,  etc.)  may  be  tried  if 
the  symptoms  are  not  pressing,  but  the  attempts  at  conservatism  must  not  be 
persisted  in  if  improvement  does  not  soon  show  itself.  Even  in  the  presence 
of  well-marked  visceral  tuberculosis  or  of  amyloid  disease  it  is  almost  always 
proper  to  prefer  excision  to  amputation  in  severe  cases  of  tuberculous  coxitis. 


CHAPTER  LXXVIII 
HIP.    ARTHRITIS  DEFORMANS 

In  cases  of  arthritis  deformans  of  the  hip  in  which  there  is  much  disability 
from  pain,  muscular  spasm,  and  deformity,  F.  H.  Albee  ("Jour.  A.  M.  A.," 
June  13,  1908)  operates  as  follows: 

Step  I. — From  a  point  just  below  and  internal  to  the  anterior  superior 
iliac  spine  make  a  5-inch  cut  through  the  skin  and  subcutaneous  tissue  along 
the  inner  border  of  the  sartorius. 

Step  2. — Divide  the  deep  fascia.  Retract  the  sartorius  outwards.  Pene- 
trate the  deep  structures  by  blunt  dissection.  Retract  the  iliacus  and  rectus 
femoris  inwards.     Expose  the  hip-joint. 

Step  3. — A  large  ring  of  osteophytes  generally  will  be  found  about  the  rim 
of  the  acetabulum.  Turn  such  upwards  with  the  soft  parts  adherent  to  them. 
This  is  easilv  done  with  chisel  and  elevator. 


990  ANCHYLOSIS    HIP 

Step  4. — Do  not  atlcmpL  to  disarticulate  the  hip,  but  willi  ihe  head  of  the 
femur  remaining  in  situ,  cut  away  about  half  its  upper  hemisphere  with  a  large 
chisel  in  a  plane  nearly  parallel  to  the  axis  of  the  femoral  neck  (Fig.  121 1). 
In  the  same  manner  flatten  the  upper  part  of  the  acetabulum  so  that  a  flat 
surface  of  femur  lies  against  a  fiat  surface  of  acetabulum,  when  the  limb  is  ab- 
ducted.    Remove  the  chips  of  bone. 


Fig.  1211.  Fig.  1212. 

Figs.  1211  and  12 12. — Albee's  operation. 

Step  5. — Abduct  the  limb  and  obtain  approximation  of  the  surfaces  of 
bone  made  flat  by  the  chisel  (Fig.  12 12).  The  position  desired  is  one  of  slight 
overcorrection  with  abduction  to  overcome  the  shortening  which  is  always 
present.  Before  obtaining  the  desired  position  open  tenotomy  of  the  abductors 
at  their  origins  may  be  necessary. 

Step  6. — Suture  the  capsule  and  soft  parts.  Apply  dressings.  Immobilize 
in  a  position  of  abduction. 

Albee  has  used  this  operation  in  five  cases  with  gratifying  results. 


CHAPTER  LXXIX 
ANCHYLOSIS  HIP 

Malpositions  with  bony  anchylosis  of  the  hip  and  certain  osseous  deformi- 
ties, such  as  coxa  vara,  are  the  principal  lesions  which  necessitate  osteotomy 
at  the  hip.  Bony  anchylosis  may  be  due  to  one  of  several  causes — e.g.,  tuber- 
culous osteo-arthritis,  fracture  of  the  femur  or  acetabulum,  etc.  When  choosing 
a  method  of  operating,  the  nature  of  the  lesion  causing  the  deformity  must  be 
taken  into  consideration.  An  operation  which  would  be  safe  in  a  case  of 
anchylosis  due  to  trauma  might,  in  one  due  to  tuberculosis,  relight  the  disease 
process  and  even  cause  its  dissemination.  The  choice  of  operation  must  also 
depend  on  whether  the  result  desired  is  a  joint  immobilized  in  good  position 
or  one  capable  of  movement. 

I.  Supra-trochanteric  Osteotomy. — (A)  Subcutaneous  with  Saw.  Adams's 
Operation  (see  p.  968). 

(B)  Division  of  the  Femoral  Neck  with  Chisel  through  a  Small  Incision. — 
Place  the  patient  on  his  sound  side.  At  a  point  immediately  above  the  great 
trochanter  make  a  vertical  incision  about  i  inch  long  down  to  the  neck  of  the 
femur.  Introduce  an  osteotome  alongside  the  knife  and  remove  the  latter. 
Turn  the  edge  of  the  osteotome  transversely  to  the  neck  of  the  femur  and 


ARTHROPLASTY    HIP 


991 


divide  it  completely.  Do  not,  as  in  the  operations  for  genu  valgum,  etc., 
partly  divide  and  partly  fracture  the  bone;  this  might  result  in  dangerous 
splintering.  Apply  dressings.  Immobilize  the  limb  in  good  position  by 
means  of  extension,  splints,  plaster  of  Paris,  or  by  a  combination  of  these 
means.     Treat  the  case  as  a  fracture. 

Note. — Division  of  the  neck  of  the  femur  is  suitable  in  cases  of  bony  anchy- 
losis where  flexion  is  the  only  deformity  present.  Of  course  when  the  head  and 
neck  are  profoundly  altered,  e.g.,  in  bad  cases  of  coxa  vara  or  of  destructive 
osteitis  the  operation  is  often  impossible. 

(C)  Open  operation  with  introduction  of  muscle  between  the  cut  surfaces 
of  the  bone  (Nekton's  operation)  (Huguier,  Traitement  des  Ankyloses). 
Arthroplasty. 

Step  I. — From  a  point  one  or  two  fingers'  breadth  below  the  anterior  superior 
iliac  spine  make  an  incision  through  the  skin  and  subcutaneous  tissue,  along 
the  anterior  border  of  the  trochanter  major. 
This  incision  is  about  6  inches  long.  Divide 
the  fascia  throughout  the  length  of  the  wound. 
Find  the  interspace  between  the  tensor  vaginae 
femoris  and  the  sartorius;  separate  and  retract 
these  muscles  outwards  and  inwards,  thus  ex- 
posing the  rectus  femoris  and  more  deeply  the 
ilio-psoas  (Fig.  12 13).  Strongly  retract  inwards 
these  two  muscles.  With  the  finger  palpate  the 
great  trochanter  and  the  anterior  surface  of  the 
articular  capsule;  expose  this  latter  completely. 
Split  the  capsule  from  the  anterior  inferior  iliac 
spine  to  the  trochanter,  preserving  the  ilio- 
femoral band  as  well  as  possible.  By  blunt 
dissection  denude  the  anterior  surface  of  the 
neck  of  the  femur  and  expose  the  junction  of 
the  head  of  the  femur  with  the  cotyloid  cavity. 
(These  structures  are  fused  together.) 

Step  2. — With  osteotome  and  mallet  divide 
the  head  of  the  femur  where  it  is  fused  to  the  pelvis.  Preserve  as  much  as 
possible  of  the  head  of  the  bone  attached  to  the  neck.  When  the  bone  is 
divided,  clean  out  the  cotyloid  cavity  with  gouge  and  rongeurs  so  as  to  make 
it  concave  and  smooth.  Smooth  and  round  off  the  remnant  of  the  head  of 
the  femur.  If  the  trochanter  and  neck  of  the  femur  are  very  much  deformed 
and  are  so  anchylosed  to  the  ilium  that  it  is  impossible  to  reform  the  head  and 
neck  of  the  bone,  divide  the  fused  mass;  cut  a  cavity  in  the  iliac  bone;  see 
that  this  cavity  is  provided  with  a  prominent  superior  and  posterior  border; 
round  off  the  top  of  the  upper  end  of  the  femur  so  that  it  may  fit  into  the 
above-mentioned  cavity. 

Step  3. — The  new  articulating  surfaces  having  been  prepared,  interpose  a 
layer  of  muscle  between  them  as  follows:  Divide  the  rectus  femoris  muscle 
about  4  inches  below  its  origin,  mobilize  it,  let  it  fall  into  the  new-formed 
cotyloid  cavity  and  fix  it  there  with  a  few  sutures  (Fig.  12 14). 


Fig.  1213. 


992 


ANCHYLOSIS    HIP 


Step  4. — Place  the  femur  in  position.  Close  the  wound  with  or  without 
drainage.  Apply  dressings  and  extension.  Keep  immobilized  until  the 
wound  has  healed  and  then  gradually  begin  exercises. 

Rochet  has  shown  that  by  operating  from  the  front  the  glutei  muscles  and 
the  strong  upper  and  posterior  parts  of  the  capsule  are  preserved  intact.  These 
structures  prevent  the  femur  from  riding  up  over  the  ilium.  In  some  cases 
where  there  is  much  inversion  of  the  thigh,  the  anterior  operation  is  impossible 
and  it  becomes  necessary  to  adopt  Langenbeck's  or  OUier's  incision  for  excision 


—  d 


Fig.  1214. — Nelaton's  arthroplasty.     (Huguier.) 
a.  Flap  of  rectus  muscle;  6,  ilio.  femoral  band;  c,  tensor  fasciae  latae;  d,  sartorius;  e,  neck  of  femur. 

of  the  hip.  The  operation  so  far  as  exposing  the  joint  is  concerned  is  the  same 
as  in  excision  and  requires  no  special  notice  at  this  place.  The  bones  are  divided 
and  treated  as  in  Nelaton's  operation,  but  the  muscle  flap  used  for  interposition 
is  obtained  from  one  of  the  glutei. 

Mvirphy's  Operation. — J.  B.  Murphy  ("Journ.  A.  M.  A.,"  May  20,  27; 
June  3,  1905),  reasoning  from  Langemak's  classical  researches  into  the  origin 
of  bursae  ("Archiv  fur  klin.  Chir.,"  Ixx,  946)  and  from  some  experiments  of 
his  own,  concludes  that  fascia  and  fat  are  more  suitable  than  muscle  for  inter- 
position between  the  ends  of  the  bone  after  section.  In  the  case  of  a  school- 
boy Murphy  operated  as  follows  and  obtained  a  brilliant  result: 

Step  I. — Make  a  V-shaped  incision,  with  the  trochanter  in  the  centre  of 
the  V,  reaching  from  a  point  4  inches  above  to  a  point  2  inches  below  the  tro- 
chanter. The  open  end  of  the  V  is  5  inches  wide  and  directed  upwards.  Reflect 
upwards  the  V-shaped  flap  containing  skin,  superficial  fascia,  and  fascia  lata 
(Figs.  1215  and  1216). 

Step  2. — With  a  needle  and  guiding  suture,  pass  a  Gigli  wire  saw  round 
the   base  of  the  trochanter  major  and  divide  it  transversely.    This  may  be 


ARTHROPLASTY    HIP 


993 


Fig.  1215.  Fig.  1216. 

Fig.  1 215  AND  12 16. — Result  of  arthroplasty.     {Murphy.) 


Fig.  1 21 7. — Arthroplasty.     {Murphy.) 


63 


994 


ANCHYLOSIS   HIP 


Fig.  i2iS. — Arthroplasty.     [Murphy.) 


Fig.  1219. — Skin  reflected.     Fascial  flap  out-      Fig.  1220. — Division  of  trochanter  major, 
lined.     (Guillot  and  Dehelly,  J.  de  Chir.)  (GuiUot  and  Dehelly,  J.  d*  Chir.) 


ARTHROPLASTY   HIP 


995 


done  with  an  osteotome.  Turn  the  severed  trochanter  with  its  attached 
muscles  upwards  (Figs.  1217,  1218  and  1221). 

Step  3. — Incise  the  articular  capsule  and  separate  it  from  the  ilium  all  the 
way  round. 

Step  4. — Chisel  the  bony  material  (head  of  femur  and  new  bone)  fiUing  the 
acetabulum  from  the  latter,  beginning  at  their  line  of  junction  and  so  cutting 
that  as  much  as  possible  of  the  femoral  head  is  retained  (Figs.  1222  and  1226). 
After  cutting  most  of  the  line  of  union,  the  remainder  may  be  fractured  by 
moving  the  thigh. 

Step  5. — With  chisel,  rongeurs,  and  scoop,  smooth  and  deepen  the  cotyloid 
cavity.     Similarly  round  off  and  smooth  the  head  of  the  femur. 


Fig.  1 22 1. — Trochanteric  muscles  re- 
flected upwards.  Joint  opened.  {Guillot 
and  Dehelly,  J.  de  Chir.) 


Fig.  1222. — Separation  of  anchylosed  bones. 
{Guillot  and  Dehelly,  J.  de  Chir.) 


Step  6. — Dissect  the  fascia  lata  from  the  rest  of  the  original  V-flap  leaving 
its  base  intact.  With  this  fascial  flap,  line  the  new  cotyloid  cavity.  Fix  the 
new  lining  in  position  by  a  few  sutures.  Only  a  part  of  the  flap  and  that  near 
its  base  is  required  for  this  purpose,  the  apical  portion  will  be  used  to  cover 
the  femur.  By  manipulations  •  return  the  head  of  the  femur  into  the  socket 
(Fig.  1 2 18).  Suture  the  free  margin  or  apical  portion  of  the  fascial  flap  to  the 
periosteum  and  capsule  attached  to  the  neck  of  the  femur.  This  is  important,  as 
Murphy  considers  it  essential  that  every  part  of  the  new  articulating  surfaces 
be  covered  with  fascia. 

Step  7.— Peg  or  wire  the  divided  trochanter  major  in  its  old  position.  Close 
the  wound.     Dress  and  apply  extension. 

N.  B. — It  may  be  necessary  to  perform  tenotomy  on  one  or  several  muscles 
and  so  overcome  their  contraction  before  a  good  position  is  obtained.  (Figs. 
1215,  1216  and  1227  show  the  result  in  a  case  of  Murphy's.) 


996 


ANCHYLOSIS    HIP 


The  series  of  illustrations  published  by  Guillot  and  Dehelly  (J.  de  Chir., 
March,   1914)  are  so  much  more  illuminating  than  words  or  than  Murphy's 


Fig.  1223. — Reaming  acetabulum. 
{Guillot  and  Dehelly,  J.  de  Chir.) 


Fig.  1224. — Fascial  flap  made  to  line  acetab- 
ulum.    {Guillot  and  Dehelly,  J.  de  Chir.) 


Fig.   1225. — Mobilized  trochanter  replaced  and  nailed.     Isuture  of  divided  structures. 
{Guillot  and  Dehelly,  J.  de  Chir.) 


own  figures  that  they  are  included  here  and  may  almost  take  the  place  of  the 
description  in  the  text.     Figs.  1219  to  1225. 


OSTEOTOMY  HIP  997 

n.  Trochanteric  Osteotomy. — Rhea  Barton  (Philadelphia)  was  the  first 
to  correct  deformity  in  hip  anchylosis  by  osteotomy.  His  line  of  section  was 
through  the  trochanter  major  (Fig.  1228).     This  operation  is  not  performed  now. 

m.  Intertrochanteric  Osteotomy. — Sayre's  Operation. — Step  i. — Make 
a  vertical  incision  from  a  point  just  above  the  tip  of  the  great  trochanter 
downwards  for  6  inches  along  the  mid-line  of  the  outer  surface  of  the  femur. 
From  the  middle  of  this  incision  make  a  transverse  cut  directly  backwards  for 
a  short  distance. 

Step  2. — Expose  the  anterior,  outer,  and  posterior  surfaces  of  the  upper  end  of 
the  femur  by  means  of  the  periosteal  elevator  until  the  trochanter  minorcan  be  felt. 

Step  3. — Pass  a  chain  or  Gigli  wire  saw  around  the  femur  between  the  major 
and  minor  trochanters,  (a)  Make  a  A  or  U-shaped  section  of  the  bone  (Fig. 
1229).  Divide  the  upper  end  of  the  lower  fragment  transversely,  removing 
a  segment  of  bone  one-eighth  of  an  inch  thick  at  its  outer  and  inner  margins. 
With  chisel  and  forceps  round  the  upper  end 
of  the  lower  fragment  so  as  to  fit  into  the 
cavity  in  the  upper  fragment. 

Step  4.- — Close  the  wound  and  treat  as  a 
compound  fracture.  Sayre's  object  was  to 
obtain  a  mobile  joint,  but  one  can  hardly  ex- 
pect much  success  from  the  original  opera- 
tion. The  author  suggests  the  following 
modification  of  the  Sayre  method: 

Step  I. — Make  a  V-shaped  incision  having 

the  trochanter  midway  between  its  anterior 

and  posterior  limbs,  reaching  from  immedi-         ^  ,      ^     r  i    •     ri- 

^  '.  °  .  I'IG.  1226. — Anchylosis  of  hip. 

ately  above  to  a  point  about  5  or  6  inches 
below.  The  open  end  of  the  V  incision  is  directed  upwards  and  the  distance 
between  the  two  vertical  portions  of  the  V  is  about  2)^  to  3  inches.  Reflect 
upwards  the  V-shaped  flap  which  must  consist  of  skin,  subcutaneous  tissue, 
and  fascia  lata  (as  in  Murphy's  operation). 

Step  2. — Pass  a  Gigli  wire  saw  around  the  femur  between  the  two  trochanters 
and  divide  the  bone  transversely  (the  division  may  be  made  with  an  osteotome). 

Step  3. — With  a  gouge  and  rongeurs  excavate  a  bowl-shaped  depression 
in  the  mass  of  fused  bone  (trochanter  major,  head  and  neck  of  femur  and  ilium) 
which  represents  the  anchylosed  hip. 

Step  4. — Separate  the  fascia  lata  from  the  reflected  V-shaped  flap,  leaving 
it  attached  by  its  base.     With  this  flap  line  the  newrmade  cotyloid  cavity. 

Step  5. — With  rongeurs,  etc.,  round  ofi  the  upper  end  of  the  lower  fragment 
of  femur  and  fit  it  into  the  new  cotyloid  cavity. 

Step  6. — Close  the  wound.  Apply  dressings  and  extension.  When  the 
wound  is  healed  begin  motion. 

IV.  Subtrochanteric  Osteotomy. — Advantages  over  the  supra-  or  inter- 
trochanteric operation:  (a)  Ease  in  performance.  (6)  Remoteness  from  articula- 
tion (important  in  tuberculous  disease),  (c)  Section  is  below  insertion  of 
the  psoas  muscle.  If  this  muscle  could  act  on  the  lower  fragment  it  might  cause 
recurrence  of  the  mal-position. 


998 


ANCHYLOSIS   HIP 


(A)  Transverse  Linear  Subtrochanteric  Osteotomy  (Gant's  Operation). — 
Step  I. — At  a  point  four  lingers'  breadth  below  the  lip  of  the  great  trochanter 
over  the  external  surface  of  the  femur  make  a  vertical  incision  down  to  the 
bone.  The  incision  must  be  of  sufl5cient  length  to  permit  the  easy  introduction 
of  an  osteotome. 

Step  2. — Introduce  the  osteotome  with  its  cutting  edge  parallel  to  the  wound; 
when  the  osteotome  reaches  the  bone,  turn  it  so  that  its  cutting  edge  becomes 
transverse  to  the  long  axis  of  the  bone.  Cut  through  the  bone  as  in  supra- 
condyloid  osteotomy  (Fig.  1230). 


Fig.  1227. — Arthroplasty.     {Murphy.) 


Step  3. — Remove  the  osteotome.  It  is  usually  unnecessary  to  insert  sutures. 
Place  the  limb  in  good  position.     Apply  dressings  and  extension. 

N.  B. — The  bone  section  may  be  made  with  an  Adams's  or  Jones'  saw 
instead  of  with  an  osteotome. 

(B)  Oblique  Linear  Subtrochanteric  Osteotomy  (Terrier,  Hannequin). — 
Step  I. — Make  a  vertical  incision  5-6  inches  in  length  along  the  middle  of 
the  outer  surface  of  the  femur  from  the  top  of  the  trochanter  major  down- 
wards. Separate  the  periosteum  from  the  bone  over  its  anterior  and  external 
surfaces  corresponding  to  the  line  of  section  of  the  bone. 


OSTEOTOMY    HIP 


999 


Step  2. — With  an  osteotome  or  chisel,  cut  a  groove  across  the  outer  surface 
of  the  femur  immediately  below  the  great  trochanter.  This  groove  prevents 
slipping  of  the  osteotome  when  the  oblique  section  is  begun.  Using  this  groove 
as  a  starting-point,  divide  the  bone  obliquely  from  above  downwards  and  in- 


FlG. 


1228. — Rhea  Barton's 
osteotomy. 


Fig.  1229. — Sayre's 
osteotorA}'. 


Fig.  1230. — Gant's 
osteotomy. 


wards.  The  antero-posterior  plane  of  section  ought  not  to  be  exactly  straight 
but  ought  to  be  slightly  oblique  from  in  front  backwards  and  inwards.  This 
gives  better  apposition  of  the  fragments  when  extension  is  applied  (Figs.  1231 
and  1232). 


Fig.  1231.  Fig.  1232. 

Figs.  1231  and  1232. — Oblique  osteotomy.     {Hoffa.) 


The  advantage  to  be  gained  from  the  obliquity  of  section  is  that,  when 
much  shortening  of  the  limb  is  present,  extension  may  cause  the  divided  sur- 
faces to  slide  on  each  other,  and  thus  give  some  lengthening  while  the  fragments 
still  remain  in  apposition. 


lOOO 


ANCHYLOSIS    HIP 


(C)   Linear  Oblique  Trochanteric  Osteotomy  (Berger's  Operation). — The 

operation  is  almost  identical  with  the  preceding,  but  the  line  of  section  is  as 
shown   in   Figs.    1233,    1234.     The   technic  of  Berger's  operation  is  diflScult 


Fig.  1233.        I'^iG.  1234-  Fig.  1235. 

Figs.  1233,  1234  and  1235. — Oblique  trochanteric  osteotomy. 


{Jones. 


but  the  use  of  Jones'  saw  greatly  simplifies  it  as  the  hook  at  the  end  of  the 
blade  prevents  transfixion  of  the  tissues  and  also  prevents  the  saw  escaping 
from  its  groove  in  the  bone.  Robert  Jones  has  frequently  performed  this 
operation  with  complete  success  in  cases  where  besides  flexion  there  was  much 


Fig.   1236. — Abduction  splint.     (Jones.) 


adduction  with  pelvic  tilting.  After  dividing  the  bone  he  cuts  the  adductors 
subcutaneously  and  in  the  case  of  a  youth  or  adult  applies  traction  by  means 
of  pulleys.     By  this  traction  an  inch  or  more  of  true  lengthening  may  often  be 


OSTEOTOMY   HIP 


lOOI 


obtained  (Fig.  1235):  After  applying  proper  dressings  he  places  the  leg  in  an 
abduction  splint  (Figs.  1236  and  1237),  which  is  arranged  so  as  to  keep  up  the 
extension.  The  degree  of  abduction  desired  depends  on  the  amount  of  short- 
ening and  of  pelvic  tilting,  i.e.,  the  amount  of  true  shortening.  Fig.  1238  shows 
clearly  how  abduction  may,  by  tilting  of  the  pelvis,  give  apparent  lengthening 
to  a  truly  shortened  limb.  The  patient  must  be  kept  in  the  splint  for  seven  or 
eight  weeks  or  until  bony  union  is  complete.  Jones,  following  his  uncle, 
H.  O.  Thomas,  and  Rushton  Parker,  does  not  fear  dividing  the  bone  through 
inflamed  tissue  when  this  is  necessary.  After  bony  union  is  secured  and  the 
splint  removed  the  limb  should  be  allowed  to  leave  the  abducted  position  slowly, 
and  exercise  should  be  prescribed  to  depress  the  pelvis  on  the  affected  side  and 
so  obtain  apparent  lengthening  of  the  short  limb. 


Fig.   1237. — Abduction  splint.     (Jones.) 


(D)  Cuneiform  Subtrochanteric  Osteotomy. — Step  i. — Make  a  2-  to  3-inch 
vertical  incision  over  the  external  surface  of  the  femur,  having  its  middle 
at  a  point  about  four  fingers'  breadth  below  the  tip  of  the  trochanter  major. 
Retract  the  edges  of  the  wound  and  reflect  the  periosteum  over  an  area  involving 
the  width  of  the  bone. 

Step  2. — With  chisel  and  mallet  excise  a  wedge  of  bone.  The  wedge  must 
of  course  be  so  placed  as  to  correct  the  deformity,  e.g.,  if  there  is  a  deforming 
degree  of  flexion  the  base  of  the  wedge  must  be  on  the  posterior  surface  of  the 
bone;  to  correct  adduction  the  base  of  the  wedge  must  be  external  (Fig.  1239). 
A  modification  of  cuneiform  is  trapezoidal  osteotomy  and  is  sufficiently  ex- 
plained by  Figs.  1240  and  1241. 

Step  3. — Straighten  the  bone.     Introduce  a  few  sutures.     Apply  dressings. 
Immobilize. 


1002 


ANCHYLOSIS   HIP 


Whitman  advises  cuneiform  osteotomy  at  the  level  of  the  lesser  trochanter 
in  young  children  with  coxa  vara.  He  writes:  "In  childhood  the  neck  of  the 
femur  is  short  and  the  strain  to  which  it  is  likely  to  be  subjected  slight,  thus 
operative  treatment  may  be  indicated  as  a  prophylactic  measure  while  in  adoles- 
cence operative  treatment  may  be  deferred  until  the  progression  of  the  de- 


FlG.  1238. — Diagram  showing  how  abduc- 
tion gives  apparent  lengthening  to  a  limb. 


Fig.   1239. — Cuneiform  subtrochanteric 
osteotomy.     {Berger  and  Banzet.) 


formity  has  ceased.  In  the  technic  of  this  procedure  there  are  several  points  of 
importance.  First,  all  restriction  of  abduction  of  ligamentous  or  muscular 
origin,  must  be  overcome  by  vigorous  manipulation  before  the  operation  on 
the  bone,  otherwise  it  will  be  difficult  to  bring  the  two  fragments  into  proper 
apposition.  The  base  of  the  wedge  should  be  about  three-quarters  of  an  inch 
in  breadth,  directly  opposite  the  trochanter  minor;  the  upper  section  should  be 
practically  at  a  right  angle  with  the  shaft,  the  lower  being  more  oblique  (Fig. 


Fig.  i24or. 
Figs.  1240  a^sd  1241. — Trapezoidal  osteotomy. 


Fig.  1241. 

{Berger  and  Banzet.) 


1242).  The  cortical  substances  on  the  inner  aspect  of  the  bone  should  not  be 
divided,  but,  reinforced  by  the  cartilaginous  trochanter  minor,  should  serve  as 
a  hinge  on  which  the  shaft  of  the  femur  is  gently  forced  outwards,  until  the 
opening  is  closed  by  the  apposition  of  the  fragments  after  the  upper  segment 
has  been  fixed  by  contact  with  the  margin  of  the  acetabulum  (Fig.  1242),  thus 
the  continuity  of  the  bone  is  preserved.  The  leg  is  then  held  in  the  attitude 
of  extreme  abduction,  by  means  of  a  plaster  spica  bandage,  which  should 
include  the  foot  also,  until  the  union  is  firm. 

"The  opportunity  for  treatment  of  coxa  vara,  in  earliest  childhood,  is  rarely 


JONES     OPERATION 


1003 


oflfered.  It  is  usually  the  direct  result  of  rachitis,  and  in  the  early  stage,  at 
least,  it  is  probably  accompanied  by  other  rachitic  distortions.  It  would  be 
well,  therefore,  to  examine  the  hip-joints  of  rachitic  children,  especially  those 
who  present  the  deformity  of  genu  valgum  with  reference  to  this  distortion." 


Fig.  1242. — Whitman's  operation.     (Whitman.) 


Fig.  1243. 

Figs.  1243  axd  1244. 


Fig.  1244. 

(Jones.) 


-R.  Jones'  operation. 

Jones's  Operation. — In  bony  anchylosis  of  the  hip  following  tuberculosis 
or  sepsis  and  in  certain  forms  of  coxitis,  e.g.,  malum  coxae  senilis,  where  the 


I004 


ANCHYLOSIS    HIP 


body  weight  acting  on  the  head  of  the  bone,  and  articular  friction  keep  the 
disease  active,  Robert  Jones  produces  a  pseudo-arthrosis  without  disarticulating 
the  head  of  the  femur.  The  operation  produces  much  less  shock  than  does  ex- 
cision of  the  head  of  the  bone  and  in  suitable  case  has  given  excellent  functional 
results. 


Fig.  1245.  Fig.  1246. 

Figs.  1245  and  1246. — R.  Jones'  operation.     {Jones.) 


Fig.  1247. — R.  Jones'  operation.     {Jones.) 

Step  I. — Make  a  6-inch  longitudinal  incision  along  the  outer  surface  of  the 
upper  end  of  the  femur.  One-half  of  the  incision  is  above  the  mid-point  of  the 
upper  border  of  the  trochanter  major  and  one-half  is  below.  This  cut  in  its 
lower  half  penetrates  to  the  periosteum  or  bone.     Retract  the  soft  parts. 

Step  2. — Incise  the  periosteum  transversely  at  the  base  of  the  trochanter 
just  below  the  insertion  of  the  gluteal  muscles.     From  this  line  cut  through  the 


POSTERIOR   DISLOCATION    HIP  IOO5 

trochanter  to  its  junction  with  the  femoral  neck,  using  a  saw  or  a  wide  osteotome 
(Fig.  1243).     Retract  the  separated  trochanter  upwards. 

Step  3. — Open  the  joint.  Divide  the  neck  of  the  femur  near  the  head  of  the 
bone  with  an  osteotome  (Fig.  1243). 

Step  4. — Exert  strong  extension  on  the  femur.  Apply  the  cut  surface  of  the 
separated  trochanter  to  the  cut  surface  of  the  neck  of  the  femur  and  fix  it  there 
with  a  screw  nail  (Fig.  1244).  This  fixes  the  trochanter  to  the  head  of  the  femur 
which  is  still  in  the  acetabulum. 

Step  5. — Close  the  wound  with  deep  and  superficial  sutures.  When  there  is 
much  tenderness  it  may  be  necessary  to  remove  a  section  of  the  neck  instead  of 
merely  dividing  it,  so  as  to  avoid  "impinging."  "In  the  case  of  an  anchylosed 
sound  joint  following  sepsis  it  may  be  advisable,  instead  of  dividing  the  neck 
near  the  acetabulum,  to  divide  it  near  the  trochanter  (Fig.  1245)."  Where  there 
has  been  much  injury  due  to  disease  more  bone  may  be  removed  as  shown  in 
Figs.  1246  and  1247. 


CHAPTER  LXXX 
OLD  DISLOCATIONS  OF  THE  HIP 

When  a  dislocation  of  the  hip  has  remained  unreduced  for  a  few  weeks  it  has 
become  practically  irreducible  by  manipulation  alone.  Even  recent  dislocations 
may  resist  manipulative  reduction.  The  principal  conditions  or  lesions  pre- 
venting reduction  are:  (a)  The  filling  of  the  cotyloid  cavity  with  fibrous  tissue 
which  often  becomes  osseous,  {h)  The  interposition  between  the  femur  and 
the  acetabulum  of  shreds  of  capsule,  fascia,  muscle,  etc.,  to  which  may  be  at- 
tached fragments  of  bone  torn  from  the  trochanter  or  broken  off  the  rim  of  the 
acetabulum. 

(c)  Changes  in  the  shape  of  the  head  of  the  femur  due  to  its  adaptation 
to  new  surroundings,  also  fixation  of  the  femoral  head  in  a  new-formed 
acetabulum. 

{d)  The  femoral  head  may  be  grasped  tightly  in  a  collar  formed  by  the  small 
external  rotator  muscles. 

(e)  The  muscles,  ligaments,  and  fascia  surrounding  the  dislocated  bone 
adapt  themselves  to  their  new  conditions,  hence  they  are  contracted  or  shortened 
in  places  and  so  obstruct  reduction. 

(/)  Fractures  of  the  head  of  the  bone  and  even  of  the  shaft  seriously  interfere 
with  reduction. 

I.  Posterior  Dislocations. — ^Method  A. — Step  i. — Make  a  5-inch  incision 
over  the  region  of  the  acetabulum  along  the  posterior  portion  of  the  trochanter 
major  (Fig.  1248).  Divide  the  tissues  attached  to  the  posterior  margin  of  the 
trochanter;  while  doing  this  hug  the  bone. 

Step  2. — Expose  and  clean  out  the  acetabulum.  If  necessary  for  reduction 
remove  the  parts  of  posterior  wall  of  the  acetabulum  with  chisel  or  rongeurs. 
This  assists  reduction  and  provides  for  drainage. 

Step  3. — ^Loosen  the  head  of  the  femur  from  its  surroundings  by  manipula- 
tion, by  blunt  dissection,  and,  if  necessary,  by  sharp  dissection. 


ioo6 


OLD    DISLOCATIONS    OF    THE    HIP 


Step  4. — Reduce  the  dislocation  by  manipulation  of  the  limb  and  by  direct 
pressure,  etc.,  on  the  head  of  the  bone. 

Step  5. — Provide  for  drainage.  Close  the  wound.  Dress.  Apply  ex- 
tension. While  operating  remember  that  the  great  sciatic  nerve  is  sometimes 
picked  up  by  the  dislocated  femur  and  passes  as  a  tight  band  over  the  neck 
of  the  bone  (Fig.  1249)  and  is  thus  in  distinct  danger. 

Method  B. — A.  von  Bergmann  ("Archiv  fur  khn.  Chir.,"  Ixix.  592)  advises 
the  use  of  Larghi's  incision  in  cases  of  the  old  hip  dislocation  whether  traumatic 
or  congenital  in  origin. 

Step  I. — Make  an  incision  parallel  to,  and  immediately  below  the  crest  of  the 
illium  from  the  posterior  inferior,  past 
the  anterior  superior  spine  to  the  an- 
terior inferior  spine  between  the  tensor 
vaginae  femoris  and  sartorius  muscle. 
This  exposes  the  origin  of  the  gluteus 
maximus  and  medius. 


Fig. 


-Exposure  of  dislocated  hip. 
{.After  Hoffa.) 


Fig.  1249. — Posterior  dislocation  of  hip. 
Sciatic  nerve  stretches  over  neck  of  femur. 
{Allis.) 


Step  2. — Corresponding  to  the  skin  incision,  divide  the  gluteus  maximus 
medius  and  minimus  close  to  their  origin,  but  preserve  the  periosteum  until  the 
top  of  the  sciatic  notch  is  reached;  at  this  level  divide  the  periosteum  and  reflect 
it  also  downwards  along  with  the  overlying  soft  parts  (this  preserves  the  superior 
gluteal  artery  from  injury).  Continue  the  dissection  or  separation  downwards 
subperiosteally  until  the  acetabulum  is  well  exposed. 

Step  3. — After  exposure  of  the  acetabulum,  separate  the  soft  parts  from  both 
trochanters  by  division,  under  guidance  of  the  eye,  of  the  muscular  insertions. 
To  do  this  various  manipulations  of  the  thigh  are  necessary  so  as  to  make 
prominent  the  dislocated  head  of  the  femur. 

Step  4. — Examine  the  acetabulum.     If  necessary  prepare  it  for  the  reception 


ANTERIOR    DISLOCATION    HIP  IOO7 

of  the  head  of  the  femur.  By  manipulation  and  traction  reduce  the  dislocation. 
Various  tenotomies  may  be  necessary  to  permit  of  reduction. 

Step  5. — Close  the  wound  with  or  without  drainage.     Dress. 

Method  C. — Cheyne  and  Burghard  recommend  anterior  arthrotomy.  M. 
L.  Harris  uses  the  same  route.  In  one  case  Spencer  found  that  it  would  have 
been  impossible  to  reach  and  clear  the  acetabulum  through  a  posterior  incision 
without  resecting  the  head  of  the  femur. 

Step  I. — Make  a  4-inch  incision  downwards  and  forwards  from  just  beneath 
the  anterior  superior  spine  and  between  the  tensor  vaginae  femoris  and  the 
sartorius. 

Step  2. — Separate  the  above-mentioned  muscles^nd  so  expose  the  region  of 
the  head  and  neck  of  the  femur.  "In  order  to  get  satisfactory  access  to  the 
acetabulum,  it  will  generally  be  found  necessary  to  detach  some  of  the  muscles 
from  the  ilium.  Division  of  the  tensor  vaginae  femoris  and  the  anterior  part  of 
the  gluteus  minimus  may  be  necessary,  as  they  will  probably  be  somewhat 
shortened." 

Step  3. — Incise  the  joint  capsule  near  its  insertion  into  the  neck  of  the  femur. 
Divide  the  Y-Ugament  and  obstructive  bands.     Clean  out  the  acetabulum. 

Step  4. — Reduce  the  dislocation.  It  may  be  necessary  to  divide  the  tendon 
of  the  obturator  internus  before  success  is  attained.  Close  the  wound  without 
drainage  if  hemostasis  is  complete  and  asepsis  assured;  if  necessary  posterior 
drainage  may  be  provided. 

After-treatment. — ^Whatever  method  of  operating  is  chosen,  extension  by 
weight  and  pulley  should  be  applied.  At  an  early  date  begin  gentle  passive 
motion.  As  soon  as  the  wound  has  nearly  healed,  change  the  direction  of  the 
extension  from  day  to  day;  e.g.,  at  first  the  extension  is  directly  in  the  Hne  of 
the  body,  change  it  so  that  the  hip  is  sUghtly  flexed,  then  make  the  extension  in 
such  a  manner  that  there  is  a  Httle  abduction,  and  so  on,  changing  the  position 
sHghtly  every  day.  Passive  movements  must  be  employed  daily,  unless  signs 
of  inflammation  are  present  in  the  wound.  At  as  early  a  period  as  possible 
after  heaUng  of  the  wound  is  complete,  active  movements  should  be  initiated. 
Too  much  importance  cannot  be  placed  on  thorough  after-treatment. 

II.  Anterior  Dislocations. — ^Perhaps  the  most  practical  way  to  describe  the 
operative  reduction  of  anterior  dislocations  will  be  to  give  a  resume  of  a  case 
operated  on  and  reported  by  Endlich  ("Archiv  fiir  klin.  Chir.,"  Ivi,  585). 
Male,  thirty-seven  years  of  age.  Obturator  dislocation  of  three  months'  dura- 
tion. Incision  along  the  lower  (posterior)  edge  of  the  gracihs  from  the 
symphysis  pubis  downwards.  The  head  of  the  femur  was  reached  after  the 
adductors  were  penetrated.  The  femoral  head  lay  in  a  very  firm  capsule  of 
fibrous  tissue  containing  many  fragments  of  bone. 

Owing  to  the  depth  of  the  wound  and  density  of  tissues  the  bone  could  not 
be  freed  sufficiently.  The  patient  was  turned  on  his  right  side.  Langenbeck's 
incision,  six  inches  long,  was  made,  beginning  below  the  trochanter  major  and 
running  upwards  and  backwards  towards  the  posterior  superior  iliac  spine.  Af- 
ter penetration  of  the  gluteal  muscles  the  acetabulum  was  reached  and  found 
filled  with  firm  fibrous  tissue  which  was  removed.  The  femoral  head  lying  in 
front  of  the  acetabulum  was  freed  from  the  adherent  soft  parts  by  blunt  and  sharp 


IOo8  OLD    DISLOCATIONS    OF    THE    HIP 

dissection.  Much  scar  tissue  containing  shell-like  fragments  of  bone  was  re- 
moved. After  removal  with  the  chisel  of  a  portion  of  the  anterior  edge  of  the  coty- 
loid cavity  opposite  the  femoral  head,  reduction  by  manipulation  was  successful. 
Both  wounds  were  loosely  packed  with  gauze.  Dressings  and  extension  applied. 
The  result  was  at  first  disappointing,  but  poverty  forcing  the  patient  (a  laborer) 
to  work,  his  hard  labor  proved  the  best  after-treatment  and  the  outcome  was 
most  gratifying.  In  such  a  case  as  the  above  it  probably  would  be  better  to 
omit  the  first  (internal)  cut  made  by  Endlich  and  content  one's  self  with  the 
Langenbeck  incision. 

Dislocation  of  the  Hip  Complicated  by  Fractures. — Fracture  of  the  shaft 
of  the  femur  complicating  dislocation  may  hinder  reduction  by  preventing  the 
use  of  the  bone  as  a  lever,  and  thus  compel  operation. 

When  there  is  extra-capsular  fracture  of  the  neck  of  the  femur,  expose  the 
bone,  if  possible  reduce  the  dislocation,  and  then  treat  the  fracture  secundum 
artem  (preferably  by  the  appHcation  of  a  buried  metal  splint).  If  reduction  of 
the  dislocation  is  impossible  or  improper,  the  separated  head  of  the  bone  may 
be  excised,  or  if  it  is  causing  no  pressure  symptoms  and  will  apparently  not  in- 
terfere with  the  ultimate  result  it  may  be  left  in  situ,  the  surgeon  aiming  to 
obtain  a  useful  pseudarthrosis. 

Intracapsular  fracture  compHcating  dislocation  usually  calls  for  excision 
of  the  head  of  the  bone. 

When  operative  reduction  is  impossible  or  seems  too  severe  a  tax  on  the 
patient,  excision  of  the  head  of  the  bone  may  be  indicated.  Osteotomy  may 
be  practised  instead  of  excision.  The  aim  of  this  operation  is  to  correct  dis- 
abling deformity  and  it  may  be  performed  in  such  a  fashion  as  to  provide  a  new 
joint  (see  Osteotomy).  Reduction  when  proper  is  of  course  the  operation  of 
choice.  Excision  is  preferable  to  osteotomy  when  the  displaced  bone  is  causing 
symptoms,  e.g.,  pain  and  paralysis  from  pressure.  Osteotomy  may  be  prefer- 
able in  the  absence  of  the  above  troubles  and  when  it  is  doubtful  if  the  patient's 
strength  is  equal  to  the  strain  involved  in  the  operation  of  excision,  and  when 
disabling  deformity  is  present  resulting  from  the  malposition.  Sometimes 
the  malposition  may  be  corrected  to  a  practical  extent  by  non-operative  treat- 
ment. This  is  well  worth  trying.  When  the  dislocated  head  is  not  causing 
pressure  symptoms  and  when  after  exposure  reduction  is  impossible,  it  is  not 
always  necessary  to  excise  the  head  of  the  bone.  "The  best  thing  is  probably 
to  try  and  form  a  new  acetabulum  upon  the  iUac  bone,  in  the  new  position  that 
the  head  of  the  bone  occupies,  and  to  so  substitute  a  stable  and  movable  joint 
for  the  unstable  and  useless  one  resulting  from  the  dislocation.  To  do  this  a 
portion  of  the  pelvis  is  gouged  away  opposite  the  head  of  the  bone  until  a 
shallow  bed  is  formed  in  which  the  head  can  lie.  Instead  of  removing  the 
portions  of  bone  so  raised,  it  is  well  to  simply  gouge  them  upwards  and  then  bend 
them  at  right  angles  to  the  pelvis,  so  that  they  form  a  sort  of  buttress,  pre- 
venting the  head  of  the  bone  being  pulled  farther  up.  In  the  course  of  a  few 
weeks  considerable  callus  is  thrown  out  around  the  portions  of  bone  detached 
in  this  way,  and  thus  an  obstacle  to  the  further  dislocation  of  the  head  is 
obtained"  (Cheyne  and  Burghard). 


ETIOLOGY   AND   PROGNOSIS  lOOQ 

CHAPTER  LXXXI 
CONGENITAL  LUXATION  OF  THE  HIP 

GwiLYM  G.  Davis  and  F.  D.  Dickson 

There  are  some  afifections  which,  without  doing  special  harm,  the  practising 
physician  or  general  surgeon  can  deliberately  ignore  and  relegate  to  the  care 
of  the  specialist,  but  a  congenital  luxation  of  the  hip  is  not  one  of  them.  Al- 
though the  treatment  can  be  intrusted  to  the  specialist,  it  is  incumbent  on  those 
who  first  see  these  cases  to  recognize  their  serious  character,  and  this  in  too 
many  cases  they  fail  to  do.  The  affection  is  a  frequent  one;  its  manifestations 
are  obscure,  especially  in  its  early  stages;  untreated  it  never  undergoes  spon- 
taneous cure,  but  progressively  gets  worse,  deforming  and  even  disabling  the 
patient.  Failure  to  recognize  the  affection  and  delay  in  instituting  treatment 
increase  the  difficulty  of  remedying  it  and  may  even  render  the  patient  a 
permanent  and  more  or  less  helpless  cripple.  For  these  reasons  the  general 
physician  and  surgeon  should  have  a  sufficient  knowledge  of  it  to  enable  him  to 
suspect  and  possibly  diagnose  its  presence  and  inform  the  parents  as  to  the 
course  to  be  pursued  in  having  it  properly  treated. 

Etiology. — The  cause  of  this  affection  is  unknown.  In  some  cases  the 
luxation  is  produced  at  the  time  of  birth,  but  few,  however,  can  be  accounted 
for  in  this  manner;  in  some  heredity  seems  to  play  a  part;  intra-uterine  disease 
has  also  been  held  to  be  a  factor,  but  this  has  not  been  generally  accepted. 
Retarded  development  does  not  account  for  it.  Perhaps  the  most  favorably 
received  theory  is  that  the  luxation  is  the  result  of  slowly  acting  force  exerted 
during  intra-uterine  life.  This  is  supposed  to  occur  in  cases  in  which  there  is  a 
lack  of  amniotic  fluid,  thus  allowing  the  uterine  walls  to  act  more  directly  and 
forcibly  on  the  extremities.  Codivilla  states  that  they  are  flexed,  adducted  and 
rotated  inwardly.  This  condition  existing  for  a  considerable  time  destroys 
the  stability  of  the  joint  and  favors  anatomical  changes;  the  capsule  becomes 
relaxed,  the  acetabulum  shallow  and  the  upper  end  of  the  femur  altered. 
The  preponderance  of  the  affection  in  females — six  or  seven  to  one — -is  ex- 
plained by  the  sexual  anatomical  differences  in  the  pelvis,  which  begin  to 
manifest  themselves  as  early  as  the  fifth  month  of  intra-uterine  life. 

Prognosis. — Some  surgeons  appear  to  consider  congenital  luxation  of  the 
hip  as  not  a  very  serious  affection,  but  with  this  we  cannot  agree.  It  is  de- 
forming, painful,  disabhng,  and  greatly  interferes  with  the  patient's  usefulness 
and  ability  to  earn  a  Hvelihood.  The  affection  is  least  marked  at  birth.  There 
is  no  pain  and  usually  it  is  only  when  the  child  begins  to  walk  that  the  trouble  is 
recognized.  The  gait  of  a  one-sided  luxation  is  a  marked  Hmp;  of  a  double, 
a  distinct  waddle.  Soon  the  back  becomes  hollow.  Perhaps  for  several  years 
the  patient  may  go  about  in  this  condition,  deformed  and  limping,  somewhat 
disabled  but  still  fairly  active.  As  age  advances  the  displacement  becomes 
more  marked.     Pain,  in  various  degrees,  is  experienced.     Difficulty  is  found  in 

64 


lOIO 


CONGENITAL    LUXATION    OF    THE    HIP 


going  up  and  down  stairs  and  walking  long  distances  is  impossible.  After 
puberty  a  rapid  increase  is  noted  and  if  compelled  to  earn  their  livelihood  these 
patients  try  to  obtain  a  sitting  occupation.  Even  then  they  are  sufferers, 
and  from  time  to  time,  at  least  temporarily,  are  compelled  to  rest  in  bed.  While 
there  may  be  intervals  when  they  are  free  from  pain,  slill  they  are  liable  to  be 
disabled  at  any  time,  and  so  they  pass  a  more  or  less  miserable  existence.  If 
pain  is  at  all  constant  it  prevents  them  from  taking  a  sufficient  amount  of 
exercise  and  this  with  advancing  years  causes  them  to  take  on  fat  and  increase  in 
weight  which  all  tends  to  aggravate  their  distress,  and  their  condition  often 
becomes  pitiable. 

Anatomy. — The  bony  changes  are  marked.  The  acetabulum  (Fig.  1250) 
is  less  in  size  than  normal,  it  loses  its  round  form  and  becomes  narrowed  at 
the  sides,  thus  making  it  longer  vertically  than  in  its  horizontal  axis.     The 


Fig.  1250. 


Fig.  12 ^ I. 


cartilage  becomes  thicker,  thus  reducing  the  depth  of  the  acetabulum  and  the 
fat  and  fibrous  tissue  from  the  region  of  the  cotyloid  notch  enroach  upwards  and 
also  help  to  fill  it  up.  The  cartilaginous  rim,  especially  above  and  posterior, 
atrophies  and  this  together  with  the  filling  up  of  the  acetabulum  by  the  fatty 
and  fibrous  tissues  practically,  in  many  cases,  obliterates  the  concavity;  hence 
when  the  head  is  replaced  it  frequently  reluxates.  Sometimes  masses  of  carti- 
lage and  bone  are  fond  in  the  acetabulum  in  operative  cases;  these  are  con- 
sidered by  Lorenz  to  be  out-growths  from  the  posterior  wall. 

The  acetabular  changes  are  frequently  found  at  birth,  though  they  increase 
with  age.  In  old  cases,  sometimes,  more  or  less  bony  out-growths  and  hollows 
exist  above  the  acetabulum,  which  tend  to  make  the  articulation  more  firm 
and  secure. 

The  femur,  also,  at  its  upper  extremity  (Fig.  1251),  while  somewhat  deformed 
at  birth,  is  still  more  deformed  as  age  advances.  The  head  is  smaller  than  nor- 
mal and  flattened  on  its  inner  posterior  portion.  In  some  cases  it  is  more  or  less 
pointed  while  in  others  it  is  markedly  flattened,  having  a  somewhat  mushroom- 
like shape.     The  neck  shortens,  and  its  angle  with  the  shaft  decreases  from  130° 


SYMPTOMS  lOII 

frequently  to  a  right  angle.  It  also  becomes  anteverted  from  the  io°  or  15° 
of  normal  to  almost  or  quite  90°.  In  extreme  cases  it  may  even  point  anteriorly 
instead  of  inwardly. 

The  pelvis,  while  at  birth  nearly  normal,  as  years  progress  becomes  distorted; 
it,  too,  is  atrophied.  The  true  pelvis  is  enlarged,  especially  in  its  transverse 
diameter,  the  subpubic  angle  is  increased,  the  promontory  of  the  sacrum  more 
projecting,  and  the  tuber  ischii  wider  apart.  In  one-sided  luxations  the  asym- 
metry is  marked,  one  side  being  distorted  while  the  other  is  more  nearly  normal. 
The  pelvis  tilts  downwards,  lordosis  is  marked,  and  the  abdomen  protrudes. 
These  conditions  with  the  accompanying  distortions  sometimes  give  rise  to 
difficulties  in  parturition,  but  not  frequently. 

The  capsule  is  stretched  and,  being  compressed  between  the  head  and  side 
of  the  ilium,  it  may  fuse  or  become  united  with  the  periosteum  beneath.  The 
outer  side  of  the  capsule  is  stretched  across  the  acetabulum  and  in  rare  cases  is 
fused  with  the  fatty  fibrous  mass  occupying  it.  Between  the  original  ace- 
tabulum and  the  head  of  the  bone  the  capsule  may  be  contracted,  making  the 
joint  cavity  hour-glass  shape.  The  ligamentum  teres,  while  present  at  birth, 
soon  atrophies.  In  rare  instances  it  is  thickened,  but  usually  it  is  small  in  size 
or  even  lacking.  When  it  persists  it  is  found  as  a  long,  flat  ribbon-like  strand 
(Fig.  1250).  Shortening  of  the  muscles  was  formerly  regarded  as  the  greatest 
obstacle  to  reposition,  and  the  cutting  operations  were  largely  founded  on  this 
supposition.  The  head  being  above  and  posterior  to  its  normal  position,  it 
is  evident  that  the  muscles  going  up  and  back  from  the  region  of  the  trochanters. 
i.e.,  the  glutei  will  be  somewhat  shortened,  also  the  muscles  going  down 
anteriorly  from  the  pelvis  to  the  femur,  particularly  the  adductors;  but  this 
shortening  is  of  Httle  practical  moment,  because  it  is  re;3,dily  overcome  in  the 
manipulations  used  in  reduction  without  the  necessity  of  especially  rupturing 
them,  as  does  Lorenz,  or  dividing  them,  as  did  Broadhurst,  Hoffa,  and  others. 

Symptoms  and  Diagnosis. — The  history  is  that  of  a  congenital  affection, 
not  an  acquired  one,  and  an  absence  of  traumatism.  This  aids  in  excluding 
hip  disease  and  coxa  vara.  A  marked  limp  appearing  when  the  child  begins 
to  walk  is  usually  the  first  thing  noticed  and  causes  a  physician  to  be  consulted. 
With  the  limp  is  associated  a  sinking  of  the  trunk  and  a  rolling  motion,  which  in 
bilateral  cases  produces  a  distinctly  waddling  gait.  It  is  peculiar  and  markedly 
different  from  that  due  to  coxalgia,  coxa  vara,  or  simple  shortening,  but  re- 
sembles more  that  of  paralysis.  It  is  usually  marked  from  the  time  the  child 
begins  to  walk  and  may  vary  in  degree  at  different  periods  of  life.  Pain  is 
often  lacking  in  young  children  but  they  frequently  tire  readily,  and,  as  the 
patient  grows  older,  it  may  become  so  distressing  as  to  necessitate  confinement 
to  bed  for  considerable  periods  of  time.  The  affection  is  best  diagnosed  by  its 
physical  signs.  It  should  be  remembered  that  the  head  of  the  femur  is  above 
and  usually  behind  the  acetabulum.  This  tends  to  make  the  trochanter  of  the 
affected  side  prominent.  In  a  unilateral  luxation  this  may  be  somewhat  con- 
cealed by  an  inclination  of  the  trunk  towards  the  affected  side,  but  in  double 
luxations  (Fig.  1252)  it  is  sufficiently  marked  to  widen  the  space  considerably 
across  the  perineum  from  one  thigh  to  the  other.  In  unilateral  luxations 
(Fig.  1253)  the  tilting  of  the  trunk  towards  the  affected  side  will  be  evident. 


IOI2 


CONGENITAL   LUXATION    OF   THE    HIP 


There  is  no  turning  inwards  of  the  foot  such  as  is  present  in  traumatic  luxations. 
Viewed  from  the  side  there  will  be  a  hollowness  of  the  back  (Fig.  1254), 
lordosis,  due  to  the  tilting  of  the  pelvis  forward  and  an  accompanying  promi- 
nence of  the  buttocks.     In  unilateral  cases  a  twisting  of  the  pelvis  may  be 


Fig.  1252. 


Fig.  1253. 


Fig.  1254. 


noticeable,  and  in  order  to  compensate  for  the  shortening  of  the  aflfected  limb 
the  opposite  one  may  be  slightly  flexed  both  at  the  hip  and  knee.  A  tendency 
to  flexion  of  these  joints  exists  also  in  the  affected  limb  and  particularly  so  in 
the  older  cases  of  double  luxation;  when  the  patient  stands  upright,  flexion  of 
both  hips  and  knees  may  be  marked.  This  is  due  to  the  tilting  of  the  pelvis 
forwards. 


Fig.  1255. 


Fig.  1256. 


Viewed  posteriorly  the  increased  breadth  across  the  pelvis  from  one  trochan- 
ter to  the  other  is  noticed  (Fig.  1252);  the  trochanters  are  prominent  and  the 
buttock  beneath  flattened.  In  unilateral  luxation  the  gluteo-femoral  fold  of  the 
affected  side  is  lower  than  that  of  the  sound  side,  and  the  trunk  is  also  inclined 
towards  the  affected  side.  Trendelenburg  has  pointed  out  that  if  the  child 
stands  on  the  sound  leg  and  flexes  the  affected  one  the  lines  of  the  folds  of  the 


SYMPTOMS 


IO13 


buttocks  will  remain  nearly  level  (Fig.  1255),  whereas  if  it  stands  on  the  affected 
limb  and  flexes  the  sound  one  the  gluteal  fold  on  the  sound  or  flexed  side  will 
drop.     This  is  due  to  the  increased  tilting  of  the  pelvis  in  the  latter  case. 

On  more  closely  examining  the  patient  it  will  be  found  that  by  actual 
measurement  in  unilateral  cases  there  will  be  a  shortening  on  the  affected  side 
which  is  considerable  and  in  old  cases  may  amount  to  one  and  a  half  to  two 
inches.  It  is  rendered  apparent  by  adopting  AUis's  procedure  of  having  the 
patient  flat  on  the  back  and  flexing  the  knees  and  hips  to  a  right  angle,  the  knee 
of  the  sound  side  will  be  seen  to  project  far  above  that  of  the  affected  side  (Fig. 
1256).  If  the  patient  is  seated  on  a  chair  in  front  of  the  examiner  one  knee  can 
be  both  seen  and  felt  to  be  considerably  in  advance  of  the  other.  To  determine 
the  location  of  the  shortening  it  is  necessary  to  compare  a  bony  landmark  of  the 
femur  vnth  one  on  the  pelvis.     For  this  purpose  the  upper  edge  of  the  greater 

Iliacus  Muscle, 

Poupart's  Llg. 

Psoas  Muscle. 

Femoral  A. 

Te moral  V. 

'B morale. 

'Pectineus 

Mus. 


Fig.  1257. 


Fig.  i2t;8. 


trochanter  and  the  anterior  superior  spine  of  the  ilium  are  used.  If  the  meas- 
ured distance  from  the  tip  of  the  greater  trochanter  on  one  side  to  the  corre- 
sponding external  malleolus  is  the  same  as  that  of  the  opposite  side  while  the 
distances  from  the  anterior  superior  spine  to  the  internal  malleolus  on  the  two 
sides  differ,  it  is  evident  that  the  cause  of  this  difference  is  located  above  the 
greater  trochanter  and  that  it  lies  higher  than  normal.  This  may  be  due  to 
either  dislocation,  fracture,  or  disease  affecting  the  head  and  neck  of  the  bone. 
Normally,  the  upper  edge  or  tip  of  the  greater  trochanter  lies  almost  exactly 
on  a  line  drawn  from  the  anterior  superior  spine  to  the  tuberosity  of  the 
ischium — Nelaton's  Hne  (Fig.  1257).  In  congenital  luxations,  the  upper 
edge  of  the  trochanter  is  considerably  above  it,  proportionate  to  the 
amount  of  shortening.  Normally,  the  upper  edge  of  the  trochanter  lies  ob- 
liquely downwards  and  backwards  from  the  anterior  superior  spine,  but  in 
these  luxations  it  is  usually  opposite  the  level  of  the  anterior  spine  and  some- 
times above  it.  What  may  be  called  the  iliotrochanteric  angle  is  lessened  or 
even  abolished.  The  position  of  the  head  of  the  bone  should  be  identified. 
Normally,  it  can  be  recognized  l>'ing  beneath  the  femoral  artery  just  below 


IOI4  CONGENITAL  LUXATION  OF  THE  HIP 

Poupart's  ligament.  The  artery  crosses  the  femoral  head  a  little  internal  to  its 
middle  (Fig.  1258).  If  the  hip  is  grasped  between  the  thumb  anteriorly  and 
fingers  posteriorly,  the  thumb  being  just  external  to  the  artery,  by  rotating 
the  limb  the  head  can  be  felt  moving  under  the  thumb.  In  luxations  the 
head  is  displaced  posteriorly,  upwards  and  outwards.  So  deep  is  it  that  it  is 
more  readily  recognized  by  the  fingers  which  are  posterior  than  by  the  thumb 
which  is  anterior;  this  is  especially  the  case  when  the  limb  is  markedly  rotated 
inwards.  The  range  of  motion  of  the  luxated  hip  is  increased  in  adduction 
while  it  is  decreased  in  abduction.  The  lessened  abduction  is  usually  not  so 
marked  as  in  coxa  vara  (a  lessening  of  the  angle  between  the  neck  and  shaft), 
although  in  some  cases  a  condition  of  coxa  vara  may  be  present  in  which  case 
abduction  would  be  markedly  restricted.  Adduction  may  be  so  much  increased 
as  to  allow  the  thigh  of  the  affected  side  to  be  brought  across  the  groin  of  the 
opposite  one. 

The  looseness  of  the  joint  may  be  demonstrated  with  the  child  lying  on  the 
back,  having  its  limbs  either  extended  or  flexed.  If  the  limb  to  be  examined  is 
extended,  the  surgeon  grasps  the  two  sides  of  the  pelvis  with  his  hands  to  fix  it. 


Fig.  1259. 

On  the  suspected  side  the  thumb  is  placed  on  the  anterior  superior  spine  while 
the  index  finger  touches  the  top  of  the  greater  trochanter.  An  assistant  now 
grasps  the  leg  and  alternately  pulls  it  down  and  pushes  it  up.  If  the  hip  is 
luxated  the  greater  trochanter  will  be  felt  sliding  up  and  down. 

In  examining  the  limb  in  a  flexed  position  (Fig.  1259),  a  method  valuable  in 
children,  the  knee  is  grasped  with  one  hand  and  the  thigh  flexed  to  a  right  angle. 
The  thumb  of  the  other  hand  is  placed  in  front  of  the  anterior  spine  and  the 
fingers  beneath  the  trochanter.  On  pushing  and  pulling  the  femur  with  one 
hand  the  greater  trochanter  is  felt  with  the  other  to  slide  up  and  down  on  the 
side  of  the  pelvis.  Sometimes  in  examining  these  congenitally  luxated  hips  in 
this  manner  a  distinct  grating  or  cracking  can  be  felt. 

While  one  is  usually  able  to  diagnose  the  condition  by  the  physical  exami- 
nation, it  is  nevertheless  desirable  whenever  possible  to  have  a  skiagraph  made. 
This  will  enable  one  to  judge  with  exactness  the' height  of  the  head  in  relation 
to  the  acetabulum  and  to  a  less  extent  the  amount  of  anteversion  of  the  neck,  and 
may  give  considerable  information  concerning  the  formation  of  both  the  head 
and  upper  end  of  the  femur  as  well  as  the  acetabulum.  It  will  not,  however, 
enable  one  to  detect  a  posterior  displacement.  Fortunately,  this  latter  is  almost 
always  associated  with  a  certain  degree  of  upward  displacement  which  can  be 


TREATMENT  IO15 

recognized,  and  a  posterior  displacement  can  usually  be  detected  by  a  careful 
physical  examination. 

Treatment. — In  1826  Dupuytren  stated  that  cure  of  congenital  luxation 
of  the  hip  was  impossible,  but  advised  a  pelvic  girdle  as  a  palliative  measure. 
Later  Landerer  used  a  corset  to  counteract  the  lordosis  and  Langgaard  devised 
a  brace  which  was  fastened  about  the  pelvis,  passed  down  the  thigh  and  pos- 
sessed  a  pad  which  made  screw  pressure  over  the  trochanter. 

Attempts  at  immediate  reposition  were  made  by  Humbert,  but  were  not 
successful,  and  the  subject  was  brought  into  prominence  by  C.  G.  Pravaz,  of 
Lyons,  in  1847.  Instead  of  the  rapid  traction  of  Humbert,  he  used  strong 
continuous  traction  for  four  to  eight  months  and  then  by  means  of  extension, 
abduction,  and  strong  pressure  by  a  large  roll  under  the  trochanter  replaced  the 
head.  Reluxations  he  treated  by  repeated  replacements.  His  results  were  not 
sufl5ciently  good  and  his  methods  were  abandoned,  only  to  be  revived  by  Buck- 
minster  Brown  of  New  York,  who  was  followed  by  Bradford  of  Boston,  Adams 
of  London,  and  others.  The  extension  treatment  was  brought  to  its  greatest 
perfection  by  Max  Schede  and  Mikulicz  in  1894,  both  of  whom  obtained  fairly 
good  results. 

The  operative  treatment  began  about  1840  with  Guerin  who  tenotomized 
the  muscles  attached  to  the  greater  trochanter.  He  was  followed  by  Brodhurst, 
Bouvier,  Barwell,  Pravaz,  Jr.,  Coolidge,  and  others.  Resection  of  the  head  by 
Rose  in  1874  and  Margary,  of  Italy,  in  1882  proved  after  a  full  trial  to  be 
unsatisfactory. 

The  question  of  operative  treatment  was  finally  solved  by  Alfonzo  Poggi,  of 
Bologna,  who  in  1888  replaced  the  head  of  the  femur  in  a  newly  made  acetabu- 
lum by  open  incision.  He  was  followed  by  Hoffa,  who  in  1890  and  subsequently 
systematized  the  technic  and  caused  the  operation  to  be  generally  accepted.  In 
1892  Lorenz  advocated  an  incision  along  the  posterior  edge  of  the  tensor  fasciae 
f  emoris  muscle  instead  of  the  posterior  incision  of  Langenbeck  as  used  by  HoflFa. 
Hoffa  himself  later  adopted  a  straight  incision  along  the  anterior  edge  of  the 
greater  trochanter.  The  cutting  operation  reached  its  acme  in  1894  when  it 
was  advised  by  many  in  preference  to  all  other  measures. 

At  the  International  Congress  in  Rome  in  1894,  papers  were  read  by  Hoffa 
and  Lorenz  advocating  their  cutting  operations.  Kirmisson  and  Mikulicz  in- 
clined to  traction  treatment  and  Paci  gave  a  resume  of  the  work  which  he  had 
previously  published  in  the  "Archivio  di  ortopedia"  in  1890,  1891,  1892,  and 
1893.  He  stated  that  he  had  practised  his  bloodless  reposition  method  in 
twenty-eight  cases,  twenty-three  of  congenital  luxation,  three  of  pathological, 
and  two  of  old  traumatic.  He  claimed  good  results  from  it  in  patients  from 
three  to  twenty-one  years  of  age.  He  presented  the  pelvis  of  a  child  of  seven 
years  in  whom  Nota,  of  Turin,  had  replaced  the  hips  four  months  previously. 
In  one  of  these  hips  there  was  practically  a  perfect  result.  He  also  demonstrated 
his  method  on  a  patient  before  the  assembled  members. 

The  effect  was  magical.  From  this  time  forth  the  bloodless  method  was 
taken  up  and  the  cutting  operation  reserved  for  exceptional  cases.  The  follow- 
ing year  Lorenz,  of  Vienna,  brought  out  his  modification  of  Paci's  method,  and 
some  changes  have  been  introduced  by  various  surgeons  since  that  date. 


ioi6 


CONGENITAL   LUXATION    OF   THE    HIP 


Method  of  Pad.— ("  Transactions  of  Eleventh  International  Medical 
Congress,"  Rome,  1894,  p.  378.)  Paci,  as  he  himself  said,  used  the  ordinary 
circumduction  method  which  had  been  systematized  in  Italy  by  Fabbri.  It 
was  as  follows:  First,  flex  the  thigh  well  on  the  abdomen,  then  push  forcibly 
down  on  the  knee  so  as  to  force  the  head  downwards.  Second,  while  retain- 
ing the  limb  in  the  previous  position  slowly  abduct  the  knee  until  it  is  i^  cm. 


Fig.  1260. 

(6  inches)  away  from  the  side  of  the  body.  Third,  rotate  externally  until  the 
axis  of  the  leg  (held  at  90°  to  the  thigh)  is  perpendicular  to  the  long  axis  of  the 
body.  Fourth,  gradually  extend  the  Hmb  while  being  held  in  external  rotation. 
The  extension  was  carried  as  far  as  was  possible  without  the  head  reluxat- 
ing.  Sometimes  the  thigh  was  bent  over  the  edge  of  the  table  and  force  was 
used,  to  the  extent  in  one  case  of  breaking  the  femur.  The  limb  was  placed 
in  plaster  and  weight  extension  used  for  four  months  and  then  removed  and 

the  patient  kept  on  crutches  for  six 
months  longer. 

Lorenz  Technic. — (Joachimsthal, 
"Handbuch  der  Orthopadischen 
Chirurgie,"  vol.  ii,  169,  etc.)  The 
thigh  is  abducted  until  the  ad- 
ductor muscles  are  tense.  These 
are  then  ruptured  by  direct  pressure 
made  with  the  ulnar  border  of  the 
hand  by  cutting  or  sawing  move- 
ments. In  difl&cult  cases  abducting 
and  rotary  movements  are  made  to  mobilize  the  joint.  Also  traction  may 
be  made,  either  manual  by  the  surgeon  or  instrumental  or  by  two  assistants 
pulling  on  a  skein  of  yarn  looped  around  the  malleoli  or  the  condyles  of  the 
femur.  Counter-traction  is  made  by  fastening  a  sheet  to  the  table  while  the 
perineum  is  protected  by  a  pad  of  spongy  rubber. 

Reduction  (Fig.  1260)  is  to  be  accomplished  by  having  an  assistant  fix  the 
pelvis  by  pressure  on  the  opposite  side;  the  operator  then  grasps  the  hip  with 


Fig.  1 261. 


DAVIS     METHOD 


IOI7 


one  hand,  the  thumb  being  posteriorly  on  the  trochanter,  and  the  flexed  knee 
with  the  other,  the  thigh  being  vertical.  The  trochanter  is  then  pushed  up- 
wards and  forwards  with  one  hand,  while  the  thigh  is  lifted  (traction)  and 
abducted  with  the  other  until  it  is  at  right  angles  to  the  long  axis  of  the  body 
in  the  frontal  plane  or  even  a  little  more.  If  these  manoeuvres  do  not  sufl&ce, 
a  wedge-shaped  block  (its  edge  covered  with  padding)  is  placed  beneath  the 
trochanter  and  the  abduction  is  made  over  this   (Fig.   1261). 

Hoffa  ("  Joachimsthal,"  vol.  ii,  p.  176)  abducted  to  90°  the  flexed  and 
strongly  externally  rotated  thigh.  It  was  moved  to  and  from  the  body,  up 
and  down  like  a  pump-handle  ("  Pumpenschwengel")  until  it  reached  the 
horizontal. 

The  Bartlett  machine  ("Journal  of  Medical  Research,"  x,  440,  1904), 
much  used  in  a  modified  form  in  Boston,  resembles  in  principle  that  of  Max 
Schede.  By  it  traction  is  made  with  a  wanch  and  the  femur  forcibly  abducted 
to  90°.  The  limb  is  then  removed  from  the  apparatus  and  the  luxation  re- 
placed by  manipulation,  or  attempts  may  be  made  to  push  the  head  into 
place  while  traction  is  still  being  made. 

R.  H.  Hibbs  ("New  York  Medical  Jour.,"  April  25,  1908)  fastens  the  patient 
to  a  table  by  two  straps  passing  over  the  crest  of  the  ilia  and  down  between 
the  thighs,  thus  fixing  the  pelvis  firmly.  Then  the  leg  is  extended  on  the 
thigh,  with  the  thigh  held  in  adduction  and  flexion  on  the  abdomen,  thus 
forcing  the  head  below  the  acetabulum.  A  metal  wedge-shaped  block  is 
then  brought  up  through  a  hole  in  the  table  and  adjusted,  by  a  ball-and- 
socket  joint,  against  the  trochanter  so  as  to  direct  the  head  upwards  and  for- 
wards. The  thigh  is  then  extended  and  abducted,  forcing  the  head  to  travel 
upwards,  anteriorly,  into  the  acetabulum.  He  has  used  the  method  in  fourteen 
hips  in  thirteen  children  from  twenty 
months  to  eleven  years  of  age.  The 
limb  is  put  up  in  var}dng  degrees  of 
flexion  and  abduction  and  he  "doubts 
the  necessity  of  any  case  wearing 
plaster  more  than  two  months,  and  at 
the  most  three,  and  in  many  a  shorter 
time."  In  only  one  case  was  there 
reluxation  requiring  a  replacement. 

Author's  Pressure  Method  (G.  G. 
Davis,  "American  Journal  of  Orthopedic 
Surgery,"  Jan.,  1907): 

The  commonly  used  means  of  replacing  a  congenital  luxation  of  the  hip 
is  by  the  Paci-Lorenz  method.  This  is  essentially  a  lever  method,  the  fulcrum 
being  either  the  ilio-femoral  (Y)  ligament,  a  block,  the  hand  as  used  by  Lorenz, 
the  edge  of  the  table  as  used  by  Paci,  or  a  hard  roll  as  used  by  Pravaz.  The 
accidents  accompanying  this  method*  have  been  numerous  and  are  a  constant 
menace.  To  avoid  them  and  yet  to  apply  the  requisite  amount  of  force  the 
writer  substitutes  direct  pressure  for  leverage.  It  is  applied  as  follows:  The 
child  is  placed  on  the  table  face  downwards  with  the  pelvis  resting  on  a  sand-bag 
and  the  leg  hanging  down  over  the  edge  of  the  table.     If  the  table  is  well 


wiiisimmiMiM 

Fig.  1262 


Hi 


ioi8 


CONGENITAL   LUXATION    OF    THE    HIP 


padded  the  sand  pillow  may  be  dispensed  with.  The  thigh  is  then  well  flexed 
and  brought  close  to  the  body  of  the  patient,  the  knee  being  flexed,  and  held 
there  either  by  the  operator  (Fig.  1262)  or  by  assistant  (Fig.  1263).  The 
operator  then  places  the  base  of  the  palms  of  his  hands  on  the  trochanter 
and  head  and  makes  downward  pressure  aided  by  the  weight  of  his  body.  By 
this  means  the  head  is  forced  from  its  posterior  to  an  anterior  position  and,  in 
easy  cases,  the  reduction  is  practically  complete,  sometimes  taking  place  with 
the  usual  jump  or  click.  If  the  case  is  more  difiicult  and  more  abduction  is 
required,  the  patient  may  be  brought  more  towards  the  middle  of  the  table  so 
that  the  knee  and  part  of  the  thigh  are  supported  by  its  edge  and  pressure  again 
appUed.  Still  more  abduction  can  be  obtained  by  placing  a  pad  of  towels 
beneath  the  knee  so  as  to  elevate  it  still  more  (Fig.  1264).  By  this  means 
hyperabduction  (beyond  the  frontal  plane)  can  be  obtained  if  desired.  The 
head  being  low  down  the  thigh  may  still  be  in  a  position  of  marked  flexion.  It 
is  then  flexed  and  extended  by  the  pump-handle  movement  of  Hoffa  until  it  is 
at  right  angles  to  the  long  axis  of  the  body  when  the  plaster  cast  can  be  applied. 


'''Kill!llillli;iliiii;illaiii;iLii!i;iliili 
Fig.  1263. 


Fig.  1264. 


The  limb  can  be  placed  in  either  external  or  internal  rotation.  If  the  latter, 
then  the  cast  extends  below  the  knee.  Traction  and  tearing  or  cutting  of  the 
muscles  are  not  practised  because  unnecessary,  although  in  an  exceptionally 
difficult  case  tenotomy  of  the  adductor  longus  might  be  of  service.  The 
method  has  been  used  in  about  fifteen  cases.  In  one,  age  sixteen  years,  it 
failed.  In  another,  aged  twelve  years  lacking  one  month,  it  took  four  attempts 
to  get  a  satisfactory  amount  of  abduction.  In  the  others,  from  two  to  ten 
and  one-half  years,  satisfactory  reduction  was  accomplished  at  a  single  seance. 

Fixation:  Applying  the  Plaster  Bandage. — Reduction  having  been  ac- 
compUshed,  the  child  is  turned  on  its  back  and  placed  on  a  pelvic  support 
(Fig.  1265)  with  the  limbs  in  the  desired  position,  either  projecting  out  at  right 
angles  to  the  body  or  flexed  or  adducted  to  the  extent  desired.  We  put  the 
limb  up  in  extreme  abduction  for  the  first  dressing  and  invert  it  and  lessen 
the  abduction  at  the  second  dressing.  A  strip  of  flannel  bandage  is  laid  on 
the  leg  next  the  skin,  long  enough  to  project  considerably  beyond  the  edges 
of  the  plaster.  This  is  to  be  used  for  cleaning  purposes,  being  pulled  to  and 
fro  at  intervals  while  the  bandage  is  being  worn. 

The  limb  and  pelvis  are  covered  either  with  a  flannel  bandage  or  stockinette 
and  felt  pads  placed  on  the  sides  of  the  pelvis  and  inner  surfaces  of  the  knee  to 


FLXATION 


IOI9 


Fig.  126^. 


avoid  pressure  sores.  The  plaster  bandage  is  then  applied  in  the  form  of  a 
spica  embracing  the  thigh  and  pelvis.  If  internal  rotation  is  desired,  the 
plaster  must  include  a  part  of  the  leg  below  the  knee.  In  order  to  strengthen 
the  bandage  and  prevent  reluxation  a  strip  of  strap-iron  can  be  placed  in  the 
posterior  part  of  the  bandage  running  down  from  the  pelvis  to  the  thigh.  Felt 
pads  can  be  placed  beneath  this  strip  between  it  and  the  trochanter  so  as  to 
force  and  maintain  the  head  as  far  anterior  as  is  desired  (Fig.  1266).  If  both 
limbs  are  placed  in  internal  rotation  as  suggested  by  Schede  and  advised  by 
Mueller  the  patient  sleeps  on  a  suspended  or  supported  Bradford  frame  (Fig, 
1267)  with  the  legs  hanging  down  over  its  sides.  If  only  one  side  is  involved 
the  patient  can  sleep  on  an  ordinary  bed  with  the  leg  hanging  over  its  edge. 

The  first  plaster  dressing  is  left  on  from  one 
to  three  or  five  months.  If  the  tendency  to  re- 
luxation  is  slight  the  dressings  are  changed  at  short 
intervals;  if  the  tendency  to  reluxate  is  marked 
the  dressings  are  kept  on  longer.  In  favorable 
cases  in  young  children  a  single  dressing  will  sufi&ce. 
In  others  the  limb  will  have  to  be  brought  down 
gradually  at  each  change  of  bandage.  From  three 
months  to  nine  months  or  even  longer  may  elapse 
before  all  retaining  bandages  are  discarded.  Lorenz  has  laid  considerable 
stress  on  subsequent  massage  and  gymnastics,  but  if  the  reposition  and  sta- 
bility of  the  joint  are  good  they  are  not  especially  needed,  especially  if  the 
muscles  have  not  been  unduly  injured  by  a  preliminary  (I  beUeve  unneces- 
sary) mobilization. 

If  both  hips  are  luxated,  nearly  all  surgeons  prefer  to  reduce  them  simulta- 
neously instead  of  treating  them  one  after  the  other.  If  the  hips  are  operated 
on  simultaneously  the  child  is  disabled  on  both  sides 
and  locomotion  is  practically  impossible  until  the  limbs 
are  brought  down  at  subequent  dressings.  If,  how- 
ever, only  one  has  been  operated  on,  then,  if  the  cast 
is  satisfactory,  the  child  can  go  around  on  crutches  or  a 
high  shoe  in  two  or  three  days.  In  cases  near  the  age 
limit  preliminary  weight  extension  in  bed  for  two  to 
four  weeks  with  the  leg  in  an  abducted  position  may 
be  tried. 

In  some  instances,  particularly  in  double  luxations, 
difficulty  may  be  experienced  in  bringing  the  limbs 
down  parallel.  When  such  is  the  case  a  strip  of  metal 
may  be  incorporated  in  the  bandage  running  across 
from  the  inside  of  one  thigh  to  that  of  the  other  just 
above  the  knees.  This  will  tend  to  prevent  abduction.  If  the  plaster  cast 
has  been  removed,  Lorenz  advises  the  use  of  an  elastic  band  passing  across 
from  one  knee  to  the  other.  To  enable  a  patient  with  a  one-sided  luxation  to 
go  around,  a  high  patten  or  shoe  is  used  on  the  affected  leg  (Fig.  126S). 

Double  luxation  cases  can,  as  suggested  by  Lorenz,  be  given  a  small  bench 
with  rollers;  by  sitting  astride  it  the  child  can  push  itself  along  (Fig.  1269). 


Fig.  1266. 


I020 


CONGENITAL   LUXATION    OF   THE   HIP 


As  pointed  out  by  Gourdon,  Kirmisson,  and  others,  when  the  limb  is  placed 
in  extreme  abduction  the  head  is  not  pointing  correctly  into  the  acetabulum, 
but  is  looking  more  forwards.  Hence  if  this  position  is  maintained  too  long 
the  anterior  part  of  the  joint  is  weakened  and  an  anterior  transposition  may 
result.  For  this  reason  it  is  best  to  change  the  position  of  the  limb  as  soon  as 
possible,  without  reluxation  occurring,  from  the  primary  position  of  extreme 
abduction  to  one  of  moderate  internal  rotation,  at  the  same  time  bringing 


Fig.  1267. 


the  hmb  down  a  little  or  even  to  about  45°;  the  head  then  bores  directly  into 
the  socket  and  is  about  perpendicular  to  the  lateral  pelvic  plane.  The  greater 
the  amount  of  anteversion  of  the  head  and  neck  that  is  present  the  greater 
is  the  amount  of  internal  rotation  necessary.  In  cases  with  extreme  antever- 
sion of  the  neck  an  osteotomy  to  correct  it,  as  advised  by  Kirmisson,  may  be 
necessary,  but  that  is  very  rare. 

Results. — It  is  practically  impossible  to  give 
an  accurate  statement  of  results.  What  one 
operator  calls  a  good  result  another  will  call  bad; 
what  one  calls  an  eccentric  replacement,  another 
will  call  a  reluxation.  Le  Damany  has  called  at- 
tention to  the  unreliability  of  the  statements  of 
the  mother  as  to  the  great  improvement  eflfected. 


Fig.  1268. 


Fig.  1269. 


Certain  it  is  that  with  a  judicious  amount  of  suggestion  on  the  part  of  the 
surgeon  the  parents  at  times  may  be  persuaded  to  do  and  see  almost  any- 
thing. One  fact,  however,  is  evident  and  that  is  that  the  methods  of  replace- 
ment as  well  as  of  subsequent  treatment  as  now  generally  employed  have  not 
changed  materially  since  their  general  introduction. 

Lorenz,  at  the  Lisbon  International  Congress  in  1906,  stated  that  ideal 


OPEN   OPERATION  I02I 

results  were  obtained  in  50  per  cent.,  and  of  the  other  50  per  cent,  the  greater 
part  were  transpositions  below  the  anterior  superior  spine  of  the  ilium. 

Kirmisson  at  the  same  congress  stated  that  in  twenty-eight  unilateral 
cases,  two  were  found  impossible  of  reduction  and  that  good  or  even  perfect 
results  were  obtained  in  eleven,  or  39  per  cent.  Of  twenty-four  double  cases 
only  two  had  good  permanent  results.  The  results  in  double  luxations  are 
about  one-half  as  good  as  in  single  luxations.  Many  operators  claim  more 
than  50  per  cent,  cures,  especially  in  single  luxations. 

The  fact  remains  that,  according  to  Lorenz,  and  his  statement  is  probably 
close  to  the  truth,  there  are  50  per  cent,  more  or  less  imperfect  results. 

He  claims  that  in  the  transpositions  or  what  he  calls  "lateral  apposition," 
cases  below  and  a  httle  outside  the  anterior  spine,  while  the  limping  is  not 
improved  the  endurance  is,  and  that  they  do  not  tend  to  luxate  posteriorly. 

We  would  Hke  to  agree  with  him  in  his  view,  but  at  present,  at  least,  cannot. 
While  the  treatment  undoubtedly  does  permanently  benefit  many  of  the  cases, 
in  others  the  condition  seems  to  get  worse  rather  than  remain  stationary  until 
the  cases  can  scarcely  be  distinguished  from  those  who  have  had  no  treatment 
at  all.  In  other  words,  we  class  transpositions  under  the  head  of  failures, 
not  total,  it  is  true,  but  far  from  satisfactory.  So  distrustful  of  the  results  of 
the  bloodless  reposition  is  Sherman,  of  San  Francisco,  that  he  advocates 
replacement  by  open  operation,  not  making  a  new  acetabulum,  but  apposing 
cartilage  to  cartilage.  His  statistics  are:  In  twenty-nine  cases  there  were 
twelve  functionally  normal  joints;  eight  anterior  transpositions,  one  death  and 
one  ankylosis  from  infection.  In  twenty-seven  cases  followed  by  osteotomy 
he  had  70.3  per  cent,  of  normal  function. 

Personally,  the  difficulty  experienced  has  not  been  in  the  reduction,  but 
in  maintaining  the  reduction.  There  seems  to  be  Httle  doubt  that  in  some 
cases  the  acetabulum  is  so  shallow  as  to  absolutely  fail  to  give  proper  fixation 
for  the  head  of  the  femur. 

When  it  becomes  evident,  after  a  thorough  trial  of  fixation,  that  it  is  im- 
possible to  get  a  stable  joint,  then  we  believe  that  at  present  the  best  plan  is 
to  make  an  anterior  incision  and  deepen  the  acetabulum. 

Reduction  by  Open  or  Cutting  Operation. — It  is  also  to  the  Italians  that 
the  credit  belongs  of  being  the  first  to  indicate  the  proper  means  to  treat  other- 
wise irreducible  cases  by  operative  means.  Alfonzo  Poggi,  of  Bologna  ("Arch- 
ivio  di  Ortopedia,"  1888),  on  January  29,  1888,  replaced  the  unresected  head 
as  nearly  as  possible  in  a  newly  scooped-out  acetabulum  by  open  incision 
Many  operations  had  been  done  before  that  time,  but  they  were  mainly  on  the 
muscles  or  resections  of  the  head  of  the  femur.  Two  years  later  Hoffa  brought 
out  his  well-known  method,  and  it  is  to  him  that  the  world  is  indebted  for 
placing  the  operation  on  a  firm  basis  and  causing  its  worth  to  be  generally 
recognized. 

Hoflfa  at  first  used  Langenbeck's  incision  which  is  a  longitudinal  one  over 
the  posterior  portion  of  the  joint.  He  also  detached  the  muscles  from  the  great 
trochanter.  Later  he  made  an  incision  beginning  .5  cm.  (3^  inch)  in  front  of 
the  upper  end  of  the  anterior  edge  of  the  greater  trochanter  and  prolonged 
downwards  for  6  cm.  {2%  inches)  in  front  of  the  trochanter.    Lorenz  modified 


I022 


CONGENITAL   LUXATION    OF    THE    HIP 


Hoffa's  operation  by  making  his  incision  6  to  7  cm.  long  downwards  and  back- 
wards from  just  behind  the  anterior  superior  spine  to  the  greater  trochanter 
It  passed  along  the  posterior  border  of  the  tensor  fasciae  femoris  muscle.  He 
avoided  the  division  of  the  muscles.  The  operation  so  performed  has  been 
called  the  HofiFa-Lorenz  operation. 

The  Smith-Peterson  incision  gives  an  excellent  exposure  of  the  hip  joint. 
This  incision  is  made  just  below  and  parallel  to  the  crest  of  the  ilium  starting  at  a 
point  4  to  5  inches  posterior  to  the  anterior  superior  spine  and  running  toward 
it.  From  this  point  the  incision  is  continued  down  onto  the  thigh,  running 
downward  and  slightly  outward,  for  a  distance  of  about  5  inches.  This  arm  of 
the  incision  runs  along  the  anterior  edge  of  the  tensor  fasciae  femoris  muscle. 
The  fascia  lata  is  cut  along  the  entire  incision,  exposing  the  gluteal  and  tensor 
fasiae  femoris  muscles.  The  gluteal  muscles  are  incised  and  lifted  from  the 
ilium,  the  tensor  fasciae  femoris  separated  from  the  sartorius  and  iliacus  muscles 
by  blunt  dissection  and  the  flap  turned  outward.  The  superior  gluteal  vessels 
and  nerve  He  in  the  flap  and  are  not  injured  so  there  is  little  hemorrhage  to  be 
controlled.  This  incision  exposes  the  capsule,  the  head  and  neck  of  the  femur 
and  gives  free  access  to  the  acetabulum. 

The  WTiter  operates  as  follows:  An  incision  (Fig.  1270)  three  or  four  inches 
long  is  made  directly  downwards  from  the  anterior  superior  spine.  The  fascia 
lata  is  split  and  the  sartorius  and  ihacus  muscles  pulled 
inwards  and  the  tensor  fasciae  femoris  and  anterior 
edges  of  the  gluteus  medius  and  minimus  pulled  out- 
wards. The  separation  of  these  muscles  is  made  by 
blunt  dissection  in  the  line  of  the  incision  and  exposes 
the  capsule  of  the  joint  and  the  neck  of  the  femur. 
The  capsule  is  freely  opened  and  the  finger  intro- 
duced downwards  to  determine  the  amount  of  con- 
traction of  the  capsule  and  the  condition  of  the  ace- 
tabulum below.  If  any  remnants  of  the  ligamentum 
teres  are  present  they  are  to  be  cut  away.  The  cap- 
sule is  almost  invariably  found  thickened  and  it's 
lumen  contracted,  especially  in  the  older  cases.  An  attempt  may  be  made  to 
dilate  the  capsule  by  introducing  a  Pryor  dilator  (Fig.  1271)  but  free  incision  of 
the  constrictions  and  cutting  away  of  the  capsule  to  permit  free  passage  of  the 
head  should  be  resorted  to  if  necessary.  The  latter  is  usually  the  best  proceed- 
ure.  If  the  acetabulum  is  sufficiently  empty  and  well  formed,  attempts  at 
reduction  can  at  once  be  made. 

If  the  acetabulum  is  either  filled  with  fibro-fatty  material  or  is  too  shallow 
to  securely  lodge  the  head  of  the  femur,  then  it  is  to  be  cleansed  out. 

This  may  be  done  with  a  wood  carver's  gouge,  which  is  sharply  beveled  on 
its  outer  surface  (Fig.  1272),  or,  what  is  not  so  good,  with  a  sharp  Volkmann 
curette.  To  further  smooth  the  cavity  and  even  undercut,  if  necessary,  the 
writer's  rose  burr  (see  Fig.  1273)  will  be  found  of  service.  It  has  cutting  blades 
on  only  half  of  its  circumference  in  order  to  avoid  wounding  the  head  of  the 
femur.  Attempts  at  reduction  may  now  be  made  by  the  usual  procedures 
of  Paci  or  Lorenz.     If  these  fail,  then  the  writer's  lever,  shown  in  Fig.  1274 


Fig.  1270. 


OPEN   OPERATION 


1023 


may  be  tried.  The  small  or  large  blade,  which  can  be  reversed  for  use  on  the 
opposite  sides,  is  used  according  to  the  size  and  age  of  the  patient.  One  end 
is  hooked  under  the  edge  of  the  acetabulum  while  the  other  passes  over  the 


Fig.  1 27 1. 


Fig.  1272. 


Fig.  1273. 


Fig.  1274. 


head  of  the  femur  (Fig.  1275).     By  depressing  the  lever  and  abducting    the 
femur  the  head  can  be  made  to  enter  the  acetabulum.     The  most  satisfac- 
tory method  of  reduction,  however,  is  by  direct  traction  on  the  limb.     By 
utilizing  the  powerful  traction  obtainable  with 
a  Hawley    or    McKenna  table   the  dislocated 
head  can  be  readily  drawn  down  to  the  aceta- 
bulum in  young  individuals,  even  in  the  older 
cases  this  method  is  quite  successful.     A  distinct 
advantage  in  this  proceedure  is  that  your  trac- 
tion   is    continuously    maintained    while    the 
fixation  dressing  is  being  applied  and  the  danger 
of  the  head  reluxating  is  lessened. 

In  operating  the  greatest  care  is  to  be  taken 
not  to  injure  the  cartilaginous  covering  of  the 
head  of  the  femur.  Removal  of  the  cartilage 
and  exposure  of  the  bare  bone  of  both  the  head 
of  the  femur  and  acetabulum  is  liable  to  lead 
to  anchylosis  or  restriction  of  motion.  The  limb 
is  to  be  put  up  in  plaster  of  Paris  in  a  sufficiently 
abducted  and  extended  position  to  prevent 
reluxation.  The  plaster  may  be  removed  every 
three  or  four  weeks  and  passive  motion  made, 
ten  or  twelve  weeks.  Should  it  be  found  to  be  absolutely  impossible 
to  replace  the  head  in  the  acetabulum,  then  a  new  one  should  be  dug 
out  of  the  side  of  the  ilium  and  the  head  placed  therein.  When  this 
procedure  is  carried  out  the  turning  down  of  a  bone  flap  from  the  (Albee) 


1275. 


It    may  be  discarded  in 


I024  KNEE-JOINT 

aids  materially  in  forming  a  good  roof  for  the  acetabulum  and  increases  it's 
depth.  Care  should  be  taken  to  maintain  powerful  traction  on  the  limb  in  the 
fixation  dressing  so  that  the  flap  may  not  be  subjected  to  pressure  and  give 
way.  This  will  give  a  stable  support,  but  of  course  increases  the  shortening. 
Anchylosis  is  not  likely  to  occur  if  the  cartilage  on  the  head  of  the  femur  is  kept 
intact. 

While  the  cutting  operation  is  regarded  unfavorably  by  many,  the  writer  has 
found  it  to  be  very  satisfactory.  It  must  be  admitted,  however,  that  the  opera- 
tion is  a  difficult  one  and  demands  a  skilled  technic  both  from  the  standpoint 
of  asepsis  and  reduction.  It  is  the  only  thing  that  gives  a  fair  promise  of  a 
stable  and  satisfactory  result. 


CHAPTER  LXXXII 

KNEE-JOINT 

PUNCTURE.    LAVAGE.    INJECTIONS 

Puncture  of  the  knee  is  most  commonly  practised  to  withdraw  serous  effu- 
sions, recent  blood  extravasations,  etc.,  and  as  a  preliminary  to  lavage  and  the 
injection  of  various  curative  agents.  The  preparation  of  the  patient,  surgeon, 
assistants,  and  material  must  be  as  careful  as  if  for  an  arthrectomy. 

Step  I. — ^At  the  chosen  point  a  little  above  and  external  to  the  patella  inject 
a  few  drops  of  cocaine  or  analogous  solution  into  the  skin.  With  a  tenotome 
puncture  the  skin.  Through  the  puncture  pass  a  trocar  and  cannula  down- 
wards and  inwards  in  such  a  fashion  that  its  point  is  made  to  touch  the  articular 
surface  of  the  patella.     This  insures  that  the  instrument  has  entered  the  joint. 

Step  2. — Withdraw  the  stilette.  Let  the  fluid  escape.  Clots  of  fibrin  may 
plug  the  cannula;  these  may  be  removed  by  a  probe.  If  nothing  further  is 
required,  remove  the  instrument  and  apply  a  dressing  which  will  exercise 
elastic  pressure  on  the  knee.  If  it  is  desired  to  practise  lavage  or  injection, 
proceed  to  Step  3. 

Step  3. — With  an  irrigator,  or  better,  a  common  glass  syringe  connected 
with  the  cannula  by  sterile  rubber  tubing,  fill  the  joint  with  salt  solution  or  some 
mild  antiseptic;  disconnect  the  syringe  from  the  cannula;  permit  the  fluid  to 
escape;  repeat  this  washing  as  often  as  may  seem  necessary.  If  the  disease  is 
simple  hydrops  articulli  many  surgeons  follow  the  lavage  by  injecting  about 
three  drams  of  5  per  cent,  carbolized  water.  When  tuberculosis  is  present 
one  may  inject  the  same  quantity  of  a  sterile  emulsion  of  iodoform  in  glycerine 
(10  per  cent,  to  20  per  cent.).  J.  B.  Murphy  uses  the  following  emulsion: 
Iodoform,  10  per  cent.;  formalin,  2  per  cent.;  glycerine,  q.  s.  In  empyema  of  the 
knee  Murphy,  after  puncture  and  lavage,  injects  a  sufficiency  of  a  2  per  cent, 
solution  of  formalin  in  glycerine  to  produce  a  mild  amount  of  tension  in  the  joint. 
He  also  uses  this  injection  as  a  preliminary  to  most  arthrotomies,  as  he  believes 
the  simple  arthritis  produced  by  it  acts  as  an  immunizing  agent  against  infection 
during  the  major  operation.  In  cases  of  traumatic  dry  arthritis  Rovsing  omits 
all  lavage,  notes  that  no  fluid  escapes  through  the  cannula  (if  any  turbid  fluid 
escapes  injection  of  vaseline  is  contraindicated)  and  then  injects  about  10  or 
12  c.c.  of  sterile  vaseline  (see  p.  980). 


INJECTIONS 


1025 


Step  4. — Withdraw  the  cannula.  If  necessary,  close  the  puncture  with  a 
stitch.  Apply  dressings  and  a  splint  or  light  starch  bandage.  The  usual  prac- 
tice is  to  keep  the  patient  in  bed  for  a  few  days  and  then  permit  him  to  go  about 
with  crutches.  Willcms  advises  strongly  against  the  use  of  any  splints  and 
urges  immediate  and  persistent  active  motion.  This  is  good  advice.  The 
injection  may  be  repeated  in  from  two  to  six  weeks.  The  treatment  is  not 
suitable  when  osteal  lesions  are  present.  If  there  is  no  marked  improvement 
after  two  or  three  weeks,  abandon  the  method. 

Sclerogenic  Injections  (Lannelongue).— Nature  seems  to  cure  tuberculous 
foci  by  imprisoning  them  in  an  impenetrable  capsule  of  fibrous  tissue.  Lan- 
nelongue has  sought  to  stimulate  nature  to  produce  this  capsule.  His  method 
is  as  follows:  Cleanse  the  parts  to  be  operated  on.  Charge  an  aseptic  hypo- 
dermic syringe  with  a  10  per  cent,  solution  of  chloride  of  zinc.  Inject  8  to 
10  minims  of  this  solution  at  each  of  various  points  around  the  diseased  area. 
These  injections  must  be  made  into  healthy  tissue,  but  immediately  adjoining 
the  disease.  The  irritating  chloride  of  zinc  is 
supposed  to  lead  to  the  formation  of  scar 
tissue.  Excellent  results  have  been  claimed, 
but  the  method  has  not  become  very  popular. 
Mauclaire  and  Walther  (Mem.  et  Bui.  Soc.  de 
Chir.  de  Paris,  xlv,  1052,  1920)  advocate  the 
method  in  synovial  tuberculous  arthritis 
even  when  there  are  some  osseous  lesions. 
They  warn  against  any  pressure  being  exerted 
on  the  piston  of  the  syringe  during  with- 
drawal of  the  needle  for  fear  of  injury  to  the 
skin.  Broca  saw  Lannelongue's  patients  for 
several  years  and  does  not  use  the  method. 

Arthrotomy  Knee. — Arthrotomy  may  be 
performed  for  several  purposes:  (a)  Ex- 
ploratory; (b)  for  the  removal  of  the  fluids, 
e.g.,  serous  effusion,  blood,  pus;  (c)  as  a 
preventive  measure  after  infected  or  sus- 
pected wounds;  (d)  as  a  substitute  for  punc- 
ture and  injection;  here  the  wound  must  be 
closed  after  the  selected  remedial  fluid  has 
on  the  knee. 

Murphy,  whenever  possible,  prepare  the 
joint  by  injecting  glycerine-formalin  solution 
a  week  or  ten  days  before  performing  arthro- 
tomy.    Arthrotomy   may   be   performd   in  several  ways: 

(A)  Antero -lateral  Incision. — For  exploratory  purposes  or  if  serous  or  bloody 
fluid  is  alone  present,  make  an  incis  on  one  finger's  breadth  external  to  the  pa- 
tella from  the  level  of  the  lower  edge  of  the  patella  to  a  point  about  two 
fingers'  breadth  above  the  upper  end  of  the  patella  (Fig.  1276).  This  incision 
is  slightly  curved,  the  concavity  being  towards  the  patella.  Divide  the  skin 
and  fascia.     When  the  synovialis  is  reached  pick  it  up  with  forceps  and  cut 

65 


Fig.  1276. — .Arthrotomy.     (Labey.) 


I026 


KNEE-JOINT 


between  the  forceps  so  as  to  open  the  joint.  Enlarge  the  wound  in  the  synovialis 
with  scissors  so  as  to  gain  access  to  the  upper  pouch  of  the  joint.  Of  course 
under  certain  circumstances  a  smaller  incision  suffices  and  should  be  made; 
for  exploration  and  for  many  other  purposes  the  larger  cut  described  is  essential. 


Fig. 


1277. — Drainage  knee.     The  tube  must  not  enter  the  joint  cavity,  and  if  possible  do 
not  pass  any  instrument  through  the  joint.     (Labey.) 


If  pus  is  present  or  if  the  single  incision  is  insufficient,  make  an  identical  cut  on 
the  opposite  side  of  the  patella  (Fig.  1227).  If  drainage  is  required  the  wounds 
may  be  left  open  and  loosely  filled  with  gauze.  Never  permit  any  drainage 
tube  or  foreign  body  to  penetrate    the  synoviahs.     In   draining  a  joint  the 

tube  ought  merely  to  reach  to  the  synovialis. 

(B)  The  above  incisions  may  not  provide 
sufficient  drainage  for  the  joint  cavity  near 
the  popliteal  space,  hence  it  may  be  necessary 
to  supplement  them  by  postero-lateral  incisions 
on  one  or  both  sides.  These  are,  under  the 
^^'wm  ■■/  li  I  "'**^^  circumstances,  mere  counter-openings.  A 
■^'"^     m  \   v>.,       f  postero-lateral    counter-opening    is    conven- 

iently made  as  follows:  Pass  a  closed  forceps 
through  the  antero-lateral  wound  (Fig.  1278), 
through  the  joint  and  make  it  raise  up  the 
soft  parts  on  the  outer  side  just  anterior  to 
the  hamstrings,  thus  avoiding  the  external 
popliteal  nerve;  on  the  inner  side  it  may  go 
between  the  tendons.  With  a  knife  make 
a  longitudinal  cut  so  as  to  expose  the  forceps, 
seize  the  end  of  a  rubber  tube  in  the  forceps  and  with  it  pull  the  tube  down 
to  but  not  into  the  wound  in  the  synovialis.  Do  not  permit  any  tube  to  be 
in  the  joint  as  it  is  certain  to  injure  the  synovialis  disastrously.  Postero- 
lateral incisions  may  and  often  are  made  as  the  primary  incision,  especially 


Ftg.  1278. — Drainage  knee.  Coun- 
ter opening  being  made.  The  tube 
shown  should  not  penetrate  the 
syqovialis.    (Labry.) 


ARTHROTOMY  IO27 

in  cases  of  pyarthrosis,  as  they  by  ihemselves  give  good  access  not  only  to 
the  joint,  but  also  to  those  popliteal  bursae  which  most  commonly  communicate 
with  the  joint.     The  operation  is  as  follows: 

(a)  On  the  outer  side. 

Step  I. — Extend  the  knee.  Palpate  the  tendon  of  the  biceps.  Make  an 
incision  about  2}^^  inches  long,  just  in  front  of,  and  parallel  to  the  tendon. 
This  cut  extends  nearly  down  to  the  head  of  the  fibula  and  divides  the  skin  and 
fascia. 

Step  2. — Slightly  flex  the  knee  so  as  to  expose  the  anterior  border  of  the 
biceps  tendon.  Retract  the  tendon  backwards  and  expose  the  posterior  border 
of  the  external  condyle  of  the  femur. 

Step  3. — Open  the  capsule.  Introduce  the  gloved  finger  into  the  joint  and^ 
guided  by  it,  enlarge  the  opening  as  may  be  necessary, 

(b)  On  the  inner  side. 

Step  I. — The  knee  being  extended,  flex  the  thigh  on  the  pelvis.  This  per- 
mits one  to  see  and  palpate  a  longitudinal  groove  beside  and  behind  the  internal 
condyle.  The  inner  border  of  the  groove  is  formed  by  the  gracilis  (coming  from 
the  pubis),  the  outer  border  by  the  semi-tendinosus  coming  from  the  ischium. 
Make  a  longitudinal  incision  in  the  above  groove.  The  middle  of  the  incision 
should  be  opposite  the  line  of  the  knee-joint.  Divide  the  skin  and  fascia. 
Expose  the  sartorius  and  half  hidden  by  it,  the  gracilis.  To  the  popliteal  side 
of  these  tendons  note  the  narrow  tendon  of  the  semi-tendinosus  and  more 
deeply  situated  the  big  semi-membranosus  tendon.  Retract  these  tendons 
forwards. 

Step  2. — Open  the  joint  on  the  posterior  border  of  the  internal  condyle  of  the 
femur  by  an  incision  reaching  from  the  border  of  the  meniscus  to  the  upper 
end  of  the  capsule.  If  there  is  a  serous  bursa  under  the  semi-membranosus,  it 
is  easily  felt  by  the  finger  and  opened.  Instead  of  providing  tubular  drainage 
after  postero-lateral  incision,  it  has  been  advised  to  unite  the  posterior  lip  of  the 
synovial  wound  to  the  skin  by  one  or  two  catgut  sutures.  To  obtain  perfect 
drainage  it  has  been  recommended  that  the  knee  be  kept  flexed  at  an 
angle  of  at  least  20  degrees.  Willems'  treatment  (pp.  1030,  1031)  is  of  the 
utmost  importance. 

(C)  Arthrotomy  by  Transverse  Incision. — ^Dislocation  Method.— This  opera- 
tion may  be  performed  in  several  ways: 

(i)  Transverse  Section  of  the  Patella.— Make  an  incision  from  one  condyle 
of  the  femm:  to  the  other  across  the  middle  of  the  patella.  Divide  the  patella 
transversely  with  a  saw.  With  knife  or  scissors  divide  the  lateral  ligaments, 
etc.,  so  as  to  open  the  joint  to  the  full  extent  of  the  cutaneous  wound.  Strongly 
flex  the  knee  and  divide  the  crucial  ligaments.  Pull  the  upper  fragment  of  the 
patella  and  the  soft  structures  around  it  strongly  upwards  so  as  to  expose  fully 
the  upper  synovial  pouch,  to  do  this  lateral  incisions  may  be  necessary.  Pull 
the  lower  fragment  of  patella  downwards  so  as  to  expose  the  lower  articular 
pouches.  Keep  the  knee  flexed  to  such  an  extent  that  the  whole  popliteal 
surface  of  the  joint  is  exposed  but  no  injurious  compression  is  exerted  on  the 
popliteal  vessels.  After  cleaning  the  joint  cavity  and-  swabbing  with  Harring- 
ton's solution  or  its  equivalent  fill  it  loosely  with  gauze  and  apply  abundant 


I028 


KNEE-JOINT 


dressings.  Keep  the  limb  Hexed  as  noted  above  and  watch  the  circulation  of 
the  foot  carefully  lest  it  be  impeded  by  too  great  flexion  of  the  knee. 

Note. — Some  surgeons  do  not  cut  the  crucial  ligaments,  but  this  seems  to 
be  essential  in  bad  cases. 

(2)  Curved  Incision.— Reflection  of  Patella  Upwards  (Peck).— Make  a 
horseshoe-shaped  incision  from  the  posterior  border  of  one  condyle  to  a  corre- 
sponding point  on  the  other  condyle   (Fig.   1279).     The  incision  is  convex 


Fig.  1279. — Drainage  knee.     {Peck.) 

downwards  and  divides  the  tendo  patellae.  Divide  the  anterior  capsule,  both 
lateral  and  both  crucial  ligaments,  leaving  the  posterior  ligaments  alone  intact. 
Make  a  lateral  cut  on  each  side  upwards  so  as  to  permit  the  complete  turning 
upwards  of  the  anterior  flap,  including  the  patella  and  all  tissue  down  to  the 
joint  (Fig.  1280).  This  exposes  every  nook  and  cranny  of  the  upper  synovial 
pouch.     Keep  the  patellar  flap  in  its  new  position  by  means  of  a  stitch  uniting 


AKTIIKOTOMY 


1029 


it  to  the  skin  of  the  thigh.  The  rest  of  the  operation  is  the  same  as  that  already 
described.  After  recovery  from  the  infective  process  has  taken  place,  Peck 
and  others  recommend  performing  arthrectomy,  arguing  that  even  if  it  was 
possible  to  obtain  closure  of  the  wound  without  removing  the  articular  surfaces, 
yet  there  would  be  no  chance  of  getting  a  useful  joint  and  there  would  be  a 


Fig.  1280. — Drainage  knee.     {Peck.) 


probabihty  of  fibrous  anchylosis  with  subluxation  of  the  tibia  on  the  femur. 
To  the  author  it  seems  wise  not  to  adopt  any  hard  and  fast  rule;  if  reduction  and 
retention  of  the  articular  surfaces  in  proper  position  is  easy  then  endeavor  to 
obtain  a  more  or  less  mobile  joint,  if  this  fail  it  is  easy  to  resect  at  a  later  date. 

Remarks  on  Arthrotomy. — (The  general  principles  here  enunciated  apply 
equally  to  other  joints.) 

For  exploratory  purposes  unilateral  or  bilateral  incisions  are  commonly 
sufficient  though  for  many  purposes  in  the  absence  of  infection  Robert  Jones* 


1030  KNEE-JOINT 

median  section  of  the  patella  is  of  extraordinary  value.  The  preliminary  in- 
jection of  Formalin-Glycerine  urged  by  J.  B.  Murphy  is  unnecessary  as  the 
synovialis  is  really  resistant  to  infection.  When  the  exploration  is  completed, 
close  the  wound  in  the  synovialis  with  accuracy  and  then  suture  the  more  super- 
ficial structures.  To  avoid  possible  anchylosis,  Willems  insists  on  active  and 
persistent  motion  of  the  joint  to  be  begun  as  soon  as  the  patient  comes  out  of 
the  anesthetic.  After  the  operative  removal  of  blood  and  serous  fluid  the  same 
remarks  apply.  If  fluid  reaccumulates  in  the  closed  joint  it  ought  to  be  aspir- 
ated. The  principle  of  active  mobilization  after  non-infected  lesions  of  joints 
was  urged  many  years  ago  by  the  late  Wharton  Hood  of  London  in  his  entranc- 
ingly  practical  book  'The  Treatment  of  Injuries'  (MacMillan  and  Co.).  All 
wounds  of  joints  ought,  if  possible,  to  be  converted  into  clean  closed  lesions  and 
treated  on  the  above  principles. 

Wounds  of  Joints. — Remember  the  essential  distinction  between  contam- 
ination and  infection.  All  wounds  of  joints  must  be  considered  contaminated. 
It  takes  a  varying  time  for  the  contaminating  infective  material  to  multiply 
and  penetrate  the  tissues.  It  commonly  takes  from  twenty-four  to  forty-eight 
hours  before  a  septic  arthritis  develops  (Pierre  Duval,  Surg.,  Gyn.  and  Obst., 
Sept.,  1919). 

In  every  wound  the  damaged  skin  should  be  removed.  In  many  cases  of 
through  and  through  machine  gun  wounds  this  suffices.  In  most  cases  the 
whole  track  of  the  wound  must  be  excised  cleanly  with,  of  course  removal  of 
all  foreign  bodies,  etc. 

When  the  joint  cavity  is  reached  freshly  sterilized  instruments  and  gloves 
should  be  used.  (In  severe  joint  lesions  Duval  begins  with  arthrotomy  and 
does  the  wound  excision  later  in  the  same  sitting.)  If  there  is  no  great  intra- 
articular injury,  trim  and  suture  the  synovial  wound  with  meticulous  care. 
Close  the  more  superficial  wound  with,  if  thought  necessary,  a  silkworm  gut 
drain  down  to  but  not  through  the  synovial  wound. 

If  there  is  much  destruction  of  the  soft  parts  and  it  is  therefore  impossible 
to  close  the  wound  after  'debridement'  a  strong  endeavor  must  be  made  to 
close  the  synovial  cavity,  if  necessary,  by  mobilization  of  the  neighboring  syn- 
ovialis such  as  the  supra-patellar  pouch. 

Active  mobilization  should  be  begun  at  once.  In  the  knee  in  the  absence 
of  damage  to  the  bone  very  early  walking  is  a  valuable  means  of  treatment. 
The  use  of  antiseptics  has  been  given  up  when  operation  can  be  performed 
early.  During  1914  and  1915  the  mortality  of  knee  joint  wounds  was  27.6 
per  cent,  and  there  were  .^o  per  cent,  amputations.  During  1916,  1917  and 
1918  the  mortaUty  was  0.9  per  cent,  and  amputations  were  done  in  2.9  per  cent, 
of  the  cases.  The  improvement  was  due  to  early  operation  and  avoidance  of 
intra-articular  drainage. 

When  there  is  injury  to  the  bone  the  lines  of  fracture  must  be  cleaned,  with 
the  chisel  if  necessary,  and  all  parts  must  be  retained  to  as  great  an  extent  as 
possible.  When  the  bone  injuries  are  lateral  and  at  the  same  time  extra- 
articular or  intra-articular,  by  proper  suture  of  the  synoviaHs  the  cavities  are 
separated  from  the  joint.  Bone  cavities  when  well  cleaned  can  be  left  open  in 
the  joint,  may  be  plugged  with  bone  wax  or  by  a  pedunculated  flap  of  muscle. 


Wll.l.KMS'    TREATMENT  IO3I 

Fissures  of  the  bone  should  be  opened  by  a  lever  and  lightly  pared.  Nails  or 
screws  may  be  used  when  necessary  to  keep  fragments  in  proper  line.  As  far 
as  possible  a  normal  joint  outHne  must  be  preserved.  When  this  is  done  the 
joint  is  to  be  treated  almost  exactly  as  when  there  has  been  no  bone  injury. 
If  active  mobilization  causes  displacement  of  large  bone  fragments,  it  is  contra- 
indicated,  hence  part  of  the  necessity  for  fixation  of  such  fragments.  Division 
of  the  patellar  ligament  provided  that  it  has  been  well  sutured  does  not  neces- 
sarily interfere  with  active  mobilization.  Excision  of  an  injured  joint  is  rarely 
necessary  excejn  when  the  traumatism  has  practically  performed  that  operation. 

Purulent  Arthritis. — In  all  cases  of  purulent  arthritis  it  is  notoriously  difl5- 
cult  to  provide  eilicient  drainage.  Apart  from  extremely  extensive  operations 
which  inevitably  cause  anchylosis  the  only  thorough  drainage  is  obtained  by 
means  of  active  motion  during  which  the  pus  is  squeezed  out  of  the  joint.  Wil- 
lems  (Surg.,  Gyn.  and  Obst.,  June,  1919) performs  lateral  or  bilateral  arthrotomy 
as  early  as  possible.  In  the  knee  the  incisions  extend  from  above  the  supra- 
patellar (subfemoral)  bursa  down  to  below  the  articular  interhne.  As  soon  as 
the  patient  awakens  from  anesthesia,  active  movements  are  begun  and  are  kept 
up  at  frequent  intervals  in  spite  of  pain,  the  feeling  of  weight  in  the  Umb,  etc. 
Active  motion  is  necessary  to  express  the  pus.  Pain  especially  posteriorly  is  a 
sign  that  there  has  been  too  little  motion.  If  the  Willems'  method  is  thoroughly 
carried  out  recovery  should  ensue  in  about  two  months  without  anchylosis  even 
when  there  is  some  slight  osseous  lesion.  When  there  is  a  grave  intra-articular 
bone  lesion  the  results  are  much  less  certain. 

Irrigation  of  the  joint  is  unnecessary  and  may  be  harmful.  As  suppuration 
lessens,  progressively  close  the  arthrotomy  wound  only  leaving  such  opening 
as  is  strictly  necessary  for  the  escape  of  the  pus  which  is  still  forming.  The 
patient  should  walk  early  before  the  wound  is  healed,  this  helps  to  expel  the  pus. 
Willems  writes  "preservation  of  the  articular  mobility  seems  due  to  the  fact 
that  the  perfect  drainage  limits  infection  to  the  synovia  alone  and  prevents  its 
propagation  to  the  cartilage  and  bone," 

Arthrotomy  for  the  Removal  of  Loose  Bodies. — Several  varieties  of  organic 
bodies  may  lie  loose  in  the  joint  and  cause  very  distressing  and  crippling 
symptoms.  The  bodies  may  be  single  or  multiple,  may  be  absolutely  free  or  be 
pedunculated.  The  bodies  may  occupy  almost  any  part  of  the  cavity,  but  only 
give  rise  to  symptoms  when  nipped  between  the  articular  surfaces.  They  may 
be  very  movable  and  hence  are  liable  to  get  out  of  reach.  The  patient  by 
making  certain  movements  can  often  bring  the  body  into  a  superficial  position. 
If  the  body  is  very  mobile  it  is  sometimes  wise,  after  thorough  cleansing  of  the 
parts,  to  harpoon  and  so  fix  it  with  a  sterile  needle.  It  is  then  easy  to  cut  down 
on  to  the  body  under  a  local  anesthetic  and  remove  it  without  introducing  a  finger 
into  the  wound. 

Usually  a  general  anesthetic  will  be  required  and  a  larger  incision  made  in 
order  to  explore  the  cavity  with  a  gloved  finger.  The  operation  is  essentially 
that  of  antero-lateral  arthrotomy.  When  a  delicate  pedicle  is  present  it  is 
easily  ruptured;  a  stronger  pedicle  may  require  a  snip  of  the  scissors.  The 
wound  is  closed  by  two  layers  of  sutures  without  drainage. 

Loose  bodies  can  often  be  demonstrated  by  the  X-rays,  but  a  warning  is 


1032 


KNEE-JOINT 


Fig.  1281. 


Fig.  1282. — {Freeman.) 


INTERNAL  DERANGEMENT  IO33 

here  necessary.     In  the  gastrocnemei  muscles  there  are  often  present  smal 
sesamoid  bones  (Fig.  1281),  which  may  be  mistaken  for  loose  bodies  in  the  joint. 

Displaced  Semilunar  Cartilage.  Internal  Derangement  of  the  Knee- 
joint  (Hey). — Many  methods  have  been  devised  for  exposing  a  displaced 
semilunar  cartilage.  Annandale  in  1885  described  a  method  of  anchoring  the 
cartilage  through  a  simple  transverse  incision. 

Freeman  reflects  a  U-shaped  flap  of  all  the  tissues,  including  the  capsule, 
upon  the  internal  or  external  surface  of  the  joint,  as  required,  and  lying  between 
the  lateral  ligament,  on  one  hand,  and  the  patella  and  its  ligament  on  the  other 
(Fig.  1282). 

The  base  of  the  flap  may  either  be  upwards  or  downwards  but  it  must  be  so 
placed  as  to  freely  expose  the  upper  edge  of  the  tibia  and  the  semilunar  cartilage. 

It  is  now  easy,  in  suitable  cases,  to  reduce  the  cartilage  and  fix  its  edge  to 
the  periosteum  by  a  few  stitches.  This  treatment  is  now  practically  discarded 
in  favor  of  excision  which  gives  as  good  results  and  more  insurance  against 
recurrence.  When  the  cartilage  is  exposed  seize  it  with  a  strong  hemostatic 
forceps  or  pull  it  outwards  with  a  blunt  hook.  Cut  it  from  its  moorings  with 
scissors  or  twist  it  until  it  tears  free.  Close  the  wound  in  the  capsule  and  fascia 
with  fine  catgut.  Close  the  skin  wound.  Dress.  Apply  a  posterior  splint 
or  a  starch  bandage.  Begin  gentle  motion  in  about  two  weeks.  Gradually 
increase  motion.  Massage  is  useful.  A  number  of  weeks  may  pass  before 
absolutely  free  and  comfortable  motion  is  possible. 

Jones'  Operation. — -Robert  Jones  ("Annals  Surgery,"  Dec,  1909)  describes 
his  method  of  operating  as  follows:  "For  some  time  I  have  given  over  operating 
with  the  knee  in  such  a  position  that  it  has  to  be  further  flexed  during  the  pro- 
ceedings. Unless  the  greatest  care  is  taken,  the  clothes  get  shifted  or  air  is  in- 
troduced into  the  joint.  All  surgeons  of  experience  will  have  noted  this.  To 
avoid  this  risk  I  begin  the  operation  with  the  patient's  knee  hanging  at  right 
angles  over  the  foot  of  the  table  (Figs.  1283,  1284).  To  shift  during  the  opera- 
tion is  to  change  the  plane  of  the  incision.  The  final  cleaning  of  the  knee  takes 
place  while  the  joint  is  flexed  and  the  skin  tense.  Some  thicknesses  of  sterile 
gauze  squeezed  out  of  i  to  1000  biniodide  of  mercury  is  wrapped  round  the 
joint  and  the  incision  is  made  through  the  gauze,  the  cut  edges  of  which  are 
fixed  to  the  wound.  The  length  of  incision  which  practically  always  suffices 
is  three  inches,  the  incision  into  the  capsule  is  much  smaller  (Fig.  1283).  Long 
skin  incisions  obviously  add  to  the  risks,  and  are  only  very  exceptionally  needed. 
The  incision  should  be  slightly  curved  and  extend  from  an  inch  within  the  lower 
angle  of  the  patella  to  half  an  inch  below  the  tibial  margin,  curving  more  acutely 
at  this  point  towards  the  lateral  Hgament.  The  interior  of  the  joint  is  then 
inspected  with  the  aid  of  carefully  applied  retractors.  No  less  authorities  than 
Sir  William  Bennett  and  Mr.  Whitelocke  advocate  entering  the  finger  for 
exploratory  purposes.  The  finger  should  never  enter  the  joint.  Neither  the 
surgeon  nor  the  assistant  should  touch  the  wound  with  anything  but  sterile 
instruments.  The  sutures  for  the  capsule  should  be  handed  on  forceps  and 
I  usually  make  the  stitches  a  blanket-stitch.  In  the  flexed  position,  the  best 
view  is  obtained  of  the  interior  of  the  joint  and  the  cartilage  can  be  well  inspected. 
If  the  capsule  plicates  and  hides  the  view,  draw  it  outwards  with  a  skeleton 


I034 


KNEE-JOINT 


retractor  which  may  be  used  to  obtain  a  good  view  in  any  direction.  The 
cartilage  may  be  found  in  any  position.  It  may  be  detached  at  its  anterior 
extremity.     It  may  be  circumferentially  split;  it  may  be  completely  fractured; 


Fig.  1283. — Incision  of  knee.     {R.  Jones.) 

it  may  be  completely  twisted;  it  may  be  firmly  fixed  but  with  frayed  inner  border; 
it  may  be  nodular;  the  posterior  part  may  be  in  front;  it  may  be  attached  at 
its  extremities  and  free  along  the  whole  or  part  of  its  outer  border;  the  anterior 
part  may  be  ground  away,  or  found  quite  loose  as  a  separate  body,  or  only  the 


b'lG.   1284. — Incision  oi  knee.     {K.  Jona.) 

slightest  movement  may  be  possible,  due  to  loosening  of  its  moorings.  The 
examination,  which  should  be  gentle,  is  facilitated  by  a  sharp  or  blunt  hook. 
It  is  only  necessary  to  remove  the  loose  portion  of  the  cartilage,  be  it  a  frayed 
border,  a  circumferential  tear  or  a  detached  anterior  portion.     Here  I  would 


ROBERT  JONES  OPERATION  IO35 

offer  a  practical  suggestion.     Never  pull  upon  the  cartilage  nor  cut  when  pulling; 
this  detaches  more,  and  to  my  knowledge  is  a  cause  of  recurrence. 

"Note  the  degree  of  detachment  and  go  a  short  distance  further  with  a 
knife  cutting  the  cartilage  clean  across,  and  then  complete  the  incision  along 
the  outer  border.  Having  removed  the  cartilage,  look  for  fringes,  tabs  or 
other  possible  agencies  which  may  cause  trouble  in  the  future,  and  remove 
them.  Stitching  the  cartilage  should  be  an  obsolete  operation.  If  the  cartilage 
is  only  slightly  mobile  and  the  history  characteristic,  it  should  be  removed 
forthwith.  During  the  operation,  dabs  taken  directly  from  the  sterile  drum 
should  cover  the  wound  during  any  interval,  and  no  dab  should  be  used  which 
has  been  exposed  to  the  air. 

"I  never  tie  vessels,  always  use  a  tourniquet  until  the  dressings  are  bandaged, 
and  never  drain.  I  used  to  drain,  years  ago,  but  I  consider  it  quite  unneces- 
sary, and  an  additional  communication  between  skin  and  joint.  The  synovial 
membrane  capsule  and  skin  should  be  separately  sutured  and  the  sutures  should 
not  pass  through  the  whole  thickness  of  the  skin.  I  now  know  no  anxious 
moments,  the  skin  never  reddens,  nor  do  I  have  trouble  with  effusion. 

"The  stitches  are  left  in  position  for  eight  days,  the  knee  kept  slightly  bent 
in  a  splint  for  the  same  period,  or  a  few  days  longer,  and  then  passive  move- 
ments and  massage  are  started.  Special  attention  should  be  paid  to  the  weak 
quadriceps  and  in  from  three  to  four  weeks  normal  exercise  should  be  allowed." 

Robert  Jones'  median  longitudinal  section  of  the  patella  gives  remarkably 
good  access  to  the  knee  for  the  removal  of  any  misplaced  cartilages  as  well  as 
for  operation  upon  the  tibial  spines  for  which  it  was  devised. 

When  ought  we  to  operate  for  displaced  semilunar  cartilage? 

We  ought  never  to  operate  before  giving  conservative  means  a  fair  and 
protracted  trial.  Hence  acute  cases  are  not  for  operation.  Cases  without 
effusion  can  generally  be  kept  comfortable  or  cured  by  the  use  of  some  hinged 
apparatus  to  the  knee  or  even  by  raising  the  inner  side  of  the  heel  of  the  shoe 
so  as  to  make  the  patient  walk  in  a  pigeon-toed  fashion.  When  effusion  is 
present  (not  acute  synovitis)  or  when  there  is  crackling  on  motion,  operate. 
The  effusion  means  constant  irritation  and  injury  to  the  synovialis,  the  crack- 
ling generally  means  that  the  cartilage  has  become  rolled  upwards  and  joint- 
ward  more  or  less  like  a  pea. 

In  the  "British  Med.  Journ.,"  Dec.  9,  1905,  Mr.  A.  E.  Barker  describes  some 
atypical  forms  of  internal  derangements  of  the  knee.  The  symptoms  and 
history  in  these  cases  are  identical  with  the  classical  lesion.  The  pain  and 
tenderness  are  on  the  inner  and  anterior  aspect  of  the  head  of  the  tibia.  After 
opening  the  joint  by  a  curved  internal  antero-lateral  incision  Barker  found  the 
meniscus  normal,  but  when  the  knee  was  flexed  and  the  tibia  rotated  outwards 
a  long  white  "tag"  of  dense  fibrous  tissue  was  seen  projecting  backwards  from 
the  loose  tissue  behind  the  patella.     On  the  removal  of  the  tag,  cure  resulted. 

Under  similar  circumstances  after  the  same  incision  Barker  found  no  dis- 
placement of  the  internal  cartilage,  no  retropatellar  "tags,"  but  beyond  the 
crucial  ligament  he  saw  a  white  mass  which  he  pulled  forwards  with  a  hook 
and  found  it  to  be  the  external  cartilage  attached  at  both  ends  but  torn  from 
the  coronary  ligament  by  an  injury  sustained  forty-four  years  before.     Re- 


1036  KNEE-JOINT 

member  that  flexion  and  external  rotation  of  the  knee  after  it  is  opened  may 
reveal  the  cause  of  disabling  symptoms  and  permit  of  cure.  Remember  that 
the  synovialis  of  a  healthy  joint  only  feebly  resists  infection  and  hence  that 
the  ungloved  finger  must  never  touch  a  wound  made  in  a  joint. 

Repair  of  Ruptured  Crucial  Ligaments. — Mayo  Robson  operated  on  a 
man  for  lameness  resulting  from  a  severe  accident  sustained  nine  months 
previously  ("Clinical  Society,"  London,  Nov.  28,  1902).  Battle  operated  on 
a  case  in  similar  fashion.  "On  admission,  the  right  knee  was  swollen  but  free 
from  tenderness.  When  the  muscles  were  pressed  the  bones  were  in  good 
position,  but  as  soon  as  the  muscles  were  relaxed  the  tibia  fell  backwards  until 
stopped  by  the  ligamentum  patellae,  and  on  manipulation  the  head  of  the  tibia 
could  be  brought  forwards  in  front  of  the  femur,  there  being  also  free  lateral 
movement  of  the  head  of  the  tibia  on  the  femur  and  some  fluid  in  the  joint. 
Not  only  were  all  the  ligaments  relaxed,  but  the  crucial  ligaments  had  been 
ruptured.  On  November  21,  1895,  the  joint  was  opened  by  a  semilunar 
incision  carried  across  the  front  and  dividing  the  ligamentum  patellae.  The 
synovial  membrane  was  found  inflamed,  and  there  was  excess  of  fluid  in  the 
joint.  Both  crucial  ligaments  were  completely  ruptured,  having  been  torn 
from  their  upper  attachments,  the  ends  being  in  a  shreddy  condition.  They 
were  stitched  in  position  by  means  of  catgut  ligatures  and  the  anterior  being 
stitched  to  the  synovial  membrane  and  tissues  on  the  inner  side  of  the  external 
condyle,  and  the  posterior,  which  was  too  short  and  was  split  in  order  to  lengthen 
it,  was  fixed  by  sutures  to  the  synovial  membrane  and  cartilage  on  the  outer 
side  of  the  inner  condyle.  The  wound  was  then  stitched  up  by  means  of  buried 
catgut  sutures,  and  was  closed  superficially  by  interrupted  silkworm-gut 
sutures.  Complete  restoration  of  the  normal  movemeiits  of  the  joint  occured. 
The  stitches  were  removed  on  December  4,  and  on  the  fourteenth  plaster  of 
Paris  was  applied,  and  he  was  allowed  to  get  about  on  a  Thomas,  splint  and  to 
go  home.  The  plaster  was  removed  in  a  month,  after  which  movement  gradu- 
ally returned  under  massage.  When  seen  on  October  24,  1901,  the  patient 
was  walking  without  a  limp  and  could  run.  He  said  that  his  leg  was  perfectly 
strong,  and  that  he  could  work  eight  hours  a  day  at  his  old  employment  of  get- 
ting coal,  and  that  he  had  never  been  off  a  day  on  account  of  his  knee  since  the 
year  of  his  accident.  The  joint  could  be  extended  to  the  straight  line  and 
flexed  just  beyond  the  right  angle,  there  being  no  abnormal  lateral  or  antero- 
posterior mobility  whatever." 

Pringle  has  had  two  cases  of  injury  to  the  knee  in  which  abduction  while 
the  knee  was  extended  was  a  prominent  symptom.  In  both  cases  the  provisional 
diagnosis  was  ruptured  internal  lateral  ligament.  On  opening  the  knee  of 
one  of  these  cases  the  anterior  crucial  ligament,  still  attached  to  its  bony  inser- 
tion, was  found  to  be  torn  off  the  tibia,  taking  the  tibial  spine  with  it.  Pringle 
sutured  the  spine  in  place  and  obtained  a  good  result.  In  the  second  case, 
after  opening  the  knee,  the  anterior  crucial  ligament  was  found  torn  from  its 
femoral  attachment  and  was  then  sutured  by  Pringle  to  the  tissues  on  the  median 
side  of  the  external  condyle  ("Annals  of  Surgery,"  Aug.,  1907). 

W.  J.  Frick  repaired  the  ruptured  anterior  crucial  ligament  in  two  cases,  one 
of  his  patients  was  a  professional  base-ball  player  who  was  able  to  resume  his 
work  within  six  months  of  the  operation. 


CRUCIAL    LIGAMENTS  10,57 

Robert  Jones'  Operation  (R.  Jones  and  S.  Alwyn  Smith,  Brit.  Journ.,  Surg., 
i,  89)  is  designed  for  treatment  of  fractures  of  the  tibial  spine  "when  full  ex- 
tension is  not  possible  and  disability  exists  in  addition,  whether  it  be  pain  stiff- 
ness or  effusion."  Flex  the  knee  over  the  table  at  almost  a  right  angle.  Make  a 
vertical  median  incision  from  one  inch  above  the  patella  down  to  the  tubercle 
of  the  tibia.  Saw  the  patella  longitudinally  and  split  its  tendon.  Separate 
the  segments  of  the  patella  to  the  border  of  the  condyles.  Remove  the  fat  from 
behind  the  patella  and  so  gain  a  good  view  of  the  spine  and  of  the  anterior  crucial 
ligament.  Remove  any  obstructive  mass.  Straighten  the  knee.  Suture  the 
ligamentum  patellae,  the  aponeurosis  and  the  quadriceps  tendon.  Do  not  wire 
the  bone. 

E.  M.  Corner  (Trans.  Surg.  Sect.  A.  M.  A.,  1914)  is  an  enthusiastic  advo- 
cate of  the  Robert  Jones  method  of  opening  the  knee.  To  gain  free  access  he 
splits  the  quadriceps  upwards  as  far  as  may  be  necessary.  He  lays  great  stress 
on  the  importance  of  careful  suture  of  the  synovialis  with  fine  catgut  to  prevent 
blood  entering  the  knee  as  hemarthros  is  very  favorable  to  infection.  After 
operation  no  splint  is  necessary  though  its  use  for  twenty-four  hours  may  be  of 
value.  The  patient  remains  in  bed  for  three  weeks.  Active  motion  does  not 
need  to  be  preceded  by  passive  motion. 

Through  the  Jones'  incision  Corner  operates  on  displaced  semilunar  carti- 
lages; ruptured  or  stretched  crucial  ligaments;  fractures  of  the  tibial  spines; 
various  fractures  of  the  femur,  etc.  He  urges  that  the  synovialis  covering  the 
fat  below  the  patella  be  left  intact  if  possible  or,  if  divided,  that  it  be  carefully 
sutured. 

Operation  for  Stretched  or  Loose  Crucial  Ligaments  (Corner) . — The  anterior 
ligament  is  almost  invariably  affected.  Bore  a  hole  through  the  external 
condyle  and  through  the  loose  ligament.  Thread  a  wo«-absorbable  suture  on  the 
dri'l  and  pull  one  end  of  it  through  the  condyle.  Pass  the  other  end  of  the  suture 
around  the  ligament  and  pull  it  through  a  second  hole  bored  in  the  external  con- 
dyle. When  the  suture  is  tightened  and  tied  the  relaxed  ligament  is  tightened 
and  reefed. 

If  the  posterior  crucial  ligament  is  at  fault  the  suture  would  be  passed  through 
the  internal  condyle.  The  knee  ought  to  be  a  little  flexed  when  the  suture  is 
tied. 

Operation  for  Fracture  of  Tibial  Spine. — In  spite  of  the  advice  of  Robert 
Jones,  Corner  advocates  fixing  the  fragment  of  spine  by  a  catgut  suture  passed 
twice  through  the  tibia  in  the  same  way  as  is  done  through  the  femur  in  reefing 
the  crucial  ligament. 

Operation  for  Ruptured  Crucial  Ligament. — When  the  Hgament  is  so  injured 
that  its  repair  is  impossible  and  when  it  is  causing  much  disability  Corner  passes 
a  U  suture  of  wire  through  two  perforations  in  the  external  condyle  and 
loops  it  through  a  similar  wire  suture  which  perforates  the  tibia  (Fig.  1285). 
The  value  of  this  operation  is  very  doubtful. 

Operation  for  "Internal  Derangement  of  the  Knee". — Robert  Jones'  median 
incision  is  recommended  by  Corner  in  the  treatment  of  displaced  semilunar 
cartilages  and  for  loose  cartilages  even  when  they  seem  single  and  easily  excised 
through  a  small  incision  directly  over  them,  the  reason  for  this  being  that  other 


I038 


KNEE-JOINT 


remediable  lesions  are  so  often  present  which  would  be  overlooked  and  cause  sub- 
sequent chagrin  if  the  smaller  incision  had  been  selected. 


Fig.  I2.S5. 


Stump  of  ligamentum  mucosum 
txternal  semilunar  fibro- 
cartilage 


Bursa  under   quadriceps  extensor  tendon 
Patella 

Posterior  crucial  ligament 

Anterior  or  capsular  ligament 


Coronary  ligament 

Transverse  ligament 
Anterior  crucial  ligament' 


Coronary  ligament 
Internal  semilunar  fibro-cartilage 


Fig.  i286.—iDeaver.) 

Figure  1286  will  remind  the  reader  of  the  anatomy  of  the  knee. 

Figure  1287  shows  fracture  of  the  tibial  spine  in  which  the  chief  symptoms 


ARTHRECTOMY 


1039 


were  tenderness,  swelling  and  undue  lateral  mobility.  Hayden  treated  the  case 
by  immobilizing  with  plaster  of  Paris  and  obtained  a  perfect  result  about  79  days 
after  the  injury  was  received. 

Repair  of  Ruptured  Lateral  Ligaments. — When  the  lateral  ligaments  of  the 
knee  are  ruptured  they  may  be  exposed  and  sutured  but  earlier  use  and  better 
motion  and  strength  may  be  expected  from  the  following  procedure  reported  by 
E.  Lexer  ("Archiv  f.  klin.  Chir.,"  xcviii,  819).  Expose  the  injured  parts  by  a 
free  incision.  Suture  any  wound  of  the  joint  capsule.  From  the  tendon  of  the 
rectus  femoris  obtain  a  non-pedunculated  (unattached)  flap  of  suitable  length 


Fig.  1287. — {Hayden.) 


and  thickness.  Suture  the  flap  to  the  femur  above  and  the  tibia  below.  If 
mere  suturing  of  the  flap  to  the  periosteum  seems  insecure,  reflect  a  flap  of  perios- 
teum, cut  a  groove  in  the  bone,  place  the  end  of  the  flap  into  the  groove,  fix  it 
there  with  a  staple  and  cover  with  the  periosteal  flap. 

Arthrectomy. — ^Excision. — The  term  arthrectomy  is  here  used  as  meaning 
the  removal  of  synovialis  either  alone  or  plus  excision  of  the  diseased  portions  of 
cartilage  and  bone.  The  term  excision  is  reserved  for  operations  where  the  whole 
articular  surfaces  are  formally  excised. 

Method  A. — ^Lateral  Incision.— 5/e/>  i.^ — Beginning  at  the  inner  side  of  the 
ligamentum  patellae,  make  a  curved  incision  upwards  and  backwards  to  the 
anterior  margin  of  the  internal  lateral  ligament  where  it  crosses  the  line  of  the 
articulation;  continue  the  cut  upwards  over  the  internal  epicondyle  and  make  it 
curve  forwards  and  upwards  around  the  inner  and  upper  part  of  the  superior 


I040 


KNEE-JOINT 


synovial  pouch  (Fig.  1288).  Beginning  at  the  outer  side  of  the  insertion  of 
the  ligamentum  patellae,  make  a  corresponding  incision  on  the  outer  side  of  the 
joint.  Both  these  incisions  penetrate  at  once  to  the  bone  in  the  lower  part  of 
the  incision,  while  in  the  upper  part  the  vasti  are  divided  and  articular  capsule 
is  exposed. 

Step  2. — Synovialectomy. — With  sharp  retractors  elevate  the  anterior  edge 
of  the  wound  (on  the  outer  side)  from  the  capsule.  With  forceps,  knife,  and 
scissors  dissect  the  anterior  part  of  the  diseased  capsule  from  the  soft  parts  cov- 
ering it,  until  the  patella  or  the  middle  Hne  (Fig.  1289)  is  reached.  Separate  the 
upper  synovial  pouch  from  all  its  surroundings.  Divide  the  synovialis  where  it 
is  inserted  into  the  patella.  Make  a  similar  dissection  through  the  internal 
wound  and  remove  the  separated  synovialis.  Dislocate  the  patella  outwards  in 
such  a  manner  as  to  expose  its  under  surface  and  that  of  the  quadriceps  and  the 
patellar  tendons.     Inspect  these  structures  and  remove  from  them  any  shreds 

of  synovialis  which  may  have  been  left.  If  it  is 
necessary  to  remove  the  synovialis  from  the  pop- 
liteal side  of  the  joint,  make  a  partial  division  of 
the  internal  lateral  ligament  and,  if  necessary,  of 
the  tendo  patellae.  Dislocate  the  joint  so  as  to 
make  the  articular  surface  of  the  femur  (or  tibia) 
protrude  through  the  inner  wound.  To  obtain 
complete  exposure  it  is  necessary  to  divide  the 
crucial  ligaments.  With  great  care  dissect  away 
the  synovialis  from  the  popliteal  surface. 

This    completes    the   synovialectomy.      If    no 
more  disease  requires  removal,  cleanse  the  wound. 
In  tuberculous  cases  it  is  wise  to  rub  the  wound 
with  iodoform  powder.     If  possible  unite  the  cru- 
cial ligaments  with  catgut  sutures.     Repair  the 
lateral  ligament  and  patellar  tendon.     Close  the 
wound  with  or  without  drainage. 
Step  3.- — {a)  Bony  anchylosis  is  desired  though  no  bone  is  diseased.     With 
a  strong  knife  or  with  a  chisel  pare  away  the  articular  cartilage  from  the  femur, 
tibia,  and  patella,  removing  also  the  remnants  of  the  crucial  ligaments  and  the 
semilunar  cartilages.     Close  the  wound  and  treat  as  a  fracture. 

(h)  Foci  of  disease  are  found  in  the  bones  to  a  limited  extent.  The  most 
common  lesions  are  foci  of  tuberculous  granulation-tissue  infiltrating  and 
absorbing  the  bone,  and  necrotic  foci.  If  the  active  advance  of  the  disease  has 
ceased,  the  diseased  foci  will  be  found  surrounded  by  a  mass  of  sclerosed  bone — 
a  favorable  sign.  With  a  sharp  spoon  or  a  gouge  remove  all  the  diseased  tissue. 
Necrotic  foci  are  often  so  intimately  attached  to  the  surrounding  bone  that  they 
require  removal  by  means  of  chisel  and  mallet.  After  removal  of  the  disease 
swab  the  osseous  wound  with  tincture  of  iodine  or  rub  in  iodoform  powder  or  fill 
the  cavity  wth  Mosetig's  bone  plug.  Close  the  wound  with  or  without  drainage 
and  treat  as  a  fracture. 

Step  4.^ — ^Excision  or  Resection  of  the  Joint. — Synovialectomy  or  excision 
of  local  osseous  foci  of  disease  is  inadequate:  it  is  necessary  to  remove  the 


Fig.  1288. — Arthrectomy. 
Lateral  incision. 


EXCISION    KNEE 


IO4I 


articular  ends  of  the  bone.     Flex  the  hi]).     Make  the  lower  end  of  the  femur 
protrude  through  the  wound  (Fig.  1290).     Apply  a  saw  at  right  angles  to  the 


■■^^^^H 

W  ^  ^^^^H 

^^^H 

PHi^ 

^^B^M^                                        i^^l 

^^Bl^^-                      ''^^1 

i^K'^^f'^f^'^^tefc"^     '.^^^^^^^H 

^^ 

_^^ 

Fig.  1289. — Arthrectomy  through  lateral  incision. 


Fig.  1290. — Arthrectomy  through  lateral  incision. 


femur  and  saw  off  the  articular  end  of  the  bone.  Be  careful  as  to  the  line  of 
section,  so  that  when  the  sawn  surfaces  of  the  femur  and  tibia  are  approxi- 
mated the  patient  may  have  a  straight  or  very  slightly  flexed  knee   without 


I042  KNEE-JOINT 

genu  valgum.     Riedel  ("  Zenl.  fur  Chir.,"  191 2,  No.  28),  before  applying  the  saw, 

extends  the  knee  into  the  natural  straight  position  and  then  saws  partially 

through  both  the  tibia  and  fibula.     With  the  hmb  in  this  position  it  is  much 

easier  to  divide  the  bones  in  the  correct  lines.     After  partial  division  of  the  bones, 

flex  the  knee  and  complete  the  bone  section.     With  forceps  or  saw  remove  the 

posterior  sharp  edge  of  the  raw  surface  of  the  femur.     Unless  this  is  done  the 

sharp  edge  of  bone  may  do  harm  and  between  the  remnants  of  the  epicondyles 

a  dead  space  is  left  which  may  interfere  with  healing  (Riedel).     Still  keeping  the 

thigh  flexed,  push  the  articular  end  of  the  tibia  upwards  so  as  to  be  clear  of 

the  soft  parts,  especially  those  of  the  popliteal  space.     Saw  a  thin  slice  from  the 

tibia,  keeping  the  saw  parallel  to  the  articular  surface.     With  forceps  trim  the 

sharp  edges  of  the  bone.     When  removing  the  lower  end 

of  the  femur  in  young  people,  be  careful  to  locate  and 

avoid  the  epiphyseal  line.     To  bring  this  line  into  view 

it  may  be  necessary  to  shave  away  a  thin  shce  from  the 

side  of  the  inner  or  outer  condyle.     Examine  the  raw 

surfaces  of  the  bone.     If  disease  is  found  remove  it  with 

the  sharp  spoon  or  chisel.     Review  the  whole  wound 

territory  and  remove  any  remnants  of  disease,  clean, 

preferably  by  dissection,  all  fistulous  tracts.     Close  the 

wound  with  or  without  drainage.     Treat  as  a  fracture. 

Voluminous    dressings    are    necessary.      Apply    a   long 

posterior  splint.     Put  the  patient  in  bed  with  the  limb 

elevated  to  an  almost  vertical  position.     This  position 

is  retained  for  at  least  twenty- four  hours. 

The  other  methods  of  arthrectomy  and  excison  may 

be  treated  shortly  as  they  differ  from  the  above  mostly 

in  the  manner  in  which  the  joint  cavity  is  exposed. 

Method  A  has  been  described  very  fully  merely  as  a 

matter  of  convenience  not  because  of  superiority  over 

„  ,,  ,     the  other  procedures  about  to  be  considered.   I 

Fig.  1291. — Volkmanns  ,«•    ,     f     t>       tt  «  .        .^  ■»  ■   .  . 

incision.  Metnod     B. — Volkmann's     Transverse     Incision. — 

From  one  epicondyle  to  the  other  make  an  incision 
which  passes  over  the  middle  of  the  patella  (Fig.  1291).  The  cut  is  made  to 
the  bone  throughout  its  whole  course,  and  opens  the  joint.  Saw  through  the 
patella  transversely.  With  sharp  retractors  pull  the  lower  fragment  of  the 
patella  forwards  and  downwards,  thus  exposing  the  synovialis  lining  the  an- 
terior wall  of  the  lower  pouch  of  the  joint.  With  forceps,  scissors  and  knife 
dissect  the  above-mentioned  portion  of  synovialis  from  its  connections  until 
the  semilunar  cartilages  are  reached.  Remove  the  semilunar  cartilages  and 
synoviaUs  together.  Divide  the  lateral  and  crucial  ligaments.  Flex  fhe  knee 
until  the  back  of  the  calf  lies  in  contact  with  the  thigh  and  pull  the  leg  down- 
wards. By  this  manoeuvre  the  joint  is  made  to  gape  widely  and  the  posterior 
portion  of  the  capsule,  viz.,  that  opposite  the  popliteal  space,  is  made  freely 
accessible  (Fig.  1292).  Dissect  away  the  posterior  synovialis.  Remember  the 
location  of  the  popliteal  vessels  and  nerves. 

With  sharp  retractors  pull  the  upper  fragment  of  the  patella  forwards  and 


EXCISION   KNEE  IO43 

upwards  and  dissect  away  the  synovialis  of  the  upper  pouch  in  the  same  manner 
as  was  done  with  the  lower.  The  deep  fascia  of  the  thigh  may  prevent  the 
necessary  elevation  of  the  flap  containing  the  patella;  if  this  is  so  make  a  longi- 
tudinal incision  through  the  fascia  on  each  side  of  the  patella,  without  cutting 
the  skin. 


Fig.  1292. — Arthrectomy. 

Excise  the  articular  ends  of  the  bones  as  already  described.  When  closing 
the  wound  it  is  necessary  to  unite  the  divided  patella  by  means  of  sutures,  pref- 
erably of  catgut  (chromicized  or  iodized). 

Method  C. — Make  a  U-shaped  incision  from  one  epicondyle  to  the  other, 
the  convexity  of  the  incision  corresponding  to  the  insertion  of  the  ligamentum 
patellae.  The  incision  only  involves  the  skin  and  subcutaneous  tissues.  Reflect 
the  U-shaped  skin  flap  upwards.  This  exposes  the  patella  and  part  of  the  cap- 
sule of  the  joint.  Make  a  transverse  incision  through  the  fascia  covering  the 
patella.  Bisect  the  patella  transversely  with  a  saw.  Divide  the  articular 
capsule  on  each  side  of  the  patella.     Proceed  as  in  Method  B. 

Method  D. — This  method  is  the  same  as  C  except  that  the  convexity  of  the 
skin  flap  is  upwards. 

Method  E.^ — ^Beginning  at  the  posterior  part  of  one  femoral  condyle  make 
a  curved  incision  which  ends  at  a  corresponding  point  on  the  other  side  of  the 
knee.  The  lowest  point  reached  by  the  curved  incision  is  in  the  middle  line 
at  the  insertion  of  the  ligamentum  patellae.  The  cut  reaches  to  the  bone 
throughout  its  whole  length.     The  flap  thus  outlined  contains  the  patella  and 


I044  KNEE-JOINT 

must  be  reflected  upwards.  The  rest  of  the  operation  is  to  be  carried  out  on  the 
lines  laid  down  in  describing  Method  B. 

Method  F. — -This  method  is  the  same  as  Method  E,  except  that  the  con- 
vexity of  the  curve  is  directed  upwards  and  the  quadriceps  tendon  is  divided 
instead  of  the  ligamentum  patellae. 

Method  G. — Same  as  Method  B,  but  the  addition  of  two  lateral  incisions 
makes  the  wound  H-shaped.  Riedel  advises  suturing  the  transverse  wound 
and  leaving  the  lateral  ones  to  heal  by  granulation. 

Remarks  on  Arthrectomy  and  Excision.— Use  of  Tourniquet  or  Elastic 
Constrictor. — A  few  surgeons  prefer  to  omit  the  use  of  the  elastic  constrictor, 
but  the  vast  majority  find  it  not  only  harmless,  but  most  useful. 

Konig's  plan  is  adopted  by  most  surgeons;  the  constrictor  not  being  loosened 
until  after  the  patient  has  been  returned  to  bed  and  his  leg  fijced  in  a  more  or 
less  vertical  position. 

Drainage. — Most  surgeons  provide  for  drainage  by  means  of  tubes,  rubber 
tissue,  cigarettes,  or  silkworm-gut.  Rutherford  Morison  closes  the  wound  with- 
out drainage  even  when  hemostasis  is  only  attended  to  by  posture  as  noted 
above. 

Approximation  of  the  Sawn  Ends  of  the  Bones. — Many  means  have  been 
used  to  maintain  apposition  of  the  bones:  bone  pegs,  screws,  removable  pins, 
wire,  suture,  etc.,  etc.  All  are  unnecessary.  If  the  bones  are  placed  in  apposi- 
tion and  kept  at  rest  by  means  of  a  splint  nothing  further  is  required. 

Treatment  of  the  Patella. — After  arthrectomy  the  patella  is  always  care- 
fully preserved;  after  excision  of  the  joint  it  has  frequently  been  removed. 
To  the  author  it  appears  that  it  ought  to  be  preserved  unless  it  is  the  site  of  too 
much  disease  to  permit  of  conservative  treatment. 

How  much  Bone  Ought  to  be  Removed  when  Excision  is  Practised? — 
(a)  The  fermur.  Never  injure  the  epiphyseal  line  in  the  young.  Remove  as 
little  of  the  bone  as  possible,  just  enough  to  provide  a  good  raw  surface  for 
union  with  the  tibia.  Remember  that  the  line  of  section  need  not  be  above 
the  highest  point  of  the  disease  (tuberculosis),  the  foci  of  disease  may  be  re- 
moved with  spoon  and  chisel.  As  a  rule,  less  of  the  tibia  is  removed  than  of  the 
femur.     From  the  patella  only  remove  diseased  tissue. 

In  performing  arthrectomy  in  children  many  surgeons  remove  the  articular 
and  patellar  cartilage  with  a  knife  till  raw  bony  surfaces  are  exposed.  This 
gives  good  bony  anchylosis. 

Indications  for  Operations  in  Tuberculosis  of  the  Knee. — The  tendency 
of  tuberculosis  is  towards  cure.  This  must  be  remembered  by  the  ambitious 
young  operator.  General  supportive  treatment,  especially  a  generous  supply 
of  proper  food  and  a  life  in  the  open  air  in  proper  surroundings  explain  why 
it  is  easier  to  get  good  results  in  the  rich  than  in  the  poor. 

When  tuberculous  disease  is  associated  with  much  effusion  into  the  knee, 
evacuation  of  the  fluid  and  injection  of  various  liquids,  e.g.,  iodoform  emulsion, 
are  beneficial  when  combined  with  other  conservative  treatment.  When 
tuberculous  abscesses  (cold  abscesses)  exist  in  connection  with  a  joint,  but  if 
the  joint  functions  are  still  fairly  well  preserved,  treat  the  abscess  as  an  indepen- 
dent lesion,  by  evacuation  and  injection  or  by  excising  its  lining  membrane  and 


ARTHRITIS   DEFORMANS  IO45 

closing  the  wound  without  drainage.  At  the  same  time  treat  the  joint  conser- 
vatively.    Secondary  (pyogenic)  infection  calls  for  radical  treatment. 

If  the  functions  of  a  joint  are  irreparably  lost  the  sooner  excision  of  the  tuber- 
culous synovial  membrane  and  other  diseased  parts  is  performed,  the  better. 
"The  best  test  of  the  amount  of  damage  done  to  the  joint  is  the  extent  of  its 
mobility  under  an  anaesthetic.  A  creaking  stiff  joint  with  only  slight  mobility 
under  anesthesia  should  be  excised"  (Morison). 

Any  method  of  operating  is  good  which  fills  the  following  requirements: 
Free  access  to  the  joint.  Ready  removal  of  all  diseased  tissues,  with  the  mini- 
mum destruction  of  healthy  structures,  and  the  reconstruction  of  a  sturdy 
useful  limb  with  an  anchylosed  knee  and  as  little  shortening  as  possible. 

Operation  is  far  more  rarely  indicated  in  children  than  in  adults.  In  adults 
belonging  to  the  poorer  classes  operation  may  be  required  to  save  time  and  ex- 
pense, although  the  disease  might  well  be  considered  curable  by  conservative 
means. 

Absolutely  typical  excisions  are  rarely  proper.  The  true  surgeon,  in  suitable 
cases,  explores,  removes  the  disease,  and  repairs  the  parts  in  the  manner  best 
calculated  to  give  a  useful  limb. 

At  present  anchylosis  is  almost  always  to  be  sought  for,  but  the  work  of 
Murphy  and  others  on  the  interposition  of  fat,  etc.,  between  the  joint  surfaces, 
leads  to  the  hope  that  even  after  excision  of  the  knee  for  tuberculosis  a  good 
movable  joint  may  be  obtained. 

Arthritis  Deformans. — W.  Miiller  ("Archiv  fiir  klin.  Chir.,  xlvii,  H.  i) 
advocates  operative  interference  in  certain  cases  of  arthritis  deformans  and 
reports  good  results.  The  operation  consists  in  exposing  the  articular  cavity 
by  lateral  incisions,  excising  all  the  diseased  synovialis,  extracting  all  foreign 
bodies  and  with  a  chisel  shaving  off  all  bony  excrescences.  The  capsular  and 
skin  wounds  are  separately  closed  with  sutures,  drainage  provided,  immovable 
dressings  applied  and  rest  maintained.  Passive  motion  is  begun  as  early  as  the 
third  w'eek.  The  after-treatment  consists  of  massage  and  of  movements 
(sometimes  under  anesthesia)  patiently  carried  out.  Active  motion  is  begun 
as  early  as  possible. 

Rutherford  Morison  has  in  two  cases  obtained  good  results  by  excising  the 
joint. 

In  cases  of  "Creaking  knees"  with  effusion  Robert  Jones  opens  the  joint, 
removes  all  fringes  present  and  closes  the  wound;  if  no  effusion  is  present  he 
does  not  operate. 

In  general  terms  it  may  be  said  that  in  arthritis  deformans  if  there  is  much 
pain  and  disability,  if  conservative  treatment  has  failed  to  give  relief,  ar- 
throtomy  is  indicated  for  exploration,  to  be  followed  by  some  form  of  atyp- 
ical resection  according  to  the  lesions  found. 

Congenital  Dislocation  of  the  Knee. — ^Hiibscher's  Operation. —  Hiibscher 
(von  Salis,  "Deutsche  Zeitschrift  fiir  Chir.,"  cxiv,  148)  operated  on  a  case 
of  anterior  dislocation  of  the  tibia  on  the  femur  in  a  girl  fourteen  months  of  age. 
The  patella  was  absent.  Manual  reduction  was  impossible.  The  skin  was 
reflected  in  a  flap  from  in  front  of  the  knee  (Fig.  1293).  The  tendo  patellae 
was  found  to  be  short  and  to  constitute  an  impediment  to  reduction.     The 


1046 


PATELLA.      TUBERCULOSIS 


tendon  was  incised  longitudinally  down  to  its  insertion  into  the  tibia  (Fig.  1294). 
A  portion  of  the  tibia  corresponding  to  the  insertion  of  one-half  of  the  tendo 
patellae  was  separated  from  the  rest  of  the  bone.  The  other  half  of  the  tendon 
was  divided  transversely  high  up.     Only  after  division  of  the  anterior  capsule 


Fig.  1293.  Fig.  1294.  Fig.  1295. 

Figs.  1293,  1294,  and  1295. — Hiibscher's  operation.     {Huhscher.) 

of  the  knee  was  complete  reduction  possible.  The  two  halves  of  the  patellar 
ligament  were  united  in  such  a  manner  that  the  fragment  of  tibia  attached  to 
one  of  them  lay  in  the  normal  position  of  a  patella  (Fig.  1295).  The  wound  was 
closed.  The  knee  was  immobilized  in  a  position  of  slight  flexion.  The  result 
was  good. 


CHAPTER  LXXXIII 


PATELLA.    TUBERCULOSIS 

In  cases  of  primary  tuberculosis  of  the  patella  when  the  focus  of  disease 
is  small  Murphy  advises  the  removal  of  the  diseased  focus,  the  filling  of  the 
resulting  cavity  with  Mosetig's  iodoform  plug  or  with  his  own  glycero-gelatin- 
formalin  plug.  [Murphy's  plug  is  made  as  follows:  Boil  100  c.c.  white  gelatin 
in  150  c.c.  glycerine  and  500  c.c.  water.  Add  i  to  2  per  cent,  of  formalin.] 
In  advanced  cases  which  do  not  involve  the  whole  patella  preserve  the  carti- 
lage between  the  patella  and  the  joint  for  fear  of  infecting  the  joint.  The 
cases  suitable  for  the  above  treatment  are  rare  and  more  rarely  still,  will  a 
sufificiently  accurate  diagnosis  be  made,  as  the  operation  should  be  carried 
out  without  direct  inspection  of  the  joint  cavity. 

When  the  patella  is  irreparably  diseased,  but  the  knee-joint  has  escaped 
tuberculous  involvement,  excision  of  the  patella  is  proper.  In  such  cases  the 
knee  will  have  suffered  from  acute  synovitis,  due  to  the  proximity  of  the  tuber- 
culous foci. 

Murphy's  Method  of  Excising  the  Patella. — Preliminary  Treatment.— 
Before  almost  all  operations  on  the  knee-joint  (fractures  of  patella,  misplaced 
cartilages,  etc.).     Murphy  produces  a  chemical  or  simple  arthritis  and  only 


EXCISION    PATELLA 


1047 


Fig.  1296. — Excision  of  patella.     {Murphy.) 


Fig.  I2g7.' — Excision  of  patella.     {Murphy.) 


1048 


PATELLA.       TUBERCULOSIS 


operates  after  the  palicnt  has  recovered  from  this.  He  beUeves  that  the 
cured  arthritis  produces  a  local  immunity  to  infection  and  traumatic  irritation. 
If  this  idea  is  correct,  and  Mur[)hy  has  a  habit  of  being  correct,  the  preliminary 
treatment  is  important. 

Twenty-four  hours  prior  to  use,  prepare  a  2  to  5  per  cent,  solution  of  formalin 
in  glycerine.  Inject  2  to  6  drams  of  the  solution  into  the  joint  a  week  or  ten 
days  before  operation. 

The  Operation. — Step  i. — Open  the  knee-joint  by  a  7-inch  incision  on  the 
outer  side  of  the  patella  (Fig.  1296),  ("Surg.,  Gyn.,  Obst.,"  March,  1908,  p.  266). 

Step  2. — Make  a  subaponeurotic  excision  of  the  patella,  leaving  the  cut  ends 
of  the  quadriceps  tendon  and  tendo  patellae  exposed. 


Fig   1298. — E.xcision  of  patella.     {Murphy.) 


Step  3. — Reflect  downwards  a  flap  (A  B  C  D)  (Fig.  1297)  consisting  of 
portions  of  the  quadriceps  tendon  and  vastus  externus  muscle.  The  flap 
must  be  long  enough  to  easily  reach  the  cut  end  of  the  tendo  patellae.  Stitch 
the  end  B  C  of  the  flap  to  the  ligamentum  patellae  either  in  the  end-to-end  or 
overlapping  fashion.     Close  with  sutures  the  defect  A  E  F  D. 

Step  4. — Suture  the  aponeurosis  of  the  patella  securely  to  the  divided  edge 
of  the  flap  (Fig.  1298). 

Step  5. — Close  the  skin  wound,  after  providing  for  drainage.  Apply  dress- 
ings and  a  straight  posterior  splint. 

It  was  shown  long  ago  by  Wharton  Hood  that  the  patella  is  by  no  means 
essential  to  good  function  of  the  knee,  hence  the  above  operation  does  not 
produce  so  much  disability  as  might  be  suspected. 


LINEAR    OSTEOTOMY    OF    FEMUR  1 049 


CHAPTER  LXXXIV 

OSTEOTOMY  FOR  BONY  ANCHYLOSIS  OF  THE  KNEE 

When  tuberculosis  is  the  cause  of  the  bony  anchylosis  it  is  wise  to  operate 
as  far  as  possible  from  the  joint  lest  encapsulated  infective  agents  be  let  loose. 
Operation  is  indicated  when  malposition  interferes  seriously  with  walking  or 
standing.  Whichever  method  of  operating  on  the  anchylosed  bones  is  chosen, 
contracture  of  the  ham-string  muscles  may  interfere  with  correction.  Under 
such  circumstances  tenotomy,  tendon  lengthening,  or  perhaps  transplantation 
of  the  ham-strings  into  the  quadriceps  tendon  becomes  necessary. 

Rhea  Barton  (1835)  was  the  first  to  perform  open,  and  Langenbeck  (1852) 
to  perform  subcutaneous  osteotomy  for  knee  anchylosis.  Gurdon  Buck 
excised  an  anchylosed  knee  (essentially  a  cuneiform  osteotomy)  in  1844. 

I.  Linear  Osteotomy  of  the  Femur. — On  either  the  inner  or  outer  side  of 
the  rectus  tendon  ''on  a  level  with  a  line  drawn  transversely,  a  finger's 
breadth  above  the  upper  portion  of  the  external  condyle,"  make  a 
longitudinal  wound  sufficient  to  admit  a  Macewen  osteotome.  Proceed 
exactly  as  in  supra-condyloid  osteotomy.  Figures  1299  and  1300  show  the 
result  of  this  section. 

II.  Linear  Osteotomy  of  Both  Femur  and  Tibia.^ — This  operation  is  suitable 
in  cases  where  section  of  the  femur  alone  is  insufficient.  Divide  the  femur  as 
described  in  the  preceding  paragraphs.  Divide  the  tibia  immediately  below 
the  anterior  tubercle  (see  p.  971).  Figure  1301  shows  the  result  of  the  double 
section.  Instead  of  making  a  linear  osteotomy  of  the  tibia  Werndorff  ("Wiener 
med.  Woch.,"  lix,  No.  23)  excises  a  wedge  of  bone  with  its  base  anterior.  This 
not  only  helps  in  correcting  the  deformity  but  provides  a  fragment  of  bone 
which  he  inserts  into  the  cleft  in  the  femur  after  it  has  been  divided  and 
straightened  (Fig.  1301). 

III.  Cuneiform  Osteotomy  of  the  Femur. — Expose  the  femur  as  in  linear 
osteotomy,  but  make  the  incision  through  the  soft  parts  more  generous.  With 
a  chisel  remove  a  segment  of  bone  as  in  Figs.  1302  and  1303.  This  operation 
is  calculated  to  correct  a  graver  deformity  than  could  the  simple  linear 
section. 

IV.  Cimeiform  and  Trapezoidal  Osteotomy  of  the  Anchylosed  Knee. — 
It  is  presumed  that  the  femur,  tibia,  and  patella  are  fused  into  one  bony  mass. 

Step  I. — Apply  an  elastic  constrictor  to  the  thigh.  Expose  the  parts  to  be 
removed  by  a  large  U  flap  having  its  base  directed  upwards  or  downwards 
(it  does  not  matter  which). 

Step  2. — With  an  amputating  saw  or  with  a  very  broad  chisel  excise  a  seg- 
ment of  bone.  The  upper  cut  through  the  bone  should  be  nearly  at  a  right 
angle  to  the  axis  of  the  femur,  the  lower  cut  nearly  at  a  right  angle  to  the  axis 
of  the  tibia  (Fig.  1304). 


I050 


OSTEOTOMY   FOR   BONY   ANCHYLOSIS    OF    THE    KNEE 


Step  3. — Attend  to  hemostasis.  Place  the  divided  surface  of  bone  in  apposi- 
tion (Fig.  1305).  Close  the  wound  with  sutures  after  providing  drainage. 
Apply  dressings.  Immobilize.  The  divided  ends  of  the  bones  may  be  kept 
in  apposition  by  being  pegged  or  sutured  together  or  merely  by  means  of  the 


Fig.  1299.  Fig.  1300.  Fig.  1301. 

Figs.  1299,  1300,  and  1301. — Anchylosis  of  the  knee. 

immobilizing  splint  or  dressing.  The  great  objection  to  the  above  operation 
is  the  unavoidable  shortening  of  the  limb  (a)  from  the  removal  of  such  a  mass 
of  bone,  {h)  from  injury  to,  or  destruction  of,  the  epiphyseal  cartilages  in  the 
young. 


Fig. 


1302. 


Fig.  1303. 


Fig.  1304. 

Dotted  line  shows  cuneiform  oste- 
otomy; shaded  area  shows  curvi-cunei- 
form   osteotomy. 


Figs.  1302,  1303  .-^^nd  1304. — Anchylosis  of  the  knee. 


V.  Curvi-cuneiform  Osteotomy. — To  avoid  shortening  inherent  to  ordinary 
cuneiform  osteotomy  of  the  knee  Helferich  ("Archiv  fiir  klin.  Chir.,"  xli, 
346;  xlvi,  445)  devised  a  curvi-cuneiform  operation. 


CURVI-CUNEIFORM    OSTEOTOMY  IO51 

Step  I. — Apply  an  elastic  constrictor  to  the  thigh.  Expose  the  anterior  and 
lateral  surfaces  of  the  fused  bones  by  a  large  U  flap  or  by  a  transverse  incision 
over  the  most  prominent  part  of  the  deformity.  Reflect  the  periosteum  from 
the  area  of  bone  to  be  attacked. 

Step  2. — Note  the  position  of  the  epiphyseal  line  of  the  femur  so  as  to  avoid 
it.  To  find  the  line  it  may  be  necessary  to  shave  off  a  thin  slice  of  bone  from 
the  outer  or  inner  side  of  the  femur  with  a  chisel.  This  exploration  does  no 
harm  and  may  do  much  good.  With  a  narrow-bladed  finger-saw  divide  the 
extreme  lower  end  of  the  femur  in  a  curve  corresponding  to  the  antero-posterior 
curve  of  the  condyles  (Fig.  1304). 

Make  a  similar  curvi-linear  section  of  the  upper  end  of  the  tibia.  The 
curve  of  the  tibial  section  need  not  be  so  pronounced  as  that  of  the  femoral. 
The  result  of  the  above  is  the  removal  of  a  curved  wedge  of  bone;  all  that  now 


Cuneiform  osteotomy  Curvi-cuneiform  osteotomy 

Fig.  1305.  Fig.  1306. 

Figs.  1305  and  1306. — Anchylosis  of  the  knee. 

obstructs  correction  is  the  presence  of  contracture  of  the  ham-strings  and  of 
fascia  (Fig.  1306). 

Step  3. — Through  short  longitudinal  incisions  on  each  side  of  the  popliteal 
space  divide  the  ham-strings  and  any  obstructing  fascia.  Remember  the 
location  of  and  avoid  injury  to  the  peroneal  nerve  between  the  biceps  and  the 
gastrocnemius.  Instead  of  carrying  out  a  mere  tenotomy,  it  might  be  well  to 
unite  the  divided  ham-strings  to  the  quadriceps  tendon.  Correct  the  deformity 
without  using  too  much  violence.  Helferich  noticed  that  in  some  cases  com- 
plete correction  interfered  with  the  vascular  supply  of  the  leg;  under  these 
circumstances  he  contented  himself  with  partial  correction  at  the  time  of  opera- 
tion, but  gradually  straightened  the  limb  during  the  after-treatment  before 
solidification  had  time  to  take  place. 

Step  4. — The  divided  bones  tend  to  remain  in  apposition.  Apposition 
may  be  maintained  by  pegs,  bone,  or  periosteal  sutures,  or  by  splints  outside 
the  dressings.  Provide  for  drainage.  Close  the  wound.  Apply  dressings. 
Immobilize.  Place  the  limb  in  a  position  of  great  elevation.  Remove  elastic 
constrictor. 


1052  OSTEOTOMY   FOR  BONY   ANCHYLOSIS    OF   THE    KNEE 

N.  B. — If  desired,  the  elastic  constrictor  may  be  removed  before  the 
wound  is  closed  and  hemostasis  be  effected  by  ligatures.  In  excision  of  the 
knee  the  author  has  found  that  elevation  of  the  limb  has  always  sufficed  for 
hemostasis. 

Anchylosis  of  Patella  to  Femur. — As  an  extreme  rarity  there  may  be 
bony  anchylosis  of  the  patella  to  the  femur  with  complete  integrity  of  the  rest 
of  the  femoral  articular  cartilage.  Immobility  of  course  is  the  result.  Hel- 
ferich  demonstrated  the  technical  possibility  of  correcting  this  disability  by 
division  of  the  anchylosis  and  interposition  of  a  flap  of  muscle.  Cramer, 
without  knowledge  of  Helferich's  suggestion,  made  use  of  the  same  idea  in  a 
suitable  case.     Cramer's  operation  may  be  performed  as  follows: 

Step  1. — ^Make  a  longitudinal  incision  on  the  inner  side  of  the  patella  of 
length  sufficient  to  give  access  to  the  line  of  anchylosis  and  to  the  lower  part 
of  the  vastus  internus. 

Step  2. — With  chisel  and  mallet  separate  the  patella  from  the  femur  along 
the  line  of  anchylosis. 

Step  3. — Mobilize  a  flap  of  muscle  from  the  vastus  internus,  the  pedicle 
of  the  flap  being  inferior;  tuck  the  muscular  flap  as  smoothly  as  possible  be- 
tween the  separated  bones. 

N.  B. — Instead  of  a  muscular  flap,  one  of  fat  and  fascia,  as  suggested  by 
Murphy,  may  be  used. 

Step  4. — Close  the  wound.  Dress.  Begin  exercises  as  soon  as  the  wound 
is  healed. 

Arthroplasty. — Before  deciding  on  operation  it  is  necessary  to  note: 

1.  The  character  of  the  anchylosis — whether  fibrous  or  bony  and  whether 
the  joint  cavity  is  or  is  not  obliterated. 

2.  The  condition  of  the  muscles  which  should  move  the  joint.  If  they  are 
insufficient  or  destroyed,  operation  is  evidently  useless. 

3.  The  condition  of  the  periarticular  structures.  If  they  are  soldered 
together  into  a  mass  of  scar  tissue  arthroplasty  is  impossible. 

4.  That  the  disease  causing  the  anchylosis  is  cured. 

5.  The  general  condition  of  the  patient. 

The  principles  on  which  the  operation  of  arthroplasty  depends  for  success  are 
the  following.     (Strict  asepsis  is  assumed.) 

1.  Free  exposure  of  the  joint  by  incisions  which  will  do  least  damage. 

2.  Liberation  of  the  anchylosed  surfaces  by  means  of  knife,  scissors,  saw 
chisel,  etc. 

3.  In  case  of  bony  anchylosis  it  is  usually  necessary  to  model  the  ends  of 
the  bone  and  to  reduce  their  size.  Payr  recommends  that  this  modeling  be  done 
on  simple  lines,  no  attempt  being  made  to  sculpture  the  end  of  the  bone  into 
its  normal  shape. 

4.  Excision  of  all  the  joint  capsule  as  well  as  contracted  bands  of  fibrous 
tissue  and  of  ligaments.  Both  Murphy  and  Payr  put  much  emphasis  on  this 
principle,  and  it  certainly  is  based  on  common  sense.  Excision  of  ligaments  and 
capsule  not  only  aids  directly  in  obtaining  free  motion,  but  indirectly  also,  as  it 
means  the  removal  of  the  articular  nerve  endings  and  thus  minimizes  post- 
operative pain  and  permits  earlier  and  infinitely  less  painful  motion.     In  ex- 


ARTHROPLASTY 


lO 


:)o 


cising  the  capsule  and  ligaments  where  they  are  inserted  in  the  bone  it  is  wise 
to  shave  away  a  piece  of  the  bone  with  them. 

5.  Prevention  of  recurrence  of  the  anchylosis.  This  is  attempted  by  the 
interposition  of  pedunculated  flaps  of  living  tissue  (fat-fascia;  muscle;  tendon; 
tendon  sheath);  free  (i.e.,  non-pedunculated)  flaps  or  grafts  of  living  tissue 
(fascia;  synovial  bursas;  cartilage,  etc.);  grafts  of  foreign  structures,  e.g.,  hog's 
bladder,  prepared  amnion,  etc. 

6.  Careful  hemostasis.     Avoidance  of  drainage  except  if  necessary  by  aspira- 
tion of  any  effused  blood   after   two   or  three 
days  (Payr).     Most  surgeons  use  drainage. 

7.  Careful,  methodical,  persistent  after-treat- 
ment. 

Payr  ("Munch.  Med.  Woch.,"  Ivii,  No.  37) 
warns  against  brusque  passive  movements  as 
calculated  to  cause  injury,  and  especially  hemor- 
rhage, which  can  easily  jeopardize  the  result  de- 
sired. The  same  surgeon  frequently  prevents 
pressure  by  the  ends  of  the  bone  on  the  inter- 
posed tissues  by  using  direct  extension  by 
means  of  Steinmann's  nails. 

As  soon  as  the  skin  wound  has  united 
change  the  position  of  the  joint  frequently. 
Keep  the  muscles  in  tone  by  massage,  hot  air, 
baths,  electricity,  etc.  Payr  finds  injections  of 
fibrolysin,  repeated  every  second  day,  service- 
able. 

Gentle  passive  motion  should  be  begun  at 
once  and,  what  is  of  greater  value,  active  mo- 
tion. Tendon  transplantation  may  be  neces- 
sary to  reinforce  w^eakened  muscles. 

Murphy's  Operation. — Many  researches 
(Ledderhose,  Langemak,  Thorn,  Franz,  etc.) 
have  proved  that  ganglia  and  bursae  are  the  re- 
sults of  a  degeneration  of  connective  tissue  and 
that  the  synovialis  of  joints  is  formed  origi- 
nally by  identically  the  same  process.     J.  B. 

Murphy,   accepting  these  truths,   applied   them  to   the  operation  of  arthro- 
plasty.    Applied  to  the  knee-joint,  his  operation  is  as  follows: 

Step  I. — Apply  the  elastic  constrictor  high  up  on  the  thigh.  Make  an  ex- 
ternal longitudinal  incision  from  a  point  6  inches  above  to  a  point  3  inches  below 
the  knee-joint  (Fig.  1307).  Do  not  incise  the  deep  fascia  except  to  the  extent 
necessary  for  opening  the  joint  for  overcoming  the  anchylosis.  Make  a  4-inch 
vertical  incision  over  the  inner  side  of  the  joint. 

Step  2. — With  scalpel,  chisel,  or  saw,  free  the  patella  from  the  femur.  Do 
not  divide  the  ligamentum  patellae  or  the  quadriceps  tendon. 

Step  3. — Thoroughly  divide  and  remove  the  lateral  ligaments  of  the  knee. 
Murphy  lays  great  stress  upon  this  step. 


Fig. 


1307. — Arthroplasty. 
(Murphy.) 


I054 


OSTEOTOMY   FOR  BONY   ANCHYLOSIS    OF   THE    KNEE 


Step  4. — (a)  If  anchylosis  is  fibrous,  break  or  divide  the  adhesions,  {b) 
If  anchylosis  is  bony,  divide  the  bone  with  chisel  or  saw  and  shape  the  ends  of 
the  femur  and  tibia  in  such  a  manner  that  the  lower  end  of  the  femur  is  convex 
and  the  upper  end  of  the  tibia  is  concave  from  before  backwards. 

Step  5. — Dissect  a  large  flap  of  fascia  lata,  with  a  thin  layer  of  muscle  at- 
tached, from  the  outer  surface  of  the  vastus  externus  (Fig.  1308).  The  base  or 
pedicle  of  the  flap  is  below  and  in  front.  The  flap  must  be  long  enough  to  pass 
through  and  project  from  the  inner  side  of  the  joint,  and  large  enough  to  envelop 
the  sawn  surface  of  the  femur.  Pull  the  flap  through  the  joint;  spread  it  over 
the  lower  end  of  the  femur;  fix  it  in  position  by  a  few  catgut  stitches. 


Fig.  1308. — Arthroplasty.     {Murphy.) 


Step  6. — In  a  similar  manner  prepare  a  smaller  flap  of  fascia  and  interpose  it 
between  the  patella  and  the  femur. 

Step  7. — Close  the  wound.  Provide  for  drainage.  Dress.  Immobilize  in 
the  extended  position.  Massage  and  gentle  passive  motion  may  be  begun  after 
the  first  week.  One  patient  operated  on  by  Murphy  has  obtained  good  use  of 
the  knee  without  the  necessity  of  any  supporting  apparatus. 

Davis's  Operation. — In  a  woman  of  23  with  bony  anchylosis  of  the  knee, 
the  result  of  general  articular  rheumatism,  G.  G.  Davis  ("Am.  Journ.  Ortho- 
pedic Surg.,"  iv,  p.  379)  made  use  of  Murphy's  methods  as  follows:  "Two long 
incisions  were  made  on  the  sides  of  the  joint  and  two  rectangular  flaps  about 
4  inches  long,  consisting  of  fat  and  fascia  lata,  turned  down.  The  patella  was 
sawn  loose  from  the  femur  horizontally  and  then  a  wedge-shaped  piece  of  bone 
excised,  2}^^  inches  (6  cm.)  long  on  its  anterior  side  and  i3^  inches  (4  cm.) 
long  on  its  posterior  side.  The  end  of  the  femur  was  sawn  slightly  convex  and 
the  end  of  the  tibia  slightly  concave.  One  flap  was  turned  in  under  the  patella 
and  over  the  femur  and  the  other  drawn  transversely  over  the  sawn  surface  of 
the  tibia  and  fixed  by  a  few  catgut  sutures.  The  hmb  was  put  up  in  an  ex- 
tended position  in  plaster.  Healing  by  primary  union  except  at  drainage-tube 
opening,  which  remained  open  perhaps  three  or  four  weeks.  When  healing  was 
complete  an  apparatus  consisting  of  two  side  irons  and  a  screw  mechanism  to 
limit  the  movement  of  the  joint  was  applied.  Movement  was  so  free  from  the 
start  that  the  screw  was  discarded  and  she  was  sent  home  on  crutches.  It  is  now 
nine  months  since  the  operation.     The  joint  can  be  readily  extended  straight  and 


JOINT   TRANSPLANTATION  IO55 

flexed  at  a  right  angle.  The  apparatus  is  essential  to  give  stability  to  the 
joint." 

The  author  saw  the  patient  two  years  after  operation.  Aided  by  the  ap- 
paratus, the  patient  walks  well  and  comfortably. 

Payr's  Operation.^ — Payr's  method  of  operating  is  in  all  essentials  like  that 
of  Murphy  and  Davis.  Occasionally  he  provides  artificial  lateral  ligaments 
of  silk  and  usually  keeps  the  surface  of  the  bone  apart  by  weight  and  pulley 
traction  exerted  directly  on  the  upper  end  of  the  tibia  by  means  of  nails  screwed 
into  the  bone  (p.  916). 

Implantation  of  Animal  Membranes.— Baer  ("Johns  Hopkins  Bulletin," 
Sept.,  1909)  made  experiments  with  the  implantation  of  Cargile's  membrane 
in  joints,  but  found  that  it  was  too  delicate  and  too  soon  absorbed.  Pig's 
bladder  properly  prepared  and  chromicized  to  last  from  thirty  or  forty  days 
in  sufficiently  durable,  pliable  and  tough  to  answer  the  purpose.  The  knee- 
joint  is  opened  by  lateral  incisions,  the  anchylosis  removed  and  the  membrane 
applied  so  as  to  be  adapted  to  the  whole  contour  of  the  joint  and  fixed  in  place 
by  sutures.  "Every  raw  surface  should  be  absolutely  separated  by  it  from  that 
with  which  it  would  normally  come  in  contact."  With  the  same  object,  por- 
tions of  hernial  sac  or  of  amnion  (Hermann  Schmerz,  "Zent.  f.  Chir.,"  Oct.  14, 
191 1),  washed  in  salt  solution  and  preserved  in  2  per  cent,  formalin  solution, 
have  been  employed. 

Joint  Transplantation  for  Anchylosis  of  Knee. — E.  Lexer  (''Archiv  fur 
klin.  Chir.,"  Ixxxvi,  952)  in  1908  described  two  cases  in  which  he  transplanted 
the  entire  knee-joint.  The  following  is  a  very  free  translation  of  Lexer's  de- 
scription. "One  of  these  two  cases  was  submitted  to  operation  seven,  the 
other  four,  months  ago.  In  both  there  was  synostosis  with  marked  flexion, 
due,  respectively,  to  suppuration  and  to  tuberculosis.  To  expose  the  joint  I 
formed  a  large  flap  in  front,  having  its  convex  lower  end  at  the  level  of  the  tuber- 
osity of  the  tibia,  so  as  to  permit  reflection  of  the  remnants  of  the  ligamentum 
patellae  and  of  the  articular  capsule  with  the  flap.  Only  in  the  first  case  was 
the  ligament  present,  while  in  both  the  capsule  was  destroyed.  After  exposing 
the  synostosis  in  front,  the  soft  parts,  including  the  tendon  insertions,  were 
separated  from  the  bones,  both  laterally  and  posteriorly,  by  sharp  and  blunt 
dissection.  The  sclerosed  periosteum  remained  attached  to  the  bone.  The 
anchylosed  joint  was  now  excised  in  such  a  manner  as  to  aid  in  reestablishing 
good  position.  In  each  case  the  defect  left  between  the  femur  and  tibia,  when 
the  limb  was  straightened,  was  about  three  fingers'  breadth  in  extent.  The 
knee  was  now  excised  from  a  freshly  amputated  limb.  The  portion  used  for 
transplantation  consisted  of  the  entire  articular  surfaces  and  about  i)-^  fingers' 
breadth  of  bone  belonging  to  the  femoral  and  tibial  epiphyses.  In  both  cases 
the  crucial  ligaments  were  intact;  in  the  first  case  the  semilunar  cartilages  were 
removed,  while  in  the  second  case  these  were  retained  as  were  also  the  lateral 
insertions  of  the  capsule.  When  the  implant  was  placed  in  position  it  was 
fixed  to  the  tibia  and  femur  by  means  of  nails  or  wire. 

"The  ligamentum  patellae,  preserved  in  one  case,  was  sutured  to  the  peri- 
osteum. Healing  took  place  in  both  cases.  In  the  first  case  passive  motion 
was  impossible  because  the  patella  had  been  merely  reflected  and  replaced  at 


io=;6 


OSTEOTOMY   FOR  BONY   ANCHYLOSIS   OF   THE   KNEE 


the  operation  without  having  its  under  surface  protected  by  interposed  material, 
and  so  it  became  adherent.  Three  months  later  the  patella  was  excised." 
During  this  second  operation  the  implant  was  inspected  and  proved  to  be  solidly 
in  place  and  alive.  Both  patients  have  a  small  degree  of  motion  (in  one  passive 
flexion  to  about  45°),  and  pain  neither  on  walking  nor  standing.  There  is  no 
lateral  motion. 

Remarks. — On  reading  Lexer's  most  delightful  and  brilliant  article  one  is 
reminded  of  the  famous  recipe  for  making  hare  soup,  which  began  with  the  words 
"first  catch  your  hare."  It  is  only  fair  to  state  that  in  Lexer's  clinic  there  seems 
to  be  a  large  number  of  cases  of  senile  gangrene  without  phlegmon,  and  it  is 
from  that  source  that  he  obtains  his  material  for  implantations. 

Juxta-  or  Supra-articular  Osteotomy, — Perkins'  Operation. — This  opera- 
tion, devised  and  carried  out  by  J.  W.  Perkins,  is  applicable  to  similar  condi- 
tions in  various  articulations,  but  is  perhaps  peculiarly  appropriate  in  the  knee. 
The  principles  of  the  operation  are:  (a)  Avoidance  of  injury  to  the  articular 
structures  and,  in  the  young,  to  the  epiphyseal  line,  (b)  Avoidance  of  injury 
to,  or  undue  stretching  of,  the  great  vessels  and  nerves  of  the  popliteal  space. 
(c)  Rectification  of  deformity  with  retention  of  any  power  of  movement  which 
the  joint  may  possess. 


Fig.  1309.  Fig.  1310. 

Figs.  1309,  1310,  1311  and  1312. 


Fig.  131 1. 
-Perkins's  operation. 


Fig.    131 2. 


The  operation  is  an  extension  of  the  basal  principles  of  Macewen'  supra- 
condyloid  osteotomy. 

Example  i. — The  knee  is  in  a  position  of  flexion;  a  moderate  degree  of  further 
flexion  is  possible  but  no  further  extension.  The  structures  (ligaments,  tendons, 
vessels,  etc.)  posterior  to  the  knee  are  contracted. 

The  Operation. — Step  i. — Make  a  longitudinal  incision  2^  to  3  inches  in 
length  down  to  the  bone  on  the  inner  side  of  the  thigh.  The  lower  end  of  this 
incision  should  be  about  }4  inch  above  the  epiphyseal  line.  If  necessary,  make 
a  similar  incision  on  the  outer  side  of  the  thigh. 

Step  2. — Separate  the  periosteum  from  the  bone  and  retract  the  soft  parts 
and  periosteum  together  so  as  to  expose  a  sufficient  area  of  bone. 

Step  3.— With  osteotome,  chisel,  or  saw  excise  the  rhomboid  of  bone  ab,  cd 
(Fig.  1309).     The  segment  of  bone  removed  must  be  sufficient  to  permit  the  limb 


DISLOCATION    OF    THE    PATELLA  IO57 

to  be  straightened.  The  short  side  of  the  rhomboid  (ac)  must  be  long  enough  so 
that  when  the  Hmb  is  straight  the  structures  behind  the  knee  are  not  unduly 
stretched. 

Siep  4. — Straighten  the  limb  (Fig.  13 10).  Close  the  wound  with  or  without 
drainage.     Treat  as  a  fracture. 

Osgood  (Surg.,  Gyn.,  Obst.,  xvii,  664)  describes  an  operation  very  similar 
to  that  of  Perkins. 

Example  2.- — Genu  Recurvatum. — The  knee  is  in  a  position  of  hyperexten- 
sion  (dorsal  flexion).  Further  extension  (dorsal  flexion)  is  possible,  but  only 
adds  to  the  deformity  and  disability.  Operate  as  in  Example  i,  but  make  the 
base  of  the  rhomboid  posterior  instead  of  anterior  (Fig.  1311).  Remove  so  much 
bone  that  when  the  divided  ends  of  bone  are  put  in  apposition  the  whole  limb  is 
straight  while  the  knee-joint  is  in  its  position  of  greatest  hyperextension  (Fig. 
13 1 2).     Shortening  of  the  flexor  tendons  of  the  knee  may  be  necessary. 

Wreden's  Operation.— (" Russki  Wratsch.,"  1910,  No.  6,  Ref.  "Zentralblatt 
fiir  Chir.,"  1910,  No.  22.)  Occasionally  some  motion  remains  in  a  knee  which 
has  recovered  from  tuberculous  disease  but  is  in  a  position  of  flexion.  In  these 
cases  Wreden's  operation  may  be  used. 

Through  an  appropriate  incision  (Wreden  uses  a  Y-shaped  incision)  expose 
but  do  not  open  the  upper  synovial  pouch  of  the  knee.  Reflect  downwards  the 
synovial  pouch  along  with  the  periosteum  of  the  femur.  Divide  the  femur 
transversely  close  to  the  knee;  make  the  lower  end  of  the  shaft  of  femur  pro- 
trude from  the  wound  and  with  a  saw  "sharpen"  the  end  of  the  bone  like  a  lead 
pencil.  In  the  sawn  surface  of  the  epiphysis  construct  a  hole  suitable  to  receive 
the  pointed  end  of  the  diaphysis.  Push  the  end  of  the  diaphysis,  like  a  peg,  into 
the  hole  in  the  epiphysis  after  straightening  the  limb.  The  principle  of  the 
operation  is  the  same  as  that  of  Perkins'  method. 


CHAPTER  LXXXV 
DISLOCATION  OF  THE  PATELLA 

Recent  outward  dislocation  of  the  patella  may  be  irreducible  without  opera- 
tion when  the  ligamentum  patellae  becomes  caught  under  the  external  condyle  of 
the  femur,  or  when  there  is  such  rotation  of  the  patella  on  its  long  axis  that  its 
cartilaginous  surface  faces  forwards.  A  longitudinal  incision  made  to  the  inner 
side  of  the  patella  permits  of  reduction  and  at  the  same  time  gives  an  oppor- 
tunity to  suture  the  torn  inner  capsule  and  any  fibres  of  the  vastus  internus 
which  may  be  ruptured. 

In  old  unreduced  patellar  dislocations  there  is  always  lateral  elongation  of 
the  capsule  on  one  side  of  the  bone  and  there  may  be  cicatricial  contraction  on 
the  other  side.  (The  dislocation  is  almost  always  outwards,  hence  the  elonga- 
tion of  the  capsule  is  on  the  inner  side.)  If  disability  is  marked,  operation  is 
demanded. 

Make  an  incision  to  the  inner  side  of  the  patella  and  open  the  joint.  If 
possible  reduce  the  dislocation  and  shorten  the  elongated  capsule  laterally 

67 


1058  DISLOCATION    OF    THE    PATELLA 

either  by  excising  an  elliptical  segment  and  closing  the  wound  by  sutures  or  by 
closing  the  original  longitudinal  wound  in  such  a  fashion  as  to  make  one  edge 
of  the  wound  overlap  the  other.  If  contraction  of  the  outer  portion  of  the  cap- 
sule renders  reduction  by  simple  arthrotomy  impossible,  a  longitudinal  incision 
may  be  made  through  the  contracture.  Access  to  the  portion  of  capsule  at 
fault  may  be  obtained,  according  to  circumstances,  (o)  through  the  original 
wound,  through  the  joint  cavity,  under  the  patella,  the  capsular  division  being 
made  from  within  outwards;  (b)  through  the  original  wound  by  dissecting  the 
skin  from  over  the  patella,  retracting  the  skin  and  cutting  the  capsule  from  with- 
out inwards;  (c)  through  a  special  incision. 

If  hemostasis  is  complete  close  the  wound  without  drainage,  otherwise  insert 
a  drain  of  rubber  tissue  or  oil-silk  for  about  twenty-four  hours.  Dress.  Immo- 
bilize in  a  semi-flexed  position  until  the  wound  has  healed.  After  two  weeks 
begin  massage  and  passive  motion.  Walking  may  usually  be  begun  in  about 
five  weeks. 

Recurrent  or  Habitual  Dislocation  of  the  Patella. — When  orthopedic  appara- 
tus proves  inefficient  or  inconvenient,  operation  is  indicated. 

The  principal  conditions  favoring  the  occurrence  of  habitual  dislocation 
(Hildebrand)  are  the  following: 

1.  External  condyle  absolutely  or  relatively  less  prominent  than  internal 
condyle. 

2.  Patellar  fossa  too  small. 

3.  Genu  valgum. 

4.  Abnormal  external  rotation  of  the  lower  leg. 

5.  Abnormal  laxness  of  the  quadriceps  femoris  or  of  the  ligamentum 
patellae. 

6.  Injuries  of  the  capsule,  tears  of  the  capsule  or  of  the  vastus  internus  or  its 
tendon  which  have  healed  and  stretched. 

7.  Stretching  of  the  capsule  in  genu  valgum,  e.g.,  occasioned  by  hydrops,  etc. 
A  longitudinal  incision  along  the  inner  side  of  the  patella  down  to,  but  not 
through,  the  joint  capsule  permits  examination  as  to  its  laxity.  If  laxity  of  the 
capsule  is  the  main  lesion,  it  is  easy  (a)  to  excise  an  ellipse  from  it  and  close  the 
wound  with  sutures,  (b)  to  incise  the  capsule  and  close  the  wound  in  such  a 
fashion  that  one  edge  overlaps  the  other,  or  (c)  to  catch  the  unopened  capsule  in 
forceps,  throw  it  into  folds  and  fix  these  folds  with  sutures. 

If  the  dislocation  is  due  to  improperly  imited  tears  of  the  vastus  internus 
and  its  tendon,  the  same  longitudinal  incision  exposes  such,  and  they  may  be  so 
repaired  that  the  muscle  can  once  more  act  properly  on  the  patella.  Traumatic 
hydrops  may  cause  habitual  dislocation  in  a  knock-kneed  subject.  Osteotomy 
correcting  the  knock-knee  has  cured  the  dislocation  (Hildebrand).  Hildebrand 
reports  a  case  in  which  there  was  a  flattening  of  the  external  condyle  but 
no  knock-knee;  when  the  knee  was  extended  there  was  incomplete  luxation, 
but  in  flexion  the  luxation  disappeared.  The  tuberosity  of  the  tibia  was  trans- 
planted inwards;  the  result  was  excellent. 

The  above  hints  show  that  in  habitual  dislocation  of  the  patella  the 
surgeon  must  not  be  governed  by  hard  and  fast  rules,  but  must  as  far  as 
possible  be  guided  in  his  treatment  by  a  study  of  causation. 


DISLOCATION    PATELLA 


1059 


Goldthwaite's  Operation. — In  uncomplicated  cases  of  recurring  dislocation 
of  the  patella  Goldthvvaite's  operation,  either  alone  or  plus  capsulorrhaphy, 
is  excellent. 

Step  I. —  Expose  the  tendo  patellae  freely  through  a  longitudinal  incision. 

Step  2. — SpHt  the  tendon  longitudinally.  Divide  the  outer  half  of  the  tendon 
transversely  at  its  insertion  into  the  tibia  thus  forming  a  tendon  flap  which  has 
its  base  above  the  patella. 

Step  3. — With  closed  scissors  or  forceps  burrow  under  the  inner  (intact)  half 
of  the  patellar  tendon,  pull  the  mobilized  flap  of  tendon  through  this  tunnel  and 
unite  it  by  sutures  to  the  periosteum  and  to  the  expansion  of  the  tendon  of  the 
sartorius  muscles  (Fig.  13 13). 


Gracilis.!. 


Fig.  1313. — Goldthwaite's  operation. 


Fig.  1314. 


Whitelocke's  Operation — (Brit.  Journ  Surg.,  II,  12). — i.  Reflect  a  large, 
horseshoe-shaped  flap  of  skin  and  fascia  with  its  base  in  front  and  its  apex  reach- 
ing backwards  to  the  line  of  the  medial  ham-strings.  The  base  of  the  flap  cor- 
responds to  the  medial  margins  of  the  patella  and  its  hgament. 

2.  Expose  the  ligamentum  patellae  for  about  ^  inch  and  perforate  it  for 
about  }A  inch  in  the  middle  line. 


3.  Recognize  the  Sartorius  muscle  by  the  direction  of  its  muscular  fibres. 
Divide  the  fascial  attachment  of  this  muscle  above  and  behind  and  retract  its 
posterior  edge  forwards  to  expose  the  tendon  of  the  gracilis  which  lies  proximal 
to  the  semitendinosus.  Free  the  gracflis  from  its  surroundings,  being  careful  not 
to  injure  some  vessels  and  a  nerve  which  run  parallel  to  it.  Divide  the  gracilis 
as  close  to  its  tibial  insertion  as  possible.  At  its  insertion  the  tendon  spreads 
out  into  a  thin  expansion  about  2  inches  in  vertical  diameter. 

4.  Pull  the  end  of  the  tendon  from  behind  forwards  through  the  split  al- 
ready made  in  the  ligamentum  patellae  and  fix  it  there  with  sutures  (Fig.  13 14). 
The  tendon  in  its  new  position  passes  almost  horizontally  forwards  around  and 
over  the  internal  tuberosity  of  the  tibia.  With  a  few  stitches,  which  should  not 
penetrate  the  joint,  anchor  the  tendon  in  its  new  course  to  the  articular  capsule. 
Repair  the  connections  of  the  edge  of  the  Sartorius  which  were  dissected  in 
exposing  the  gracilis. 

If  the  gracilis  is  not  long  enough  to  reach,  without  tension,  to  the  ligamentum 
patellae,  it  is  easy  to  mobilize  a  flap  of  that  ligament  and  sew  its  free  end  to 
the  end  of  the  gracilis  tendon. 


io6o 


DISLOCATION   OF    THE   PATELLA 


5.  Close  the  wound.  Dress.  Apply  a  posterior  splint  for  about  ten  days 
or  until  the  wound  has  healed. 

Wullstein's  Operation. — In  a  severe  case  of  external  congenital  dislocation 
of  the  patella  Wullstein  ("Zentralblatt  fiir  Chir.,"  1906,  No.  38)  found 
that  the  inner  portion  of  the  joint  capsule  was  excessive  in  quantity  while 
the  outer  was  correspondingly  narrow.     He  operated  as  follows: 

Step  I. — By  means  of  a  horseshoe-shaped  incision  reflect  upwards  a  very 
large  flap  of  skin  from  over  the  knee-joint  and  thus  expose  the  anterior  and  most 
of  the  lateral  aspects  of  the  joint  as  well  as  the  ligamentum  patellae  to  below  the 
tibial  tuberosity  and  the  quadriceps  tendon  to  a  point  above  the  superior  recess 
of  the  synovialis. 

Step  2. — By  blunt  dissection  separate  the  quadriceps  tendon  and  the  liga- 
mentum patellae  from  the  underlying  portion  of  the  joint  capsule. 


Fig.  1315.  Fig.  1316. 

Figs.  1315  and  1316. — Wullstein's  operation.     {Wullstein.) 


Step  3. — To  the  outer  side  of,  and  about  3<4  inch  from  the  patella  incise  the 
capsule  (both  fibrous  and  synovial)  along  the  line  C  D  (Fig.  1316).  Make  the 
corresponding  incision  A  B  (Figs.  1315  and  1316)  on  the  inner  side  of  the  patella. 
Retract  and  elevate  the  quadriceps  muscle  and  tendon  from  the  upper  recess 
of  the  synovialis  and  continue  the  incision  A  B  and  C  D  upwards  to  meet  at  the 
point  E  corresponding  to  the  highest  part  of  the  joint  cavity.  Elevate  or  retract 
the  ligamentum  patellae  and  continue  the  incisions  A  B  and  C  D  downwards  to 
meet  at  the  point  B. 

Step  4. — Push  the  patella  inwards  to  the  extent  necessary  for  correction  of  the 
deformity.  Note  how  much  of  the  inner  portion  of  the  capsule  is  excessive  and 
guided  by  that  information  make  the  incision  X  Y  (Fig.  13 15)  parallel  to  A  B. 
Retract  the  vastus  internus  and  continue  the  cut  X  Y  under  the  vastus  to  the 
point  Z. 

Step  5. — The  incisions  F  B  A  E  and  Y  X  Z  form  a  flap  Q  of  joint  capsule  on  the 
inner  side  of  the  joint.     Transfer  the  flap  Q  under  the  patella  from  the  inner  to 


ARTHROTOMY   ANKLE 


I061 


the  outer  side  of  the  joint.  When  the  patella  is  pushed  into  its  correct  position 
the  wound  made  by  the  incision  E  C  D  B  (Fig.  13 16)  gapes.  Into  this  defect  on 
the  outer  side  of  the  joint  suture  the  flap  Q. 

Step  6. — Suture  the  capsular  wounds. 

Step  7. — Mobilize  the  sartorius  muscle  and  suture  its  outer  edge  to  the  inner 
edge  of  the  patella.     This  aids  in  keeping  the  patella  in  position. 

Step  8. — Close  the  wound.     Dress.     Immobilize. 


CHAPTER  LXXXVI 


ANKLE 

Puncture  and  Injections.- — Krause  recommends  that  the  trocar  puncture  the 
tissues  vertically  immediately  below  one  or  the  other  malleolus  and  then  that 
its  points  be  directed  upwards.  If  injections  are  necessary  they  may  be  made 
more  definitely  through  an  arthrotomy  incision  than  by  means  of  the  trocar. 
The  material  used  for  injection  varies  (carbolic  solution,  formalin-glycerine, 
iodoform  in  glycerine,  oil  or  ether,  etc.). 

Arthrotomy. — Step  i. — Make  a  2-inch  vertical  incision  along  the  anterior 
border  of  the  external  malleolus  and  ending  about  ^^  inch  below  the  tip  of 
the  malleolus.  The  extensor  tendons  and  the 
peroneus  tertius  lie  to  the  inner  side  of  the  incision. 
Divide  the  annular  ligament.  Open  the  joint 
immediately  in  front  of  the  malleolus. 

Step  2. — Pass  a  closed  forceps  through  the 
above  incision  across  the  ankle  to  the  inner  side 
of  the  limb  (Fig.  13 17).  The  forceps  must  be  in 
contact  with  the  bone,  must  pass  through  the 
joint  itself  and  so  lie  behind  the  synovial  sheath 
of  the  extensor  tendons.  Make  the  point  of  the 
forceps  raise  the  soft  parts  immediately  in  front  of 
the  internal  malleolus.  Divide  the  soft  parts  over 
the  point  of  the  forceps.  If  tubular  drainage  is 
desired  it  is  easy  to  pull  a  tube  through  the  joint. 
Experience  shows  that  a  tube  in  a  joint  is  very 
harmful  and  thus  if  a  tube  is  used  it  must  never  penetrate  the  synovialis.  Willems' 
principles  of  immediate  active  motion  as  the  best  means  of  drainage  (p.  103 1) 
must  be  remembered  though  as  Chutro  remarks  such  may  be  difficult  to  carry 
out  and  if  pain  is  absent  it  might  be  wise  to  use  the  Wassermann  test  lest  the 
want  of  pain  be  due  to  specific  disease. 

If  instead  of  draining  the  joint  it  is  desired  to  fill  it  with  iodoform  emulsion  or 
such  like  material,  this  may  be  done  through  the  incision  and  the  wound  closed 
with  sutures. 

Step  3. — If  the  single  or  double  anterior  arthrotomy  wound  is  insufficient 
for  drainage,  it  is  easy  to  make  a  posterior  counterpuncture  on  the  outer  side  of 
the  tendo  achillis.     If  it  is  necessary  to  incise  on  the  inner  side  of  the  tendo 


Fig.  1317. — Drainage  of  the 
ankle.     (Labey.) 


io62 


ANKLE 


achillis,  remember  the  position  of  the  posterior  tibial  vessels  and  nerve  as  well 
as  the  flexor  tendons  of  the  foot  and  avoid  them. 

Excision  of  the  Ankle. — ^Langenbeck's  Subperiosteal  Resection  of  the 
Ankle. — ^Lay  the  foot,  inner  side  downwards,  on  a  firm  sand-bag.  On  the  pos- 
terior margin  of  the  fibula  make  a  longitudinal  incision  i3^  to  23'^  inches  in 
length,  directly  to  the  bone.  The  lower  end  of  the  cut  is  opposite  the  tip  of  the 
malleolus.  Some  surgeons  prefer  an  I-shaped  incision  on  the  outer  surface  of  the 
fibula  (Fig.  1318). 

With  periosteal  elevator  separate  the  periosteum  and  soft  parts  together 
from  the  external  and  anterior  surfaces  of  the  bone.  At  the  lower  end  of  the 
malleolus  it  is  necessary  to  supplement  the  blunt  dissection  by  cutting  with 
scissors  or  knife.     In  cutting,  the  edge  of  the  knife  or  the  point  of  the  scissors 


.jf . 


Fig.  1318.  Fig.  13 19. 

Figs.  1318  and  1319. — Excision  ankle.     (Labey.) 


must  be  directed  against  the  bone  to  avoid  injury  to  the  periosteum  and  soft 
parts.  This  shelling  of  the  soft  parts  from  the  bone  is  carried  forwards  to  the 
synovial  insertion,  which  is  also  separated  from  the  bone. 

In  similar  fashion  clear  the  posterior  surface  of  the  fibula  of  its  coverings 
until  the  interosseous  ligament  is  reached  and  divided.  The  ligament  should  be 
injured  as  little  as  possible.  Chose  the  point  at  which  it  is  desired  to  divide  the 
fibula.  Protect  the  soft  parts  with  a  retractor  or  periosteal  elevator  and  divide 
the  bone  with  a  Gigli  wire  saw  or  chisel  (Fig.  1319).  Seize  the  upper  end  of  the 
sawn  off  portion  of  bone  with  lion  forceps,  pull  it  outwards,  divide  or  separate  all 
adhesions  with  the  elevator,  knife,  or  scissors  and  remove  the  bone.  Lay  the 
foot  on  its  outer  side.  Make  a  vertical  incision  from  the  tip  of  the  internal  mal- 
leolus upwards  for  2^^  inches  along  the  middle  line  of  the  tibia.  If  desired  one 
may  supplement  the  vertical  by  a  transverse  curved  incision  at  its  lower  end  or 
by  a  transverse  incision  at  each  end.  The  periosteum  is  divided  at  the  same 
time  as  the  skin.  With  straight  and  curved  periosteal  elevators  separate  the 
periosteum  and  all  structures  superficial  to  it  (tendons,  vessels,  nerves,  etc.)  from 
the  bone.  Divide  the  tibia  with  a  saw  or  chisel  at  the  same  level,  if  possible,  as 
the  fibula.  With  forceps,  pull  the  lower  fragment  of  bone  outwards  and  down- 
wards, at  the  same  time  severing  its  connections  to  the  interosseous  membrane 


ARTHROTOMY    ANKLE 


1063 


and  articular  capsule  with  the  periosteal  elevator,  knife,  or  scissors.  Remember 
always  to  cut  against  the  bone  so  as  to  avoid  unnecessary  injury.  Remove  the 
bone. 

(Oilier  advises  that  the  bones  should  be  divided  obliquely;  the  line  of  section 
being  from  above  and  within,  downwards  and  outwards.  He  states  that  by  so 
proceeding  greater  solidity  of  the  ankle  results.) 

E.xamine  the  astragalus.  If  it  is  diseased,  but  not  to  a  serious  extent, 
remove  the  diseased  tissues  with  the  sharp  spoon  or  chisel.  With  forceps  and 
scissors  trim  away  ragged  and  loose  pieces  of  cartilage.  If  it  is  necessary 
to  remove  the  whole  superior  portion  of  the  body  of  the  astragalus  this  may  be 
accomplished  with  the  chisel  or  saw.  If  the  saw  is  used  the  soft  parts  must  be 
protected  by  using  suitable  retractors  or  by  holding  them  aside  and  covering  them 
with  periosteal  elevators.  Pack  the  cavity  of  the  wound  with  iodoform  gauze 
leaving  the  incisions  open,  or  partially  close  the  incisions  with  sutures  and  provide 
tubular  drainage.     If  no  secondary  infection  is  present,  the  wound  cavity  may 


Fig.  1320. — Skeleton  splint  for  injuries 
near  the  ankle-joint.  (Robert  Jones,  British 
Med.  Jo  urn.) 


Fig.     1321. — Skeleton    splint    applied 
(Robert  Jones,  British  Med.  Journ.) 


be  filled  with  Mosetig's  iodoform  plug  or  some  equivalent  and  closed  without 
drainage.  Dress.  Immobilize  preferably  with  Jones'  splint  (Figs.  1320,  1321). 
If  plaster  of  Paris  is  used  while  it  is  hardening  the  foot  must  be  held  in  a 
position  at  right  angles  to  the  leg  and  neither  everted  nor  inverted.  If  much 
shortening  is  expected  the  foot  may  be  held  in  a  position  of  slight  plantar 
flexion. 

Konig's  Operation. — Konig's  operation  gives  admirably  free  access  to  the 
ankle-joint  and  is  specially  indicated  in  tuberculous  disease  where  it  is  impor- 
tant to  expose,  observe,  and  treat  not  merely  the  ankle  itself  but  the  bones  and 
joints  which  lie  near  it.  From  a  point  on  the  anterior  margin  of  the  tibia  i^^  to 
2^^  inches  above  the  ankle-joint  and  immediately  internal  to  the  extensor  ten- 
dons make  an  incision  downwards  and  forwards  over  the  articulation,  over  the 
inner  side  and  neck  of  the  astragalus  to  end  in  front  of  the  prominence  of  the 
scaphoid.  On  the  outer  side  of  the  ankle  make  a  similar  incision  along  the 
anterior  surface  and  margin  of  the  fibula,  across  the  articulation  and  ^ding  on 
the  outer  side  of  the  cuboid  at  the  level  of  the  astragalo-scaphoid  joint.  With 
forceps,  knife,  and  elevator  separate  the  whole  bridge  of  tissue  between  the  two 
cuts,  from  the  underlying  bones  (Fig.  1322).  If  the  case  is  one  of  tuberculosis, 
put  the  foot  in  a  position  of  dorsal  flexion,  lift  the  tissue  bridge  out  of  the  way 
with  a  blunt  hook,  examine  the  whole  anterior  articular  region,  remove  by 
dissection,  the  anterior  synovialis,  and,  if  a  partial  operation  will  suffice,  remove 


1064 


ANKLE 


any  diseased  bone  with  chisel  and  spoon.  Konig  writes:  "If  a  large  focus  is 
present  in  the  astragalus  there  is  always  danger  that  the  three  neighboring 
joints  are  affected  and  one  must,  as  a  rule,  remove  the  astragalus.     The  removal 


Fic.   1322. — Excision  of  ankle. 


Fig.  1323. — Excision  of  ankle. 


may  be  effected  through  either  incision,  preferably  through  the  inner,  by  the  use 
of  forceps,  scissors,  and  knife  with  the  assistance  of  strong  periosteal  elevators." 
After  the  astragalus  is  removed  a  good  view  can  be  had  of  neighboring  structures 
and  from  them  diseased  foci,  if  limited  in  extent,  may  be  removed. 


AFTER    TREATMENT  I065 

If  before  the  astragalus  is  removed  it  is  known  that  the  malleoli  ought  to 
be  excised  one  proceeds  as  follows: 

Make  the  incisions  as  already  described  down  to  the  bone,  but,  although 
dividing  the  periosteum  do  not  separate  it  from  the  malleoli  (Fig.  1323).  Intro- 
duce a  broad-bladed  chisel  into  the  wound  and  cut  from  the  outer  surface  of 
the  malleoli  a  thin  shell  of  bone.  This  osseous  shell  is  covered  by  its  periosteum 
which  is  continuous  above  with  the  periosteiim  of  the  tibia  or  fibula  as  the  case 
may  be  and  below  with  the  lateral  ligament.  Retract  the  shell  of  bone  outwards 
along  with  its  attachments,  divide  the  rest  of  the  bone  transversely  with  the 
chisel,  and  remove  the  fragment.  The  rest  of  the  operation  is  to  be  carried 
out  as  already  described.  By  the  above  procedures  even  the  calcaneal  and 
scaphoid  joints  can  be  reached  and  treated. 

The  active  operation  being  ended,  clean  the  wound  cavity  and  rub  it  with 
iodoform,  provide  drainage  either  with  tubes  or  iodoform  gauze,  partially 
close  the  wound  with  sutures,  press  the  loosened  shells  of  bone  inwards,  and 
apply  dressings.  As  an  alternative,  fill  the  cavity  with  Mosetig's  iodoform 
wax  and  close  without  drainage.  Immobilize  as  in  Oilier'  operation.  As  an- 
chylosis is  desired,  the  after-treatment  consists  in  keeping  the  parts  at  rest 
until  they  have  become  firm.  If  sinuses  form  and  persist  they  must  be  dilated 
or  opened  and  their  cause  removed. 

Ochsner's  Method. — Operation. — An  incision  is  carried  directly  across  the 
anterior  surface  of  the  ankle  from  malleolus  to  malleolus  through  the  skin 
superficial  and  deep  fascia  and  the  sheaths  of  all  the  tendons  in  the  course  of 
the  incision.  Externally  the  peroneal  artery  and  nerve  should  be  avoided,  as 
well  as  the  tendons  of  the  peroneal  muscles,  which  can  readily  be  drawn  out  of 
the  way.  Internally  the  posterior  artery  and  nerve  should  be  protected.  Each 
tendon  is  then  lifted  up  in  the  incision  and  transfixed  with  two  fine  catgut 
sutures  from  i  to  2  centimetres  apart.  These  sutures  are  caught  in  similar 
artery  forceps  for  purposes  of  identification,  then  the  tendon  is  cut  transversely 
between  these  sutures  (Fig.  1324).  After  all  the  tendons  have  been  disposed 
of  in  this  manner,  the  joint  is  opened  by  a  free  transverse  incision  and  the  sole 
of  the  foot  is  forced  back  upon  the  calf  of  the  leg.  In  this  manner  the  entire 
joint  is  opened  freely,  so  that  all  diseased  tissue  can  be  removed.  After  this 
has  been  accomplished,  the  foot  is  placed  in  position,  the  tendons  are  carefully 
adjusted,  which  can  be  done  with  great  ease,  because  the  two  sutures  upon 
two  corresponding  tendon  ends  are  fastened  to  hemostatic  forceps  of  the  same 
pattern.  Each  tendon  is  carefully  sutured  and  a  fine  stitch  is  placed  in  the 
fascia  to  cover  the  line  of  suture  in  the  tendon. ,  Then  the  skin  is  sutured  over 
all.  If  drainage  seems  necessary,  this  is  applied  through  and  through,  and  even 
in  cases  apparently  requiring  no  drainage,  I  have  usually  passed  a  few  strands 
of  catgut  or  silkworm-gut  entirely  across  the  foot,  permitting  the  ends  to  pro- 
trude from  the  lower  angles  of  the  wound  in  order  to  drain  the  serum  which  may 
be  secreted  by  the  large  surface  during  the  first  few  days.  A  large  dressing  is 
applied  and  the  foot  is  immobilized  in  a  position  at  a  little  less  than  right  angle. 

After-treatment. — The  foot  is  elevated  in  order  to  favor  return  circulation. 
If  drainage  has  been  employed,  this  is  left  in  place  from  one  to  two  weeks. 
The  dressing  is  not  changed,  unless  this  is  indicated  by  the  discharge,  for  a 


io66 


ANKLE 


week  or  ten  days,  in  order  to  avoid  moving  the  foot,  and  after  that  as  seldom 
as  possible  for  the  same  reason. 


Fig.   1324. — Excision  of  ankle.     (Oclisncr.) 


Prognosis.- — The  prognosis  is  very  good  after  this  operation.  The  free 
exposure  of  the  surfaces  insures  thoroughness,  and  consequently  the  cure  is 
usually  permanent.  The  anchylosis  of  the  surfaces  immediately  in  the  field 
of  operation  does  not  interfere  with  movement  because  the  tarso-metatarsal 
joint  will  supply  the  motion  necessary.     The  tendons  unite  readily  and  act 


DISLOCATION    ASTRAGALUS  I067 

normally.  There  is  no  operation  for  the  relief  of  joint  tuberculosis  that  has 
given  me  more  satisfaction  than  this  one  just  described.  With  this  method 
it  is  possible  often  to  obtain  a  useful  foot  in  cases  which  formerly  could  only  be 
relieved  by  an  amputation  (Ochsner,  ''Clinical  Surgery,"  p.  727). 

Remarks. — Arthrotomy  is  indicated  in  cases  of  pyogenic  arthritis  to  provide 
drainage.  It  may  also  be  used  as  a  preliminary  to  filling  the  joint  cavity  with 
iodoform  emulsion.  Arthrectomy  is  rarely  indicated.  The  results  are  not 
usually  very  gratifying  and  amputation  is  usually  the  operation  of  choice  when 
conservative  treatment  and  minor  operations  fail. 


CHAPTER    LXXXVII 
DISLOCATION  OF  THE  ASTRAGALUS 

Occasionally  the  astragalus  is  dislocated  from  both  its  superior  and  inferior 
connections.  Reduction  always  requires  a  general  anesthetic,  and  as  failure 
to  reduce  by  manipulation  is  probable,  the  surgeon  ought  to  be  prepared  to 
operate  at  once.  The  bone  so  presses  upon  the  soft  parts  that  gangrene  of 
the  skin  is  sure  to  result,  unless  reduction  is  effected  or  the  bone  excised. 

Make  an  incision  on  the  inner  side  of  the  ankle  from  a  point  i  inch  above 
the  articular  surface,  just  in  front  of  the  malleolus,  downwards  and  forwards  to 
the  internal  cuneiform  bone.  Avoid  injury  to  the  tendon  of  the  tibialis  anticus. 
Separate  and  retract  all  the  soft  parts  covering  the  astragalus.  Endeavor  to 
effect  reduction  by  exerting  traction  on  the  foot  and  pressure  on  the  astragalus. 
If  this  fails,  and  if  more  free  access  promises  some  prospect  of  success,  make 
a  corresponding  incision  on  the  outer  side  from  just  above  and  in  front  of  the 
external  malleolus  downwards  and  forwards  to  the  cuboid.  Expose  the  parts 
involved.  Once  more  attempt  reduction.  If  the  attempt  still  fails,  remove 
the  astragalus.  Astragalectomy  gives  such  good  results  that  it  is  foolish  to 
run  much  risk  in  striving  after  the  more  ideal  operation.  If  the  astragalus 
is  completely  separated  from  its  connections  or  nearly  so,  then  its  removal  must 
be  the  rule.  When  the  dislocation  is  complicated  by  fracture  and  especially 
when  it  is  compound  (open)  and  infection  is  probably  present,  astragalectomy 
followed  by  drainage  is  the  procedure  of  choice. 

Katzetistein.—(" Zent.  fiir  Chir.,"  1912,  No.  6.)  In  a  chronic  or  recurring 
dislocation  at  the  astragalo-navicular  joint  due  to  rupture  of  the  tibio-navicular 
ligament  and  causing  much  disability,  pain  and  flat  foot,  Katzenstein  obtained  a 
perfect  anatomical  and  functional  result  by  the  following  operation:  Reduce  the 
dislocation;  expose  by  incision  the  surface  of  the  internal  malleolus  and  the 
navicular  bone;  from  the  tibia  or  any  convenient  bone,  obtain  a  non-peduncu- 
lated  flap  of  periosteum,  fold  this  flap  transversely  so  that  its  periosteal  surfaces 
are  in  apposition  except  at  both  extremities;  vivify  a  small  surface  on  both  the 
internal  malleolus  and  the  navicular  bone  and  to  these  surfaces  suture  the  ends 
of  the  periosteal  flap;  close  the  wound;  immobilize  in  a  position  of  valgus. 
After  5  or  6  weeks  begin  passive  and  later  active  motion. 


Io68  SUBASTRAGALOID    DISLOCATION 


CHAPTER  LXXXVIII 
SUBASTRAGALOID  DISLOCATION 

If  manipulation  under  an  anesthetic  fails  to  reduce, operation  is  demanded. 
Baumgartner  and  Huguier  ("Revue  de  Chir.,"  Aug.,  1907)  divide  the 
cases  requiring  operation  into  two  classes  according  to  whether  the  astrag- 
alus is  or  is  not  fractured. 

I.  The  Astragalus  is  not  Fractured. — -Reduction  by  arthrotomy  is  the 
operation  of  choice.  Make  an  incision  directly  over  the  prominent  head  of 
the  astragalus.  Recognize  the  structures  obstructing  reduction.  If  these 
are  ligamentous  bands,  divide  them  in  one  or  more  places  (Quenu) ;  if  they  are 
displaced  tendons  (e.g.,  the  tendon  of  the  tibialis  anticus  sometimes  lies  along 
the  inner  and  upper  part  of  the  neck  of  the  astragalus  which  is  then  tightly 
held  between  it  and  the  calcaneo-scaphoid  ligament)  (Stimson)  the  tendons 
may  be  pushed  aside,  or  if  this  is  impossible  they  may  be  divided  and  reunited 
after  reduction  is  obtained. 

Reduce  the  dislocation  by  manipulation,  especially  by  flexing  the  foot,  and 
by  direct  pressure.  Close  the  wound  with  sutures.  Dress.  Immobilize  for 
about  three  weeks.  If  reduction  by  arthrotomy  fails,  it  is  easy  to  proceed  to 
astragalectomy,  either  complete  or  incomplete.  Only  so  much  of  the  astragalus 
ought  to  be  removed  as  will  permit  of  the  foot  being  placed  in  a  good,  useful 
position. 

II.  The  Astragalus  is  Fractured  as  well  as  Dislocated. — (a)  The  fracture 
affects  the  neck  alone.  The  separated  and  dislocated  head  of  the  bone  may  be 
reduced  or  removed  according  to  circumstances. 

(b)  The  body  of  the  bone  is  fractured.  Astragalectomy  is  usually  the  best 
procedure  to  adopt.  In  compound  (open)  dislocation  the  indications  for 
operation  are  much  the  same  as  given  above.  Astragalectomy,  then,  is  indicated 
in  cases  of  subastragaloid  dislocation,  (i)  when  the  luxation  is  irreducible  or 
operative  reduction  has  failed;  (2)  when  infection  is  present;  (3)  in  old  cases. 


OS    CALCIS 


1069 


CHAPTER  LXXXIX 
OS  CALCIS 

Exostoses  on  the  Plantar  Surface  of  Os  Calcis. — Exostoses  in  this  position 
(Figs.  1325,  1326)  are  not  extremely  rare,  but  may  be  disabling  on  account 
of  pain.     Operation  is  demanded  when  relief  is  not  obtained  by  the  use  of  a 


Fig.  1325. — Exostosis  os  calcis.     {Bradford.) 

cushioned  heel.  Make  an  incision  along  the  inner  side  of  the  foot  close  to  the 
sole  and  opposite  the  site  of  exostosis.  By  sharp  and  blunt  dissection  expose 
the  affected  portion  of  os  calcis. 


r^/, 


Fig.  1326. —  Exostosis  os  calcis.     {Bradford.) 

With  a  chisel  remove  the  bony  spur.     Close  the  wound  with  or  without 
drainage. 


1 070  BUNION 


CHAPTER  XC 
BUNION  (HALLUX  VALGUS).     HAMMER   TOE  METATARSALGIA 

Hallux  valgus  consists  in  an  inward*  deviation  of  the  great  toe,  the  last 
phalanx  of  which  may  lie  transversely  across  the  second  toe.  The  head  of  the 
metatarsal  bone  is  pushed  outwards,  is  usually  enlarged,  and  part  of  its  articu- 
lating surface  is  no  longer  apposed  to  that  of  the  phalanx.  Between  the  bone 
and  skin  there  is  a  bursa  formed  which  frequently  becomes  inflamed  (bunion). 
Dwight  has  described  a  supernumerary  bone  which  occasionally  exists 
between  the  bases  of  the  first  and  second  metatarsals.  To  this  bone  he  has  given 
the  name  intermetatarseum.  The  intermetatarseum  may  be  free  or  may  be 
fused  with  the  first  or  the  second  metatarsal  or  with  the  internal  cuneiform 
bone.  J.  K.  Young  believes  that  Dwight's  bone  is  the  cause  of  some  forms  of 
hallux  valgus  and  if  detected  by  the  X-rays  in  an  early  case  of  deformity  its 
removal  should  arrest  the  condition  and  relieve  all  symptoms.  Young  has 
performed  the  operation  on  a  case  of  six  years'  duration. 

Barker's  Operation  (Metatarsal  Osteotomy). — Support  the  outer  side  of 
the  foot  on  a  sand-bag. 

Step  I. — Make  an  incision  directly  to  the  bone,  about  one  inch  long,  over 
the  prominence  of  the  metatarsal  head,  on  the  inner  side  of  the  foot. 

Step  2. — With  a  chisel  divide  the  metatarsal  bone  transversely  at  a  point 
about  3^  inch  from  the  head.  If  the  deformity  is  great  instead  of  simply 
dividing  the  bone,  excise  a  wedge  from  it. 

Step  3. — Straighten  the  toe.     Apply  dressings.     Immobilize. 
Hueter's    Operation   (Metatarso-phalangeal  Arthrectomy). — Step  i. — By 
manipulation  locate   the   metatarso-phalangeal  joint.     Make   a  longitudinal 
incision  on  the  inner  side  of  the  foot  sufficient  to  expose  the  joint  and  the  im- 
mediately adjoining  bones. 

Step  2. — With  a  chisel  shave  off  sufficient  of  the  articular  ends  of  the  meta- 
tarsus and  phalanx  until  correction  of  the  deformity  is  easy. 

Step  3. — Close  the  wound.  Apply  dressings.   Immobilize  in  correct  position. 
Riedl's  Operation. — Osteotomy  of  the  Cuneiform  Bone. — Step  i. — Make  a 
longitudinal  incision  on  the  inner  side  of  the  foot  sufficient  to  expose  the  in- 
ternal cuneiform  bone  and  its  articulation  with  the  first  metatarsal. 

Step  2. — Avoiding  injury  to  the  insertion  of  the  tibialis  anticus,  cut  a  wedge 
of  bone  from  the  cuneiform.  The  wedge  must  have  its  base  on  the  external 
(fibular)  side  (Fig.  1327).  The  thickness  of  the  wedge  corresponds  to  the 
amount  of  metatarsal  adduction. 

Step  3. — Through  the  wound  in  the  bone  with  strong  scissors  or  knife  cut 
around  the  external  angle  of  the  base  of  the  first  metatarsal  bone  so  as  to 
mobilize  it. 

*  The  word  "inward"  is  used  in  relation  to  the  middle  line  of  the  foot. 


BUNION 


IO71 


Step  4. — Place  the  metatarsal  bone  in  correct  position  (Fig.  1327). 
Step  5. — Correct  the  position  of  the  great  toe  by  some  of  the  methods 
described. 

Step  6. — Attend  to  hemostasis.     Apply  dressings.     Immobilize. 


Fig.  1327. — Bunion.     Riedl's  operation.     {Riedl.) 


Riedl's  operation  is  only  suitable  in  cases  of  very  great  deformity  of  the 
first  metarsal  when  rectification  at  the  metatarso-phalangeal  articulation  would 
be  insuflScient. 

Robert  F.  Weir's  Operation. — On  the  inner  side  of  the  foot  make  a  longi- 
tudinal curved  incision  beginning  "in  front  at  the  hollow  of  the  phalanx  (Fig. 
1328),  running  downwards  towards  the  sole,  and  enroaching  but  slightly  on 


Fig.  1328. — Bunion.     Weir's  operation.     {Weir.) 


it,  and  passing  backwards  and  upwards  to  the  middle  of  the  metatarsal  bone." 
Reflect  the  flap  thus  outUned.  With  a  chisel  or  bone  forceps  excise  such  por- 
tions of  bony  exostosis  as  prevent  reduction  of  the  deformity.  Freely  divide 
the  inner*  side  of  the  joint  capsule  (i.e.,  the  side  next  to  the  second  toe).  If 
the  sesamoid  bones  are  dislocated  outwards,  remove  them.  Divide  the  dorsal 
tendon  near  its  insertion  and  suture  it  to  the  periosteum  at  the  outer*  side  of 
the  base  of  the  first  phalanx.  Close  the  wound.  For  two  or  three  weeks  keep 
a  pad  of  gauze  between  the  great  and  second  toes  to  help  hold  the  replaced 

*  The  words  "outer"  and  "inner"  are  used  in  relation  to  the  middle  line  of  the  foot  and 
not  of  the  bodv. 


1072  BUNION 

toe  in  position.  In  the  hands  of  Weir  the  above  operation  has  given  excellent 
results.  Weir  remarks:  "No  operation  for  the  hallux  valgus  is  well  done  that 
does  not,  before  suturing,  allow  the  toe  to  rest  easy  in  its  restored  position. 
If  any  tilting  then  results,  its  cause  must  be  investigated  and  removed  or  an 
imperfect  result  will  ensue." 

In  the  preceding  operations  any  inflamed  or  enlarged  bursa  existing  over 
the  osseous  deformity  must  be  excised. 

C.  H.  Mayo's  Operation. — This  operation  recognizes  that  excision  of  the 
head  of  the  metatarsus  is  calculated  to  leave  a  stiff  toe  and  seeks  to  avoid  this 
defect,  (i)  Reflect  a  flap  of  skin  (Fig.  1329)  downwards  on  the  inner  side  of 
the  metatarso-phalangeal  articulation.  Do  not  injure  the  bursa.  (2)  Make 
a  flap  of  the  subjacent  soft  parts  with  its  base  at  the  root  of  the  great  toe. 


iC.H.W^L.y 


I 


I'lG.   1329. — Bunion.     C.  H.  IMaju's  ui)craUou.     {Mayo.) 

Reflect  this  flap  and  with  it  the  bursa  (Fig.  1329).  (3)  To  correct  the  hallux 
valgus  excise  the  head  of  the  metatarsus  and  shave  off  any  bony  excrescences. 
If  necessary,  excise  the  articular  surface  of  the  proximal  phalanx  of  the  great 
toe  (Fig.  1330).  (4)  Turn  the  flap  containing  the  bursa  into  the  space  between 
the  metatarsus  and  the  phalanx  and  fix  it  there  by  a  few  catgut  sutures  (Fig. 
133 1).  The  bursa  having  the  same  structure  as  a  joint  takes  the  place  of  the 
excised  joint.  (5)  Pull  the  dorsal  flexor  tendon  of  the  great  toe  inwards  so  as 
to  lie  over  the  middle  of  the  new  joint  and  fix  its  sheath  in  this  position  by  a 
few  sutures.  (6)  Close  the  external  wound.  Apply  alcohol  dressings  to  the 
wound  and  between  the  first  and  second  toes.  The  patient  may  be  permitted 
to  walk  in  a  few  days.     The  results  are  excellent.     This  appeals  to  the  author 


BUNION 


1073 


Fig.  1330. — Bunion.     Mayo's  operation.     {Mayo.) 


Fig.  1331. — Bunion.     Mayo's  operation.     {Mayo.) 


68 


I074 


BUNION 


as  the  best  operation  for  bunion.  If,  when  the  patient  is  first  seen,  the  bunion 
is  inflamed,  it  must  be  treated  until  the  trouble  is  quiescent  before  operation  is 
attempted. 

HALLUX  RIGIDUS  consists  of  a  painful  stiffness  of  the  first  metatarso- 
phalangeal joint.  If  a  bar  fixed  to  the  sole  of  the  shoe  behind  the  articulation 
does  not  give  relief  and  if  there  is  much  disabihty,  excision  of  the  head  of  the 
metatarsal  with  arthroplasty  as  in  bunion,  constitutes  efficient  treatment. 

Hammer  Toe. — When  hammer  toe  is  causing  much  disability  and  non- 
operative  measures  have  failed  or  seem  unsuitable  several  methods  of  operating 
are  available. 

I.  Hoffa  strongly  recommends  Peterson's  operation,  viz.,  transverse  section 
of  all  the  soft  parts  on  the  plantar  side  of  the  toe  opposite  the  first  phalango- 

phalangeal  articulation,  extension,  application  of 
dressings  and  of  a  splint.  A  cure  may  be  expected 
in  4  or  5  weeks. 

2.  Excision  of  the  first  phalango-phalangeal 
articulation  through  a  dorsal  incision.  Excise  an 
oval  piece  of  skin  including  the  ever-present  corn, 
from  over  the  prominent  knuckle.  Excise  a  wedge 
of  bone  (base  dorsal)  including  the  joint,  and  sufficient 
in  size  to  permit  the  toe  to  be  straightened.  Divide 
the  contracted  flexor  tendon.  Close  the  wound  so  as 
to  have  a  transverse  scar.  Apply  dressings  and  a 
plantar  toe  splint.  The  splint  must  be  worn  inside 
f"       -1  the  shoe  for  several  weeks  until  there  is  solid  anky- 

^"^^^--J  i   '3  'N  ,         losis.     Robert  Jones  finds  that  it  is  unsatisfactory  to 
remove   the  articular  end  of  one  of  the  bones  con- 
stituting the  joint,  hence  the  advice  to  remove   the 
whole  articulation.     Albee  recommends  a  plantar  in- 
cision to  one  side  of  the  flexor  tendon,  excision  of  the 
offending  joint  and  retention  of  the  toe  in  a  position 
of  hyperextension  by  means  of  plaster  of  Paris. 
3.  Arthroplasty  may  take  the  place  of  excision,  the  cut  ends  of  the  bone 
being  covered  by  a  flap  of  fascia  lata  taken  from  the  thigh  or  any  convenient 
location. 

Metatarsalgia. — When  metatarsalgia  cannot  be  relieved  by  the  use  of  a 
crooked  heel  shoe  to  which  has  been  added  a  transverse  bar  behind  the  heads  of 
the  metatarsal  bones  (Fig.  1332)  the  condition  may  be  cured  by  excising  the 
head  of  the  offending  metatarsal  through  a  small  dorsal  incision.  During  con- 
valescence the  patient  may  walk  provided  he  wears  the  shoe  with  the  plantar 
bar. 


i  /liJw. 


Fig.  1332. — Crooked  heel 
shoe.  Inner  side  heel  is 
prolonged  ^i^-mch  forward 
and  is  ^  3 -inch  higher  than 
outer  side.  Bar  of  leather 
across  sole  proximal  to  head 
of  metatarsals. 


SCAPULA    ALATA  IO75 


CHAPTER  XCI 
OPERATIONS  ON  THE  SCAPULA  AND  CLAVICLE 

Scapula  Alata.  Deformity  in  Serratus  Paralysis. — When  the  serratus 
magnus  and  the  trapezius  are  paralyzed  the  scapula  becomes  very  prominent 
and  abduction  of  the  arm  impossible. 

V.  Eiselsberg  united  the  two  scapulae  so  that  they  might  support  each  other 
and  thus  permit  abduction  of  the  arm.  When  he  succeeded  in  this  the  shoulders 
were  pulled  back  so  far  that  the  clavicles  compressed  the  vascular  and  nervous 
trunks  of  the  arm  against  the  first  rib,  and  to  overcome  this  it  was  necessary  to 
make  an  oblique  osteotomy  of  the  clavicle 

Duval  gave  stability  to  the  scapula  by  uniting  it  to  the  sixth  and  seventh 
ribs  ("Revue  de  Chir.,"  1905,  No.  i). 

Duval's  Operation. — Step  i. — Make  an  incision  along  the  vertebral  border 
of  the  scapula  from  the  level  of  its  spine  down  to  its  angle.  Divide  the  trape- 
zius and  rhomboideus  major  throughout  the  extent  of  the  wound.  Retract 
the  latissimus  dorsi  strongly  downwards  (Fig.  1333). 

Step  2. — Incise  the  periosteum  along  the  exposed  border  of  the  scapula  and 
reflect  it,  along  with  the  infraspinatus,  from  the  bone  for  a  distance  of  about  3^ 
inch  (Fig.  1333). 

In  the  same  manner  separate  the  periosteum,  along  with  the  serratus  magnus, 
from  the  deep  surface  of  the  scapula.  Excise  the  periosteum  and  the  serratus 
magnus  to  an  extent  suflacient  to  permit  the  denuded  undersurface  of  the  scapula 
to  lie  freely  in  contact  with  the  sixth  and  seventh  ribs. 

Step  3. — At  a  distance  of  2^  inches  from  the  middle  line  denude  the  sixth 
and  seventh  ribs  of  their  periosteum.  To  give  the  scapula  proper  obHquity 
the  denudation  of  the  seventh  rib  should  be  about  }/2  inch  further  out  than  that 
of  the  sixth. 

Step  4. — Unite  the  scapula  to  the  ribs  by  two  wire  sutures  as  shown  in 

Fig-  1334- 

Step  5. — If  possible,  suture  the  periosteum  over  the  wires. 

Step  6. — Retract  the  inner  edge  of  the  wound  (skin,  trapezius,  rhomboid) 
and  expose  the  long  muscles  of  the  back  lying  on  the  posterior  surface  of  the 
transverse  processes  in  the  upper  angle  of  the  wound. 

Step  7. — From  the  long  muscles  of  the  back  make  a  long  and  thick  flap  with 
its  pedicle  below.  Suture  this  flap  at  the  superior  angle  of  the  scapula  to  the 
periosteum  and  the  supraspinatus. 

Step  8. — Close  the  wound  without  drainage.  Apply  dressings  and  a  plaster- 
of-Paris  corset  for  forty-eight  days. 

Duval  has  operated  three  times.     His  first  patient  was  able  to  work  as  a 


1076 


OPERATIONS    ON    THE    SCAPULA   ANT)   CLAVICLE 


waiter  without  trouble.     The  second  patient  was  improved.     The  third  was 
not  improved. 

Menciere  ("L'Encephale/'  March,  191 2;  "Lancet,"  Aug.  17,  191 2)  modifies 
Duval's  operation.  Separate  the  periosteum  from  the  fifth,  sixth  and  seventh 
ribs,  9,  10  and  11  cm.  respectively,  from  the  middle  line,  so  that  the  line  of 
attachment  of  the  scapula  will  be  oblique  from  above  downwards  and  outwards 
and  thus  the  acromion  will  be  raised.  Separation  of  the  periosteum  around  the 
ribs  permits  sutures  to  surround  these  bones  without  pressing  on  the  intercostal 
nerves.  After  completing  the  operation  ]\Ienciere  applies  an  apparatus  which 
fixes  the  arm  in  an  elevated  position  with  the  hand  resting  on  the  top  of  the  head. 
After  65  days  of  this,  immobilization  exercises  are  instituted. 


1 


Fig.  1333.— Scapula  alata.     {Duval.) 


Transplantation  of  Muscle  in  Serratus  Paralysis. — Katzenstein  ("Berliner 
klin.  Woch.,"  1908,  Dec.  28)  operated  in  two  stages  in  the  following 
manner: 

Stage  I. — Step  i. — Make  a  longitudinal  incision  near  the  middle  line  of  the 
back  from  the  third  to  the  tenth  dorsal  spines.  Expose  and  divide  the  portions 
of  the  trapezius  and  rhomboideus  major  arising  from  these  spines. 

Step  2. — Reflect  the  divided  muscles  downwards  and  outwards  and  suture 
them  snugly  to  the  periosteum  of  the  seventh,  eighth,  and  ninth  ribs  and  to  the 
latissimus  dorsi. 

Stage  II. — Step  i. — Make  a  longitudinal  incision  along  the  inner  surface 
of  the  arm  from  its  middle  up,  through  the  axilla  to  end  on  the  thoracic  wall. 

Step  2. — Isolate  and  divide  the  humeral  insertion  of  the  pectoralis  major. 
Free  the  muscle  with  its  aponeurosis  and  suture  its  tendon  to  the  axillary  border 
and  to  the  anterior  scapular  muscles. 


SERRATUS  PARALYSIS 


1077 


The  result  was  excellent  both  as  regards  appearance  and  function. 

Muscle  Transplantation  in  Paralysis  of  the  Trapezius  and  Serratus  Magnus. 
— In  a  case  of  complete  paralysis  of  the  trapezius  due  to  division  of  its  nerve, 
Katzenstein  ("Berliner  klin.  Wochsch.,"  xlvi,  No.  49) 
operated  as  follows: 

First  Stage. — Through  a  suitable  incision  expose 
the  upper  margin  of  the  latissimus  dorsi  and  by  split- 
ting the  muscle,  isolate  a  suitable  bunch  of  its  upper 
fibres;  divide  this  isolated  segment  of  muscle  at  its 
humeral  insertion  thus  forming  a  flap  with  its  pedicle 
posterior.  Suture  the  free  end  of  the  flap  to  the 
posterior  surface  of  the  scapula  below  the  origin  of  the 
triceps.  This  flap  takes  the  place  of  the  lower  fibres  of 
the  paralyzed  trapezius  (Fig.  1334). 

Second  Stage. — Through  a  suitable  incision  expose 
the  upper  part  of  the  healthy  (opposite)  trapezius. 
Divide  its  clavicular  insertion  and  carefully  preserv- 
ing its  nerve  supply  form  a  muscular  flap  and  suture 
it  (Fig.  1335)  to  the  spine  of  the  scapula. 

Third  Stage. — Form  a  flap    (Fig.    1336)  from  the 
middle  of  the  healthy  trapezius  and  suture  its  free  extremity  alongside  of  the 
flap  formed  in  the  second  stage  of  the  operation. 

The  result  of  Katzenstein's  operation  was  functionally  good.  In  complete 
paralysis  of  the  serratus  magnus  and  partial  paralysis  of  the  inferior  fibres  of 
the  trapezius  Katzenstein  devised  and  carried  out  the  following  procedure: 


Fig.  1334. — (Katzenstein.) 
I,  2,  3.  Sup.  Mid.  and 
Inf.  Segments  of_  trapezius. 
4.  Latissimus  dorsi.  5.  Flap 
from  lat.  dorsi  to  trapezius. 


Fig.  1335.- 

from 


-{Katzenstein.) 


I.  Sup.  fibres  jf  paralysed  trapezius, 
im  nealthy  trapezius. 


Flap 


Fig.  1336. — {Katzenstein.) 

I,  2,  4.  Sup.  Mid.  and  inferior  segments  of 
trapezius.  3.  Flap  transplanted  from  left  to 
reinforce  right  trapezius. 


1.  Division  of  the  spinal  origin  of  the  rhomboid  muscles  and  transplantation 
of  their  origin  to  lower  vertebrae  thus  reversing  the  action  of  the  muscles  and 
making  them  assistants  to  instead  of  antagonists  of  the  serratus  magnus. 

2.  Division  of  the  tendon  of  the  pectoralis  major  at  the  level  of  the  humerus 
and  suture  of  it  to  the  axillary  border  of  the  scapula  so  as  to  correct  the  scapula 
alatum  which  was  present.     The  result  was  excellent. 


lOyS         OPERATIONS  ON  THE  SCAPULA  AND  CLAVICLE 

Paralysis  of  Trapezius  Muscle.  Treatment  by  "free"  transplantation  of 
fascia.  Kolhschilirs  operation.  When  the  upper  arm  is  raised  above  the  hori- 
zontal this  motion  is  due  to  the  serratus  magnus  while  the  trapezius  keeps  the 
scapula  sufficiently  fixed  so  that  the  serratus  is  able  to  act  with  power.  If  the 
trapezius  is  paralyzed  it  becomes  impossible  to  raise  the  arm  unless  the  scapula 
is  held  in  place  by  some  artificial  means.  Rothschild  accomplishes  the  fixation 
of  the  scapula  in  the  following  manner.     ("Zeit.  fiir  Chir.,"  Nov.  5,  1910.) 

Step  I. — Make  an  oblique  incision  from  the  upper  and  inner  angle  of  the 
scapula,  downwards  to  the  first  lumbar  vertebra.  Expose  the  vertebral  border 
of  the  scapula,  part  of  the  paralyzed  trapezius,  part  of  the  latissimus  dorsi. 

Step  2. — From  the  thigh  excise  a  strip  of  fascia  lata  about  8  inches  long  and 
i^  inches  wide. 

Step  3. — Suture  one  end  of  the  strip  of  fascia  securely  to  the  supraspinatus 
and  its  fascia.  Suture  the  other  end  of  the  strip  to  the  latissimus  dorsi  and  deep 
muscles  near  the  spine.  Before  suturing  the  vertebral  end  of  the  strip  of  fascia 
put  so  much  tension  on  it  that  the  scapula  is  pulled  up  to  the  level  of  its  fellow 
on  the  opposite  side  and  its  vertebral  border  is  parallel  to  the  spine.  In  order 
to  prevent  adhesion  between  the  fascial  implant  and  the  skin,  Rothschild  rec- 
ommends that  a  small  opening  be  made  through  the  paralyzed  trapezius  near 
the  scapula  and  that  the  flap  be  passed  through  this  opening  and  conducted 
under  the  trapezius  to  the  site  of  its  suture  to  the  trapezius.  Rothschild  has 
found  this  operation  completely  satisfactory. 

Deltoid  Paralysis. — ^Transplantation  of  Trapezius.— Dean  Lewis'  operation. 
("Jour.  A.  M.  A.,"  Dec.  24,  1910.) 

Step  I. — Make  a  longitudinal  incision  from  the  middle  of  the  outer  border  of 
the  trapezius  to  the  junction  of  the  middle  and  lower  thirds  of  the  deltoid. 

Step  2. — Divide  the  clavicular,  acromial  and  part  of  the  spinous  attachments 
of  the  trapezius. 

Step  3. — Separate  the  atrophied  deltoid  from  the  clavicle  and  spine  of  the 
scapula  and  turn  it  down. 

Step  4. — Open  the  sheath  of  the  long  head  of  the  biceps,  lift  up  the  tendon 
and  plicate  it  (Kiliani)  so  as  to  correct  the  subluxation. 

Step  5. — Suture  the  trapezius  to  the  articular  capsule  where  it  is  attached 
to  the  humerus. 

Step  6. — Turn  the  flap  of  deltoid  upwards  over  the  trapezius  and  suture  it 
high  up  while  the  arm  is  abducted. 

Step  7. — Suture  the  upper  part  of  the  skin  wound  in  such  a  manner  as  to 
make  the  cicatrix  at  right  angles  to  the  original  direction  of  the  wound.  This 
helps  to  overcome  the  subluxation.  Close  the  rest  of  the  wound.  The  resulting 
scar  is  T-shaped,  the  horizontal  arm  of  the  T  extending  across  the  summit  of  the 
shoulders. 

Step  8. — Apply  dressings.  Immobilize  at  an  angle  of  about  100°.  After 
about  four  or  five  weeks  gradually  lower  the  arm. 

Excision  of  the  Scapula. — Indication. — Malignant  neoplasms  of  the  scapula 
constitute  the  indication  for  its  complete  removal.  As  a  rule,  as  much  as 
possible  of  the  muscles  attached  to  the  bone  should  be  removed  along  with  it, 
since  sarcoma  is  liable  to  spread  from  the  bone  along  the  muscles  (see  remarks 


EXCISION    SCAPULA  1079 

on  tumors  of  bone).  If  skin  is  involved,  the  incisions  must  be  so  planned  as 
to  surround  the  affected  areas. 

Potel  in  a  case  of  spindle-cell  sarcoma  which  involved  almost  all  the  scapula 
and  the  attached  muscles  excised  the  scapula  but  preserved  the  glenoid  fossa 
thus  keeping  the  shoulder-joint  intact.  Two  and  one-half  years  later  the  patient 
was  well  and  had  good  function.  Quenu  in  discussing  Potel's  report  advised 
preservation  of  the  glenoid  fossa,  but  if  this  is  impossible  he  advised  fixation 
of  the  head  of  the  humerus  to  the  outer  end  of  the  clavicle  (International 
Abstracts,  Aug.,  1914). 

If  the  humerus  or  axilla  are  involved,  the  question  of  inter-scapulo-thoracic 
amputation  at  once  arises.  If  the  scapula  is  fixed  to  the  chest  wall,  operation 
is  usually  contraindicated  as  the  thorax  is  invaded. 

Step  I.— Place  the  patient  on  his  back.  Abduct  the  arm.  From  the  apex 
of  the  axilla  make  a  3- inch  incision  down  the  arm,  immediately  behind  the  an- 
terior wall  of  the  axilla,  along  the  inner  and  posterior  border  of  the  coraco- 
brachialis.  Raise  the  anterior  fold  of  the  axilla  and  expose  the  coracoid  process. 
With  blunt-pointed  scissors  cut  the  three  muscles  attached  to  the  coracoid  close 
to  the  bone.  This  fully  exposes  the  axillary  artery.  The  subscapular  artery 
"arises  opposite  the  lower  border  of  the  subscapularis  and  runs  downwards 
and  inwards  along  the  anterior  border  of  that  muscle  under  cover  of  the  latissi- 
mus  dorsi.  *  *  *  it  is  accompanied  by  two  veins.  *  *  *  About  2.5  or  3.7 
cm.  (i  or  i^^  inches)  from  its  origin,  the  subscapular  artery  divides  into  two 
end  branches:  (i)  the  circumflex  (dorsal)  scapular,  and  (2)  the  dorsal  thoracic" 
(Morris)  (Fig.  1337).  Recognize  and  ligate  the  subscapular  artery.  This  step 
(Cheyne,  Jacobson)  saves  much  trouble  from  bleeding  and  the  separation  of 
the  muscles  attached  to  the  coracoid  greatly  simplifies  the  later  stages  of  the 
operation.  The  truth  of  these  observations  was  agreeably  impressed  on  the 
author  in  a  case  of  gigantic  enchondroma  in  which  he  was  associated  with 
Dr.  Sudler. 

Step  2. — Pack  the  axillary  wound.  Turn  the  patient  on  to  his  sound  side 
and  bring  his  back  close  to  the  edge  of  the  table. 

Incision  A. — Make  "a  T-shaped  incision,  one  limb  running  from  the  acromio- 
clavicular joint  inwards  to  the  superior  angle  of  the  scapula,  while  the  other  and 
longer  is  made  at  right  angles  to  the  first  down  to  the  angle  of  the  scapula." 

Incision  B. — Make  a  H  -shaped  incision,  one  cut  running  along  the  verte- 
bral border  of  the  scapula,  the  other  at  right  angles  to  it  across  the  centre  of  the 
growth. 

Incision  C. — Same  as  B  except  that  the  horizontal  cut  runs  on  the  spine  of 
the  scapula  and  reaches  to  the  acromio-clavicular  joint  or  if  a  portion  of  the 
acromion  is  to  be  preserved,  to  the  top  of  the  acromion. 

Step  3. — Incision  C  has  been  adopted.  Reflect  the  two  skin  flaps  formed 
by  the  H  -shaped  cut.  Examine  the  deltoid  and  trapezius  muscles.  If  their 
condition  is  above  suspicion,  preserve  them;  if  not,  those  portions  which  are 
attached  to  the  scapula  must  be  excised.  Pass  the  finger  under  the  deltoid 
and  hook  up  the  muscle.  If  the  muscle  is  to  be  preserved  divide  its  origin  at 
the  spine  of  the  scapula  and  reflect  the  muscle  outwards;  if  it  is  to  be  removed 
split  the  muscle  along  the  junction  of  its  scapular  and  clavicular  portions. 


io8o 


OPERATIONS    ON    THE    SCAPULA    AND    CLAVICLE 


Follow  the  scapular  portion  down  to  its  insertion  in  the  humerus  and  there 
divide  it,  leaving  the  muscle  hanging  attached  to  the  scapula.  The  clavicular 
portion  of  the  deltoid  is  left  intact. 

Step  4. — Expose  and  divide  the  following  tendons  which  are  inserted  into 
or  near  the  upper  end  of  the  humerus — subscapularis,  the  long  head  of  the 


ACKOMIAJ. 


ACriOi'f/AL 
BfiANCN 
DELTOID  _  y/ 


PECTORAUS 
fiTAJOR  Ml/SCME 


COJM  C  O  -BPA  CHIAL  IS 
MCrSCLE 

BJ9A  CHJAL  ARTERY 


OELTOID  MVSCLE 


BJCEPS  Mt/SCLE 


SUBSCAPl/lAH  ARTEKY 

AV-aUAHt'lXMPH-'^ODEa 

DORSAL  THORACIC 
,         ARTERV 


I  incUMFLEX 
S  CAPULAS 
AHTERY 


TERES  MA  J  OR 
MUSCLE 

Z  LAT/SSIMUS 
DORS!  MUSCLE 
-  _  TRICEPS  MUSCLE 
(LOf/GHEAD) 

TEMDI10US  CONNECTION  Of 
-    THF  TRICEPS  HITH  THS 
LATISSIMLS  DORSl 

PROFINDA  ARTERY 


TRICEPS  MUSCLE 
'  C MIDDLE  HEAD) 

SUPERIOR  ULNAR 
'COLLATEiRAL  ARTERY 


CUTANEOUS 
BRANCHES 


BRACHIAL  ARTERY  -- 
LACBBTUS   r/BROSUS 


RADIAL  RECURRENT- 
ARTERY 


.. -BRACHIAL  MUSCLE 


..JNFERtOR  ULNAR 
COLLATERAL  ARTERY 


-CUTANEOUS  BRANCH 


ANTIBRACHIAL 
FASCIA 


Fig.  1337. — {Morris.) 


biceps,  supra-spinatus,  infra-spinatus,  teres  minor  and  major.  The  capsule 
of  the  shoulder- joint  is  of  course  opened.  In  the  upper  and  outer  part  of  the 
wound  under  the  head  of  the  humerus,  lies  the  long  head  of  the  triceps;  isolate 
and  divide  this  carefully,  avoiding  injury  to  the  circumflex  nerve  going  to  the 
deltoid.  If  part  of  the  acromion  process  is  to  be  preserved,  divide  it  at  the 
desired  spot;  if  not,  separate  the  soft  structures  from  it  and  freely  open  the 
acromio-clavicular  articulation. 


EXCISION   SCAPULA 


1081 


Step  5. — Pass  the  finger  under  the  trapezius  muscle  and  treat  it  exactly  as 
the  deltoid  was  treated,  i.e.,  either  divide  it  at  its  insertion  along  the  upper  edge 
of  the  spine  of  the  scapula  and  reflect  it  upwards,  or  separate  (by  splitting)  its 
clavicular  from  its  scapular  portions  and,  separating  the  latter  from  the  chest- 
wall,  divide  it  as  near  its  origin  as  possible,  leaving  the  muscle  to  be  removed 
attached  to  the  scapula. 

Step  6. — At  the  upper  border  of  the  neck  of  the  bone  detach  the  omo-hyoid. 
Ligate  and  divide  the  supra-scapular  (transverse  scap.)  artery  (Fig.  1338). 


Subscapular  branch  of  transverse  scapular  artery 
Supraspinons  branch  of  transverse  scapular  artery 


Descendinfj  branch 
of  transverse  cer- 
vical artery 


Supraspinous  branch 
Subscapular  branch 


Branch  of  intercostal 
artery 


Branch  of  intercostal 
artery 
Continuation  of  de- 
scetiding   branch 
of  transverse  cer- 
vical artery 


Transverse  scapular  artery 


Acromial  branch  of 
thoraco-acromial 
Acromial  rete 


Subscapular  branch  of 

transverse  scapular 

artery 
Infraspinous  branch  of 

transverse  scapular 

artery 
Subscapular  branch  of 

axillary  artery 


Circumflex  scapular  branch 
of  subscapular  artery 


Branch  oj  circumflex 
scapular  artery 


Dorsal  thoracic  branch  of 
subscapular  artery 


Fig.  1338. — The  anastomoses  about  the  scapula.     {Morris.) 


Divide  the  levator  anguli  scapulae  at  the  upper  angle  of  the  bone  and  ligate  and 
divide  the  posterior  scapular  (descending  branch  transverse  cervical)  artery. 
Divide  the  rhomboids  and  the  serratus  magnus. 

Step  7. — Complete  the  division  of  the  capsule  of  the  shoulder-joint.  The 
first  step  in  the  operation  has  attended  to  the  freeing  of  the  coracoid  process  and 
ligation  of  the  subscapular  artery.     Remove  the  scapula. 

Step  8. — Attend  to  hemostasis.  Quenu  unites  the  antero-inferior  part  of 
the  capsule  to  the  soft  parts  under  the  clavicle.  With  a  wire  suture  he  unites 
the  upper  part  of  the  capsule  to  the  scapula  through  which  a  hole  is  bored  to  re- 
ceive the  wire.  The  long  head  of  the  biceps  is  sutured  in  the  same  fashion  to 
the  clavicle.     (If  the  scapular  portion  of  the  deltoid  has  been  preserved,  suture 


Io82  OPERATIONS  ON  THE  SCAPULA  AND  CLAVICLE 

its  lower  part,  if  possible,  to  the  rhomboid;  its  upper  part  to  the  trapezius.) 
Close  the  wound  providing  freely  for  drainage. 

"The  results  are  excellent;  the  patient  retains  all  movements  of  the  limb, 
with  the  exception  that  he  is  unable  to  abduct  the  arm  above  a  right  angle  from 
the  trunk"  (Burghard). 

Subperiosteal  Excision  Scapula  (Oilier). — Indication  for  operation  is  usu- 
ally osteomyelitis  with  its  complications  and  sequela;. 

Step  I. — Make  an  incision  down  to  the  bone  along  the  spine  of  the  scapula 
from  the  acromion  to  the  vertebral  border.  With  knife  and  elevator  separate 
the  trapezius  from  the  scapular  spine. 

Step  2. — Make  an  incision  along  and  expose  the  whole  vertebral  border  of 
the  scapula.  Through  this,  subperiosteally,  separate  the  soft  parts  from  the 
bone  both  above  and  below  the  scapular  spine. 

Step  3. — Pull  the  vertebral  edge  of  the  scapula  away  from  the  chest  and  sub- 
periosteally separate  the  subscapularis  and  all  other  soft  structures  from  the 
anterior  surface  of  the  scapula— until  the  axillary  border  and  the  neck  of  the 
bone  are  reached. 

Step  4. — Divide  the  acromio-clavicular  joint  from  below  upwards.  Divide 
the  articular  capsule  and  the  tendinous  insertions  on  the  upper  end  of  the 
humerus.  Divide  the  base  of  the  coracoid  process.  Unless  it  is  absolutely 
necessary  to  remove  the  head  of  the  scapula  it  is  better  to  divide  the  neck  of 
the  bone  and  leave  the  articulating  surface  intact. 

Subperiosteal  resection  when  indicated  is  a  much  easier  operation  than  the 
same  procedure  carried  out  on  the  normal  cadaver  because  disease  thickens  the 
periosteum  and  loosens  it  from  the  bone.  After  subperiosteal  excision  the  bone 
is  often  almost  completely  regenerated. 

Partial  Excision  of  the  Scapula. — Almost  any  portion  of  the  scapula  may 
be  excised  through  suitable  incisions,  and  such  operations  require  no  special 
description. 

Excision  of  the  Clavicle. — Subperiosteal  resection  of  the  clavicle  may  be 
demanded  in  the  treatment  of  necrosis. 

Step  I.— Make  a  cut  along  the  clavicle  from  the  acromion  process  to  the 
sternum.     Divide  the  periosteum. 

Step  2. — With  an  elevator  separate  the  periosteum  from  the  front  surface  of 
the  bone.  With  a  curved  elevator  (many  elevators  are  provided  with  a  point 
which  while  blunted  is  still  sharp  enough  to  do  damage  if  a  slip  occurs,  the 
end  of  the  best  elevator  is  more  or  less  square  with  rounded  angles)  hugging 
the  bone  separate  the  periosteum  from  the  posterior  surface  of  the  bone  near 
its  middle. 

Step  3. — (a)  With  Gigli's  saw  or  bone  forceps  divide  the  bone  near  its  middle. 
Grasp  the  end  of  the  inner  fragment  with  strong  forceps  and  pull  it  forwards. 
It  is  now  easy  to  separate  the  fragment  from  the  surrounding  soft  parts  by 
blunt  dissection  aided  by  an  occasional  snip  of  the  scissors  (the  scissors  must  be 
made  to  cut  against  the  bone)  and  so  to  remove  the  whole  inner  end  of  the  bone. 
It  is  always  best  if  possible  to  divide  the  bone  near  its  sternal  articulation  and 
to  leave  the  articular  end  of  the  bone  in  sitn.  Do  the  same  to  the  outer  end  of 
the  bone.     The  insertion  of  the  subclavius  at  the  junclion  of  the  outer  and 


EXCISION    CLAVICLE 


1083 


middle  thirds  of  the  bone  requires  sharp  division  (always  cutting  on  the  bone). 
The  coraco-  and  acromio-clavicular  Hgaments  require  division  with  knife  or 
scissors,  if  the  outer  extremity  of  the  bone  is  to  be  sacrificed,  but  it  is  always  best 
to  save  the  acromio-clavicular  joint  if  possible. 

(b)  Instead  of  dividing  the  clavicle  at  its  middle,  divide  it  near  its  outer 
end  or  open  the  acromio-clavicular  joint.  Seize  the  outer  mobilized  end  of  the 
bone  and  pull  it  forwards.  Separate  the  bone  from  the  soft  parts  subperiosteally 
and  remove  it  entire  or  in  part. 

Step  3. — Cleanse  and  close  the  wound,  providing  for  very  free  drainage 
which  is  necessary  because  the  operation  is  generally  performed  for  necrosis. 


Trapezoid 
ligament 


Tendon  of  sub- 
scapularis  muscle 


Capsule  of  the 

acromio-clavicular 

joint 

Coraco-acromial 

ligamentj 

Coraco-humeral 

ligament 


Transverse 
humeral-ligament 


Tendon  of  biceps 


Fig.  1339. — Outer  view  of  the  shoulder-joint,  showing  the  coraco-humeral  and  transverse 

humeral  ligaments.     (Morris.) 


Excision  of  Clavicle  for  Saicoina.^Step  i.— Make  an  incision  through  the 
skin  alone  along  the  whole  length  of  the  bone.  Supplement  this  cut  by  vertical 
ones,  if  required  for  the  reflection  of  the  skin  from  over  the  whole  of  the  tissues 
to  be  removed. 

Step  2: — Expose  the  outer  edge  of  the  clavicular  insertion  of  the  sterno- 
mastoid.  Pass  a  finger  or  director  (the  author  for  such  purposes  used  a  closed 
blunt-pointed  scissors  curved  on  the  flat)  behind  the  clavicular  portion  of  the 
muscle  and  divide  it  at  a  safe  distance  from  the  disease.  Expose  the  inner 
edge  of  the  clavicular  insertion  of  the  trapezius  and  divide  it  in  the  same  manner. 
In  the  same  fashion  divide  such  portions  of  the  pectoralis  major  and  the  deltoid 
as  are  attached  to  the  clavicle. 

Step  3. — Mobilize  the  acromial  end  of  the  bone  by  dividing  the  acromio  and 
coraco- clavicular  ligaments.     This  is  a  difficult  step  (Fig.  1339).     Pull  the  outer 


1084  SHOULDER 

end  of  the  clavicle  forwards.  Remember  the  subclavian  vein  which  is  separated 
from  the  bone  by  the  subclavius  muscle.  Separate  the  bone  and  tumor  up  to 
the  claviculo-sternal  articulation.     Disarticulate. 

Step  4. — Attend  to  hemostasis.  Close  the  wound.  Dress.  Treat  like  a 
fracture  of  clavicle. 

The  results  as  regards  use  of  the  arm,  strange  to  say,  are  reported  to  be  most 
excellent. 

Excision  of  the  Clavicle  with  Repair  by  Bone  Transplantation. — After  ex- 
cising the  clavicle  in  whole  or  in  part  the  defect  may  be  repaired  by  transplanting 
a  suitable  segment  of  bone,  preferably  from  the  patient  himself.  Bone  may  be 
obtained  easily  from  the  tibia.  Witzel  (Molineus,  Deutsche  Zeitsch.  f.  Chir., 
cxxi,  180)  in  two  cases  excised  the  outer  two-thirds  or  more  of  the  clavicle  and 
filled  the  osseuos  defect  by  transplantating  the  spine  of  the  scapula.  The  spine 
of  the  scapula  and  the  clavicle  were  exposed  by  an  incision  beginning  one  hand's 
breadth  from  the  vertebral  column  and  running  outwards  along  the  spine  of  the 
scapula  to  be  continued  anteriorly  two  fingers'  breadths  below  the  parallel  to  the 
clavicle.  The  epaulet  like  flap  outlined  by  the  incision  was  reflected  upwards, 
the  clavicular  insertions  of  the  pectoralis  major  and  deltoid  were  divided,  the 
acromio-clavicular  joint  opened  and  the  diseased  portion  of  clavicle  removed. 
After  separating  the  supra-  and  infra-spinati  from  the  scapular  spine,  the  latter 
was  cut  away  from  the  scapula  with  a  chisel.  (At  the  median  or  vertebral  end  it 
may  be  necessary  to  remove  a  portion  of  the  body  of  the  scapula  along  with  its 
spine).  It  was  now  easy  to  swing  the  mobilized  bone  forwards  and  to  unite  it 
with  the  stump  of  clavicle  by  a  wire  suture.  After  4  weeks,  passive  motion  was 
begun  and  in  8  weeks  there  was  almost  perfect  function. 

Prestemal  Dislocation  of  the  Clavicle. — Grunert  ("Med.  Klinik,"  May 
29,  1910)  recommends,  in  prestemal  dislocation  of  the  clavicle,  that  the  meniscus 
of  the  sterno-clavicular  joint  be  excised  and  the  bones  united  by  three  sutures. 


CHAPTER  XCII 
SHOULDER 


Intra-articular  injections  for  the  introduction  of  iodoform  emulsion  or 
Murphy's  formalin  glycerine.  Introduce  the  trocar  either  just  external  to  the 
coracoid  process  or  external  to  the  angle  of  the  acromion  {i.e.,  the  angle  formed 
by  the  junction  of  the  scapular  spine  and  the  acromion  process).  Push  the  tro- 
car into  the  prominence  formed  by  the  swelling  of  the  joint  capsule. 

Arthrotomy  for  Drainage. — It  is  usually  recommended  to  open  the  joint 
by  an  anterior  vertical  incision  as  in  arthrectomy  but  drainage  through  such  a 
cut  is  not  efficient  and  a  counter  opening  is  usually  required.  The  following 
operation  is  entirely  preferable: 

Beginning  at  the  posterior  prominence  or  angle  of  the  acromion  process 
make  an  incision  downwards  along  the  posterior  border  of  the  deltoid  for 
about  2  inches.  This  opens  the  subdeltoid  bursa.  Retract  the  edges  of 
the  wound  and  expose  the  joint  capsule  crossed  by  the  tendons  of  the  infra- 


RESECTION    SHOULDER 


I08: 


spinatus  and  teres  minor.     Incise  the  capsule.     Explore  the  joint  lest  resection 
should  be  demanded.     Drain. 

Ollier's  Operation  or  Subperiosteal  Resection. — Step  i. — Abduct  the  arm 
moderately  and  have  an  assistant  hold  it  steadily.  From  a  point  3-^  inch  below 
the  clavicle  and  beside  the  coracoid  process  make  an  incision  4)^  to  5 
inches  in  length,  which  is  directed  downwards  and  outwards  towards  the  inser- 
tion of  the  deltoid  (Fig.  1340).  The  incision  divides  the  skin  and  subcutaneous 
tissues.  Distinguish  the  anterior  or  internal  (pectoro-deltoid  groove)  border  of 
the  deltoid.  Incise  the  deltoid  a  little  to  the  outside  of,  and  parallel  to  its  inter- 
nal margin,  thus  avoiding  injury  to  the  cephalic  vein  and  a  large  branch  of  the 
acromio-thoracic  artery.  Retract  the  outer  side  of  the  wound  (skin  and  del- 
toid), thus  exposing  the  head  of  the  humerus. 

Step  2. — Rotate  the  arms  so  as  to  make  out  the  bicipital  groove.  Incise  the 
joint  capsule  throughout  its  whole  extent  parallel  and  external  to  the  tendon  of 
the  biceps.  Do  not  injure  the  acromio-coracoid  ligament.  Prolong  the  cap- 
sular incision  downwards  on  the  humerus, 
dividing  the  periosteum,  to  the  point  where  it 
is  desired  to  sever  the  bone  (Fig.  1341).  In- 
troduce a  sharp  but  not  pointed  periosteal 
elevator  and  separate  the  periosteum  and 
tendinous  insertions,  on  the  outer  side  of  the 
wound,  from  the  external  or  greater  tuberositv. 


-'^ 


Fig.  1340. — Arthrotomy. 


Fig.  1341. — Excision  of  shoulder.     {Schwartz.) 


As  the  separation  progresses  the  assistant  rotates  the  humerus  inwards.  In 
using  the  sharp  elevator  keep  the  edge  of  the  instrument  firmly  pressed  against 
the  bone,  and  when  there  is  danger  of  tearing  the  periosteum  endeavor  to  sacri- 
fice bone  rather  than  impair  the  integrity  of  its  fibrous  covering.  If  these  rules 
are  observed,  the  tendinous  insertions  and  periosteum  will  be  raised  from  the 
bone  together  and  remain  attached  to  the  fibrous  capsule  of  the  joint.  One  is 
rarely  completely  successful  in  this,  but  even  partial  success  is  benefical.  The 
external  tuberosity  having  been  denuded,  open  the  sheath  of  the  biceps  tendon, 
lift  the  tendon  from  its  groove  and  retract  it  inwards.  Separate  the  periosteum 
and  tendinous  insertions  from  the  internal  or  lesser  tuberosity  in  the  manner 
already  described,  while  doing  so  have  the  assistant  rotate  the  arm  outwards. 
Make  the  head  of  the  humerus  protrude  into  the  wound  by  carrying  the  elbow 
backwards  and  upwards.  Separate  the  posterior  and  lateral  fibrous  attach- 
ments from  the  bone  by  the  method  already  described  (Fig.  1342). 


io86 


SHOULDER 


Step  3. — Examine  the  head  of  the  bone  and  make  it  protrude  out  of  the 
wound  (Fig.  1343).  Saw  off  as  much  of  the  upper  end  of  the  humerus  as  is  ren- 
dered necessary  by  the  presence  of  disease. 

Step  4.— Examine  the  glenoid  cavity  and  if  disease  is  present  remove  it  with 
a  sharp  spoon,  chisel,  or  rongeur  forceps. 

Step  5. — With  forceps  and  scissors  dissect  away  all  diseased  synovialis. 
The  walls  of  all  sinuses  must  be  removed  by  dissection  or  by  curettement. 

Step  6. — Provide  for  posterior  tubular  drainage  by  an  incision  in  an  appro- 
priate position  behind.  Rub  the  wound  with  iodoform.  Provide  for  drainage 
of  anterior  wound  and  partially  close  it  with  sutures.  Apply  dressings.  A 
large  pad  must  be  placed  in  the  axilla  to  keep  the  upper  end  of  the  humerus 
from  falling  inwards  and  the  elbow  and  forearm  bandaged  to  the  chest.  As 
soon  as  the  wound  has  healed,  the  tone  of  the  shoulder  muscles  may  be  kept  up 


Fig.  1342.  Fig.   1343. 

Figs.  1342  and  1343. — Excision  of  shoulder.     (Schwartz.) 


by  applications  of  electricity.  No  passive  movements  or  massage  must  be 
attempted  before  the  lapse  of  about  eight  weeks  and  the  movements  of  ab- 
duction must  be  the  last  to  be  used.  The  reason  for  delaying  movement 
is  that  one  must  wait  until  the  upper  end  of  the  humerus  has  become  to  some 
extent  fixed  in  its  new  position  and  thus  avoid  an  undersirable  "flail-joint." 

In  some  cases  where  the  tissues  have  not  been  softened  by  inflammation 
it  is  very  difficult  to  detach  the  periosteum  and  tendinous  insertions  from  the 
major  and  minor  tuberosities  of  the  humerus.  After  this  feat  has  been  at- 
tempted the  detached  periosteum  is  usually  a  thing  of  "shreds  and  patches." 
In  the  case  of  the  hip-  and  ankle-joints  Konig  has  overcome  this  difiiculty  by 
chiseling  off  from  the  main  bone  a  shell  of  bone  and  retracting  it  along  with  its 
periosteal  and  tendinous  attachments.  The  method  has  many  good  features 
in  addition  to  its  simplicity  that  the  author  has  applied  to  the  shoulder-joint. 

Expose  the  shoulder  through  the  Oilier  incision.  Divide  the  periosteum 
of  the  humerus  along  the  outer  edge  of  the  bicipital  groove.  Place  a  chisel 
in  position  with  its  edge  against  the  outer  margin  of  the  bicipital  groove  and  cut 
through  the  great  tuberosity  (Fig.  1344).  Reflect  the  detached  shell  of  bone 
with  all  its  connections  outwards.    Lift  the  long  tendon  of  the  biceps  outwards. 


EXCISION    SHOULDER 


1087 


With  the  chisel  cut  the  lesser  tuberosity  free  from  the  shaft  of  the  humerus. 
Reflect  inwards  the  shell  of  bone,  with  its  periosteal  connections  and  with  the 
long  head  of  the  biceps.  Dislocate  the  head  of  the  humerus  into  the  wound, 
at  the  same  time  severing  its  posterior  attachments  with  periosteal  elevator  or 
scissors  as  already  described. 


Fig.  1344. — Author's  method  of  excision  of  shoulder. 

A.  External  shell  of  bone  (major  tuberosity  held  outwards  by  chisel);  B.  Internal  shell  of  bone  retracted 

inwards;  C.  Bicipital  groove. 


After  the  active  operation  is  completed,  examine  the  shells  of  bone  which 
remain  attached  to  the  periosteum.  If  they  show  evidences  of  disease,  remove 
them;  if  not,  replace  them.  When  the  shells  of  bone  are  replaced,  arrange  them 
in  such  a  manner  that  the  long  tendon  of  the  biceps  will  remain  superficial  to 
them. 

W.  T.  Reynold's  showed  the  author  a  method  (which  was  apparently  devised 
by  A.  W.  Mc Arthur)  for  exposing  the  shoulder  through  the  axilla.  From  a 
point  a  short  distance  below  the  coracoid  process  make  an  incision  downwards 
and  slightly  outwards  until  the  lower  edge  of  the  anterior  axillary  fold  is  divided 


io88 


SHOULDER 


and  the  pectoralis  major  is  exposed.  Divide  the  pectoraHs  major  at  right  angles 
to  its  tibres  and  about  1*2  inches  from  its  insertion.  This  gives  excellent  access 
to  the  shoulder  joint.  After  completing  whatever  procedures  are  required  on 
the  bones  or  joint,  suture  the  divided  muscle  carefull>'  and  close  the  wound. 
Good  function  of  the  shoulder  may  be  expected. 

Atypical  Resection  of  the  Shoulder. — In  children  it  is  especially  desirable 
to  avoid  typical  resection  of  the  upper  end  of  the  humerus,  because  injury  to 
or  destruction  of  the  epiphyseal  cartilage  leads  to  non-development  of  the  upper 
arm.  In  suitable  cases  one  can  expose  the  joint  by  the  Oilier  method,  examine 
the  head  of  the  humerus  and  the  glenoid  cavity  and  with  chisel  and  sharp  spoon 
remove  any  osteal  foci  of  disease  which  may  be  found.  The  principles  of  treat- 
ment are  the  same  as  in  the  case  of  the  knee-joint. 

Resection  of  the  Shoulder  from  Behind  (Kocher). — When  the  glenoid 
cavity  is  much  diseased  or  the  arthritis  is  very  diffuse,  the  usual  anterior  routes 


Trapezius 
Deltoid 


—  Infraspinatus 
Teres  major 


Fig.  1345. — Kocher's  incision.     (Kocher.) 


do  not  give  sufficiently  free  access  to  the  joint.  For  these  cases  Kocher  has 
devised  the  following  operation: 

Step  I. — Beginning  at  the  acromio-clavicular  joint,  make  an  incision  along 
the  upper  margin  of  the  spine  of  the  scapula  to  about  the  middle  of  that  bone; 
from  this  point  continue  the  incision  in  a  curve  downwards  and  outwards  to 
about  two  fingers'  breadth  from  the  posterior  axillary  fold  (Fig.  1345)- 

Step  2. — Open  the  acromio-clavicular  joint.  Divide  the  insertion  of  the 
trapezius  into  the  spine  of  the  scapula  throughout  the  length  of  the  wound. 
Expose  the  posterior  margin  of  the  deltoid,  push  the  finger  under  the  deltoid 
and  separate  it  from  the  underlying  infra-spinatus.  Divide  a  portion  of  the 
origin  of  the  deltoid  posteriorly  (Fig.  1346).  Push  the  finger  along  the  lower 
surface  of  the  spine  of  the  scapula,  between  the  deltoid  and  the  infra-spinatus 


RESECTION    SHOULDER 


1089 


to  the  place  where  the  infra-spinatus  loses  touch  with  the  spine.  Bluntly  push 
the  supra-spinatus  away  from  the  upper  surface  of  the  spine  until  the  finger  can 
be  hooked  round  the  outer  end  of  the  spine. 

Step  3. — Method  A. — With  a  chisel  make  an  oblique  section  of  the  spine  of 
the  scapula,  so  that  the  acromion  process  and  the  whole  crest  of  the  scapular 
spine  from  which  the  deltoid  arises  are  separated  from  the  body  of  the  bone. 
Before  dividing  the  bone  it  may  be  well  to  drill  holes  in  the  bone  on  each  side  of 
the  line  of  section  so  as  to  be  able  conveniently  to  wire  the  fragments  on  com- 
pletion of  the  operation.  Instead  of  boring  holes,  one  may  subperiosteally 
resect  a  small  fragment  of  bone  on  each  side  of  the  line  of  section,  thus  leaving 


Acromioclavic- 
ular joint 


Acromion  . 


I'iG.   1346.— Kocher's  incision.     (Kocher.) 


small  flaps  or  tags  of  periosteum  which  may  be  sutured  together.  In  dividino' 
the  bone  be  careful  not  to  injure  the  supra-scapular  nerve  as  it  goes  through  the 
great  scapular  notch. 

Method  B. — Instead  of  cutting  off  the  mass  of  the  spine  of  the  scapula, 
merely  cut  off,  subcortically,  that  portion  from  which  the  deltoid  arises. 

Step  4. — Turn  downwards  the  flap  of  deltoid  muscle  with  its  bony  attachments 
(Fig.  1347).  This  exposes  very  freely  the  outer  and  posterior  surfaces  of  the 
head  of  the  humerus  with  the  attachments.  Rotate  the  arm  outwards.  Make 
a  longitudinal  incision  down  to  the  bone  along  the  posterior  margin  of  the  bi- 
cipital groove  and  expose  the  biceps  tendon  up  to  its  origin  above  the  glenoid 
cavity. 

Step  5. — Beginning  at  the  posterior  margin  of  the  bicipital  groove,  separate 
the  periosteum,  and  with  it  the  external  rotators  of  the  humerus  from  the  greater 

69 


logo 


SHOULDER 


tuberosity,  and  retract  these  structures  backwards.  Inspect  the  biceps  tendon 
and  its  sheath.  Retract  the  tendon  forwards.  By  flexing  the  elbow,  rotating 
the  shoulder,  pushing  the  head  through  the  wound,  etc.,  etc.,  it  is  now  possible 
to  inspect  the  whole  joint  and  judge  if  it  is  necessary  to  resect  the  joint  or  if  a 
mere  arthrotomy  will  suffice. 

If  arthrectomy  is  necessary  proceed  to — • 

Sup  6. — Subperiosteally  separate  the  insertions  of  the  muscle  from  the  lesser 
tuberosity  forwards  and  inwards.  Complete  the  resection,  removing  all  diseased 
tissue. 

Step  7. — Replace  the  deltoid  flap  and  fix  it  in  position  by  sutures.  Provide 
drainage.     Dress. 


Clavicular  joint 

Acromial  joint- — 

Tendon  biceps- — 

Fragment  scapula- — 

Deltoid 

Joint  capsule  ^-^ 
incised 


,Supraspinatus 

Cut  surface  crest  of 
scapula 

Infraspinatus 


Fig.   1347. — Kocher's  operation.     {Koclier.) 


Kocher's  operation  sounds  formidable,  but  innervation  is  well  preserved  and 
the  after-results  are  remarkably  good.  If  partial  resection  is  sufficient  Kocher's 
method  permits  the  anterior  part  of  the  capsule,  the  subscapular  muscle  and 
the  coraco-humeral  Hgament  to  remain  uninjured,  thus  avoiding  subsequent 
dislocation. 

Excision  Shoulder. — A  rational  method  of  resection  must  comply  with  the 
following  conditions:  Catterina  ("Zentralblatt  fiir  Chir,"  1906,  No.  2). 

1.  It  must  be  safe  and  must  hazard  no  important  structures. 

2.  It  must  be  easy. 

3.  It  must  afford  a  good  view  of  all  parts  of  the  joint  cavity. 

4.  It  must  be  suitable  to  all  cases  requiring  resection. 

Catterina  endeavors  to  fulfil  these  requirements  by  temporary  resection  of 
the  outer  third  of  the  clavicle,  thus  obtaining  free  exposure  of  the  joint  and 
avoiding  injury  to  the  deltoid  and  to  the  circumflex  nerve.  The  method  is 
suitable  to  all  cases,  especially  to  those  of  old  anterior  dislocations  requiring 
reduction  or  excision. 

Step  I. — From  a  point  about  2  inches  above  the  junction  of  the  middle  and 
outer  thirds  of  the  clavicle  make  an  incision  downwards  and  outwards  through 
the  skin  and  fascia  for  about  6  inches  along  the  groove  between  the  pectoralis 


CATTERINA  S  OPERATION 


IO9I 


major  and  the  deltoid.  Retract,  or  doubly  ligate  and  divide,  the  cephalic 
vein. 

Step  2. — At  the  junction  of  its  middle  and  outer  thirds  separate  the  soft 
parts  from  the  clavicle  sufficiently  to  bore  two  holes  through  the  bone  about 
%  inch  apart.  Midway  between  these  two  holes  (which  will  serve  for  future 
wiring)  divide  the  bone  with  Gigli  wire  saw. 

Step  3. — Rotate  the  external  portion  of  the  clavicle  outwards  and  divide  its 
connections  with  the  trapezius,  the  subclavius,  and  the  coraco-clavicular  liga- 
ment.   Leave  the  clavicular  origin  of  the  deltoid  intact  (Fig.  1348). 


Fig.  1348. — Catterina's  operation.     (Catterina.) 

I.  Clavicle.  2.  External  third  clavicle.  3.  Coracoid.  4.  Acromion.  5.  Great  tuberosity  humerus. 
6.  Lesser  tuberosity  humerus.  ?■  Clav.  portion  deltoid.  8.  Pectoralis  major.  8.  Subclavius.  10. 
Trapezius.  11.  Pectoralis  minor.  12.  Long  head  biceps.  13.  Short  head  biceps.  14.  Coraco-brachialis 
15.  Coraco-acromial  ligament.  16.  Cephalic  vein.  17.  Thoracico-acrom.  art.  18.  Suprascap.  nerve. 
19.  Suprascap.  art. 


Step  4. — Reflect  the  flap  consisting  of  bone,  deltoid,  etc.,  outwards  and  back- 
wards so  as  to  expose  the  joint  fully. 

Step  5. — Treat  the  joint  secundum  artem. 

Step  6.— Replace  the  flap.  Wire  the  clavicle.  Close  the  wound  after  pro- 
viding for  drainage. 

The  head  of  the  scapula  is  diseased  or  injured,  the  head  of  the  humerus  is 
unaffected.     Resection  is  required,     v.  Esmarch  operates  as  follows: 

I.  Make  a  curved  incision  around  the  posterior  margin  of  the  acromion 
and  divide  the  fibres  of  the  deltoid  there  inserted  (Fig.  1349).  Expose  the  poste- 
rior and  upper  surface  of  the  joint  capsule. 


1092 


SHOULDER 


2.  From  ihe  middle  of  the  incision  cut  with  a  knife  down  to  the  postero- 
superior  margin  in  the  head  of  the  scapula,  make  a  longitudinal  incision  through 
the  joint  capsule  between  the  tendons  of  the  supra-  and  infra-spinatus  to  the 
middle  of  the  greater  tuberosity.  This  cut  divides  the  skin  and  the  deltoid  (in 
the  direction  of  its  fibres). 

3.  Retract  the  soft  parts.  With  a  periosteal  elevator  separate  the  long 
head  of  the  biceps,  the  articular  capsule  and  the  periosteum  all  together  from 
the  neck  of  the  scapula.  With  a  finger  saw  divide  the  neck  of  the  scapula  and 
remove  the  glenoid  cavity. 

4.  Close  the  wound  after  providing  drainage. 

When  a  shoulder  dislocation  has  remained  unreduced  for  even  a  com- 
paratively short  time,  the  head  of  the  humerus  becomes  adherent  to  its  sur- 
roundings. In  subcoracoid  and  subglenoid  dislocations 
the  vessels  and  nerves  are  stretched  directly  over  the 
head  of  the  bone,  and  as  they  are  liable  to  become 
adherent  to  the  bone  it  is  easy  to  see  how  dangerous 
vigorous  efforts  at  manual  reduction  may  become.  This 
constitutes  the  main  danger  in  manipulative  reduction, 
the  main  difficulties  arise  (a)  from  the  adhesions;  (b)  short- 
ening of  the  muscles  and  tendons  inserted  in  the  tuber- 
osities; (c)  contractions  and  alterations  of  the  capsule 
which  may  fill  up  the  glenoid  cavity;  (d)  changes  in  the 
glenoid  cavity  due  to  chipping  of  its  border  and  such  like 
lesions;  (e)  in  a  case  operated  on  by  Tully  Vaughan  bony 
material  was  found  occupying  the  glenoid  cavity.  This 
bony  material  consisted  of  a  detached  greater  tuberosity 
which  was  adherent  to  the  margins  of  the  glenoid  cavity, 
the  floor  of  which  was  smooth  and  unchanged. 

Cheyne  and  Burghard  lay  down  the  rule  that  it  is  not 
advisable  to  attempt  the  reduction  of  a  subcoracoid  or 
subglenoid  dislocation  after  four  or  five  weeks  have  elapsed  from  the  time  of 
injury,  and  that  it  is  practically  unjustifiable  to  attempt  it  after  seven  weeks. 
Even  within  the  period  mentioned  any  attemps  at  reduction  must  be  made 
with  extreme  care,  as  rupture  of  the  axillary  artery  has  resulted  from  attempts 
to  reduce  a  dislocation  of  four  weeks'  standing. 

Operations  for  reducing  (so-called  irreducible)  dislocations  of  the  shoulder 
may  be  roughly  classified  as  follows: 

I.  Subcutaneous  myotomy  or  tenotomy. 
II.  Osteotomy. 
III.  Arthrotomy  or  arthrotomy  plus  resection. 

Subcutaneous  Myotomy  and  Tenotomy. — The  few  cases  of  reduction  after 
the  subcutaneous  division  of  obstructing  bands  s^ems  to  have  been  uniformly 
successful.     [Unsuccessful  operations  have  probably  escaped  publication.] 

Weinhold  (1818)  divided  the  pectoralis  major;  Dieflfenbach  divided  the  pec- 
torahs  major,  latissimus  dorsi,  teres  major  and  minor,  and  even  some  of  the 
ligaments;  Simon  obtained  recovery  after  seventy  successive  operations  on 
one  patient.     Polaillon  operates  as  follows:     Introduce  a  sharp-pointed  teno- 


FiG.  1349. — Esmarch's 
incision.     (Esmarch.) 


DISLOCATION     SHOULDER  IO93 

tome  horizontally  from  without  inwards  to  the  head  of  the  humerus  at  a  point 
one  centimeter  below  the  tip  of  the  acromion.  Guided  by  this  instrument  in- 
troduce along  probe-pointed  tenotome  until  it  penetrates  between  the  anterior 
surface  of  the  head  of  the  humerus  and  the  deltoid.  Remove  the  sharp-pointed 
instrument.  Cutting  against  the  bone  divide  all  obstructing  fibrous  tissues. 
Paitially  withdraw  the  tenotome;  reintroduce  it  behind  the  head  of  the  humerus 
and  with  the  same  precautions  divide  all  obstructing  fibrous  bands  there 
situated.  In  similar  fashion  divide  obstructing  bands  in  any  position  around 
the  upper  end  of  the  humerus.  Delay  efforts  at  reduction  for  a  few  days  until 
the  tenotomy  wound  has  healed.  Molliere  operates  very  similarly,  but  pro- 
ceeds to  manipulative  reduction  as  soon  as  the  tenotome  is  removed.  Forgue 
and  Reclus  recommend  subcutaneous  operation  because  of  its  ease  and  safety. 
Cahier  considers  that  the  operation  possesses  all  the  disadvantages  of  work  done 
in  the  dark,  viz.,  dangers  to  nerves,  vessels,  and  to  the  long  head  of  the  biceps, 
that  it  only  incompletely  divides  obstructing  bands  and  that  it  pays  no  atten- 
tion to  the  fragments  of  bone  torn  from  the  greater  tuberosity  (when  that  is 
fractured)  and  remaining  attached  to  various  tendons.  Most  surgeons  will 
agree  with  Cahier  in  these  conclusions. 

Osteotomy  of  Humerus  for  Irreducible  Dislocation.^ — In  one  case  J.  Ewings 
Mears  performed  subcutaneous  osteotomy  for  old  subcoracoid  dislocation. 
At  first  the  result  was  good,  later  callus,  etc.,  impaired  the  usefulness  of  the 
limb.  In  cases  where  there  are  no  serious  pressure  symptoms  and  owing  to 
age,  debility,  etc.,  the  patient  is  unsuited  to  a  long  operation,  Souchon  proposes 
to  resect  one  inch  of  the  shaft  of  the  humerus  where  it  joins  the  head  and  place 
the  resected  extremity  in  or  near  the  glenoid  cavity.  This  leaves  the  head  in 
abnormal  position,  but,  as  already  noticed,  the  head  is  causing  no  serious  pressure 
symptoms  and  the  patient  is  unfit  for  more  serious  interference. 

Arthrotomy  for  Unreduced  Subglenoid  or  Subcoracoid  Dislocation  of  the 
Shoulder. 

1.  Open  the  joint  by  Ollier's  anterior  incision. 

2.  Retract  the  deltoid  outwards,  the  pectoralis  major  inwards.  This  exposes 
the  head  of  the  bone. 

3.  Examine  the  position  of  the  vessels  and  nerves;  note  if  they  adhere  to 
the  bone;  avoid  injuring  these  structures.  Examine  the  anatomical  neck  of 
the  bone;  divide  the  fibrous  structures  adherent  to  it,  with  a  periosteal  elevator 
detach  them  from  the  head  and  neck  of  the  bone;  keep  the  instrument  against 
the  bone  during  this  work  so  as  not  to  injure  the  vessels  and  nerves. 

4.  Apply  extension  to  the  arm.  With  the  finger  feel  for  bands  obstructing 
reduction;  divide  such. 

5.  Examine  the  glenoid  cavity.  If  it  is  filled  with  fibrous  tissue,  clear  such 
away  by  dissection.  If  the  capsule  is  in  fair  condition,  preserve  it;  if  it  hinders 
reduction,  divide  it,  and  after  reduction  repair  it  by  sutures.  If  the  capsule 
is  in  bad  condition,  i.e.,  contracted  and  distorted,  dissect  it  away. 

6.  Try  to  reduce  the  dislocation.  This  is  usually  possible.  If,  however, 
reduction  is  still  impossible  examine  with  the  finger  for  the  obstruction.  The 
obstruction  is  commonly  muscular  (supra  and  infraspinatus).  Very  gradually 
separate  these  muscles  at  their  insertion  into  the  great  tuberosity.     Do  not 


I094 


SHOULDER 


separate  them  one  iota  more  than  is  necessary  for  reduction.  Separation  of  the 
subscapularis  from  the  lesser  tuberosity  is  to  be  avoided  if  possible.  Complete 
the  reduction. 

7.  If  sufficient  capsule  remains,  repair  it  by  sutures.  With  sutures  restore 
the  soft  parts,  both  deep  and  superficial,  as  nearly  as  possible  to  their  normal 
condition.     Close  the  wound  with  or  without  drainage.     Dress.     Keep  the 


Fig.  1350. — (McBiiniey.) 

arm  bound  to  the  side  until  healing  is  complete.     Begin  passive  motion  early, 
using  an  anesthetic  if  necessary. 

The  operation  is  more  complex  when  there  is  fracture  of  the  neck  of  the 
bone  as  well  as  dislocation  of  the  head.  If  the  head  of  the  bone  is  seemingly 
sufficiently  nourished  reduction  must  be  attempted  by  pushing  and  prying  the 
head  of  the  bone  with  elevators,  forceps,  and  McBurney's  ingenious  hook 
(Figs.  1350  and  13  51).     Free  division  of  resisting  bands  is  of  course  necessary. 


Fig.  1351. — {McBurney.) 


After  successful  reduction,  the  fractured  bones  must  be  united  by  suture  (wire, 
chromicized  catgut)  or  by  buried  metallic  spHnting.  In  fracture-dislocation  of 
the  humerus  operation  may  be  performed  immediately,  i.e.,  before  the  lym- 
phatics have  become  clogged  with  debris  in  process  of  removal,  or  late,  i.e., 
after  the  lymphatics  have  removed  the  debris  of  destroyed  tissues  and  effused 
blood  and  before  real  attempts  at  repair  of  bone  have  begun. 

As  after-treatment  passive  motion  must  be  begun  early  (about  the  tenth 
day). 


dollixger's  operation 


1095 


Instead  of  exposing  the  joint  by  means  of  OUier's  incision  Catterina's  method 
may  be  used. 

DoUinger  ("Zentralblatt  fiir  Chlr.,"  Dec.  6,  1902)  in  seven  cases  found 


M.DELTOIDEUS 

M.PLCT.MINOR 

M.PECIMAJOR 

y^mACOBMCHIALIS 
■CAPUTBREVISM. 

m/p/m 

CEPHAUCA 


Fig.  1352. — Old  dislocation  of  shoulder.     {DoUinger. 


remarkable  absence  of  callus,  scar  tissue,  etc.     He  operated  with  excellent 
results  in  the  following  manner: 

Step  I. — Incise  from  the  clavicle  to  the  insertion  of  the  pectoralis  major 
along  the  inner  side  of  the  cephalic  vein.  Penetrate  the  cleft  between  the  del- 
toid and  the  pectoralis  major  and  expose  the  coracoid  process  (Fig.   1352). 


X"^, 

■l^     IVBFRCULMINUS  y 

^\ 

^^^^^^— ^ 

^^K\  MPECT.MINOP 

MMLrOWEUS-lm^ 

\\    ^^^y-CAPUr LONG.M. 
\^S-wf-M.SUffSCAPULAR/S 

^^CEPHALICA  -'  ^Wk 

H         uil 

^^rhMCORACOBRACMALIS 

W^'^PEmff/c/p/r/s\mm 

V^^M.PECTORAUS  MAJ 

1 

m 

I     .     - 

Fig.  1353. — Old  dislocation  of  shoulder.     (DoUinger.) 

Step  2. — -Retract  the  pectoralis  minor  up,  the  coraco-brachialis  out,  and  the 
pectoralis  major  inwards.  Expose  the  bicipital  groove  and  lesser  tuberosity. 
Do  not  injure  the  long  head  of  the  biceps.  The  humeral  head  lies  posteriorly 
and  rotated  somewhat  inwards  (Fig.  1353). 


1096 


SHOULDER 


Step  3. — Rotate  the  upper  arm  outwards,  thus  bringing  into  the  wound  the 
subscapular  and  the  head  of  the  humerus  covered  by  it  (Fig.  1354). 

Step  4. — Divide  the  tendon  of  the  subscapularis  and  expose  the  head  of  the 
humerus  (Fig.  1355).     Tt  is  possible  to  rotate  the  bone  outwards  to  any  extent 


i 


T-M-CORACOBRACmuS 


^CAPBREV.M. 

r.  8/C/P/r/S 


MPECr.MAJOR 


Fig.   1354. — Old  dislocation  of  shoulder.     {DoUingcr.) 

required  and  so  Kocher's  method  of  manipulative  reduction  becomes  easy. 
According  to  DoUinger,  the  retracted  and  perhaps  sclerosed  subscapularis 
forms  the  obstacle  to  reduction  in  uncomplicated  cases  and  under  it  lies  the  head 
of  the  humerus  in  subcoracoid  dislocation.     If,  as  happened  in  one  of  Bollinger's 


MPECLMINOR 


-CmTHUUERI 


/  M.SUBSCAPULAm 


HPECTMAJOft 


I'IG.   1355. — Old  dislocation  of  slioulder.     {Dollinger.) 


cases,  reduction  is  impossible  after  section  of  the  subscapular  tendon,  pull  the 
arm  strongly  downwards,  continue  the  split  in  the  tendon  to  the  glenoid  fossa 
and  remove  any  obstruction  present.  Sometimes  reduction  by  arthrotomy 
proves  impossible.     Under  these  circumstances  decapitation  of  the  humerus 


DISLOCATION    SHOULDER 


1097 


and  removal  of  the  head  is  proper,  unless  a  new  joint  has  formed  giving  satis- 
factory function.  Usually  there  is  great  pain  and  disturbance  due  to  pressure 
on  the  vessels  and  nerves.  The  operation  is  essentially  the  same  as  that  for 
reduction  of  the  dislocation,  but  the  head  of  the  bone  is  removed  after  section  of 
its  neck  by  means  of  a  Gigli  wire  saw.  Enough  bone  must  be  removed  to  insure 
a  good  new  joint.  As  an  aid  to  the  making  of  a  new  joint  one  may  cover  the 
divided  end  of  the  humerus  with  the  flap  of  muscle  or,  better,  of  fascia  and  fat. 
Regarding  excision,  Jonas  writes:  "This  is  an  operation  to  be  avoided  when 
possible,  on  account  of  the  resultant  flail-like  condition  of  the  arm  and  yet  must 
be  done  (a)  when  the  humeral  head  and  neck  become  too  extensively  stripped 
of  their  attachments,  experience  having  shown  that  necrosis  may  occur  in  16 
per  cent.  (Souchon)  of  the  cases;  (6)  when  osseous  union  has  occurred  between 


Unites  with  the  shaft  at  the  twentieth  year 
Tlie  upper  epiphysis  is  formed  by  the  union  of 
the  nucleus  for  the  head,  greater  tuberosity, 
and  that  for  the  lesser  tuberosity.  These  form  a 
common  epiphysis  before  uniting  with  the  shaft 

Capsular  line 


Shaft  begins  to  ossify  in  the  eighth  week  of 
intra-uterine  life 

Fig.  1356. — (Morris.) 
Ossification  of  the  humerus;  the  figure  also  shows  the  relations  of  the  epiphyseal  and  capsular  lines. 


the  head  and  the  ribs;  (c)  when,  after  a  division  of  all  the  restraining  soft  parts, 
the  head  rests  against  the  point  of  the  acromion  process"  ("Annals  Surg.," 
May,  1903). 

In  case  of  osseous  union  between  the  head  of  the  humerus  and  the  ribs  it 
would  seem  to  the  author  better  when  possible  to  divide  this  union,  trim  away 
irregularities  from  the  head  of  the  bone,  cover  it  with  a  pedunculated  flap  of 
fat  and  fascia  and  reduce  it,  thus  forming  a  new  joint  with  the  minimum  loss 
of  substance. 

In  his  classical  paper  on  irreducible  shoulder  dislocations  ("Transactions 
Am.  Surg.  Assoc,"  1897)  Souchon  comes  to  the  following  conclusions  regarding 
anterior  displacements:  "The  anterior  incision  is  the  route.  Reduction  is  the 
more  desirable  operation,  because  it  preserves  the  head  and  all  the  movements 
depending  thereon.  Reduction  should  be  done  only  in  cases  where  the  head 
and  glenoid  cavity  are  in  good  condition ;  when  no  extensive  dissections  have  to 


1098  SHOULDER 

be  made;  when  it  is  easily  effected  without  any  great  effort;  when  the  head  does 
not  need  to  be  trimmed  or  the  cup  to  be  too  deeply  scooped  or  enlarged;  when 
the  head  readily  remains  in  place,  but  not  too  tightly.  All  this  regardless  of  the 
time  or  standing  of  the  dislocation.  It  should,  however,  always  be  attempted 
conscientiously,  because  many  have  resected,  perhaps,  when  the  dislocation 
could  have  been  reduced.  Disregard  of  these  rules  may  result  in  necrosis  of 
head,  in  recurrence  of  the  dislocation  or  in  anchylosis,  with  their  inevitable 
consequences.  Resections  should  be  practised  in  all  other  cases.  When  in 
doubt  it  is  preferable  to  resect.  How  much  to  resect,  i.e.,  whether  to  saw, 
through  the  anatomical  neck,  or  obliquely  and  downwards  outside  the  tuber- 
osity, or  horizontally  on  a  level  with  the  lower  margin  of  the  head,  must  be 
determined  in  each  case;  it  is  best  to  remove  too  much  than  too  little."  The 
last  remarks  of  Souchon  require  some  modification.  In  subjects  under  eighteen 
years  of  age  it  is  most  important  not  to  injure  the  epiphyseal  cartilage  between 
the  head  and  the  shaft  (Fig.  1356).  "A  horizontal  section  with  the  saw,  starting 
at  the  internal  insertion  of  the  capsule  around  the  head,  will  surely  carry  away 
the  totality  of  the  conjugating  cartilage.  In  young  children,  if  the  resection  is 
made  below  the  epiphyseal  cartilage,  the  arm  will  cease  to  grow.  The  resected 
extremity  should  not  be  pushed  into  the  glenoid  cavity  in  children,  lest  the 
growth  of  bone  cause  anchylosis"  (Souchon). 

Posterior  or  Subspinous  Dislocation  Shoulder. — These  dislocations  are 
commonly  congenital.  Scudder's  rule  for  distinguishing  between  the  congenital 
and  traumatic  varieties  is  that  in  the  former  the  scapula,  clavicle  and  arm  bones 
are  not  so  well  developed  as  on  the  sound  side.  Only  a  few  operations  have  been 
performed  for  "irreducible"  dislocations  of  the  above  kind  and  of  these  Phelps's 
operation  seems  to  have  given  the  best  results.  Phelps's  operation  is  thus  de- 
scribed in  Souchon's  monograph:  "Curved  incision  along  the  lower  edge  of  the 
deltoid  and  on  to  the  scapula,  and  flap  turned  down;  it  would  be  best  to  curve  the 
incision  downwards  and  turn  the  flap  upwards,  as  it  would  give  better  drainage. 

Difficulties  and  complications  of  the  operation:  The  posterior  edge  of  the 
glenoid  cavity  was  gone  and  the  cavity  was  about  two-thirds  the  normal  size; 
a  portion  of  the  head  of  the  humerus  was  cut  away  in  order  to  fit  it  to  the  socket ; 
also  cut  away  a  portion  of  the  redundant  capsule  posteriorly;  the  bone  replaced 
and  a  stitch  put  in  behind  to  help  retain  the  head  in  place. 

Complications  after  the  operation:  None.  Result  immediate:  Drainage- 
tube  left  a  week.  Result  remote:  Is  satisfactory.  Dr.  A.  P.  Dudley  saw  the 
patient  a  year  after  the  operation,  and  there  was  a  little  difference  between  the 
two  arms.  Remarks:  Dr.  Dudley  did  not  doubt  that  the  injury  had  occurred 
during  delivery.  Doctors  who  had  seen  the  patient  before  were  of  the  opinion 
that  it  was  one  of  paralysis.  Dr.  A.  M.  Phelps  says  that  the  method  promised 
success  during  the  first  year,  although  one  case  has  been  operated  in  which  it 
was  successful  at  the  fifth  year." 

In  another  case  in  which  reaction  of  degeneration  was  present,  apparently 
due  to  pressure  neurosis,  the  result  obtained  by  Phelps  was  not  so  perfect,  but 
the  reaction  of  degeneration  disappeared. 

Peckham  ("Am.  Journ.  Orthopedic  Surg.,"  April,  1905)  reports  two  cases 
in  which  he  obtained  improvement  by  means  of  Phelps's  procedure. 


TRACTURE-DISLOCATION   SHOULDER  IO99 

Dislocation  plus  Fracture  of  the  Head  of  the  Humerus. — In  117  cases 
of  the  above  injury  the  fracture  was  located  at  the  surgical  neck  in  sixty-nine, 
at  the  anatomical  neck  in  twenty-seven,  at  the  "neck"  in  eleven,  at  both  surg- 
ical and  anatomical  necks  in  six;  one  case  was  comminuted,  and  the  "upper part" 
of  the  humerus  was  fractured  in  three  (McBurney  and  Dowd).  In  the  aged,  the 
feeble,  and  perhaps  in  diabetics  and  some  nephritics,  etc.,  it  is  wise  to  adopt 
Riberi's  treatment  provided  that  the  head  of  the  bone  is  not  giving  rise  to  pain 
and  other  pressure  symptoms.  This  treatment  (Riberi's)  consists  of  massage 
and  passive,  later,  active  motion,  and  aims  at  the  production  of  a  pseudarthrosis. 
In  all  other  cases  more  active  treatment  is  necessary.  Never  fail  in  recent  cases 
to  attempt  reduction,  under  an  anesthetic,  by  means  of  manipulation  and  finger 
pressure  applied  to  the  dislocated  head  of  the  humerus.  This  is  occasionally 
successful  and  the  condition  becomes  one  of  mere  fracture.  Never  attempt 
reduction  by  any  of  the  manipulations  suitable  in  uncomplicated  disloca- 
tion. It  is  wise  to  be  prepared  to  proceed  at  once  to  arthrotomy  if  simpler 
means  fail. 

Arthrotomy  for  Fracture-dislocation  of  the  Humerus.^ — McBumey's  Opera- 
tion.— Make  an  incision  about  i^-^  inches  long  about  i  inch  below  the  acromion. 
Penetrate  the  deltoid  to  the  outer  surface  of  the  upper  fragment.  Drill  a  hole 
through  the  upper  fragment  horizontally.  (This  supposes  fracture  at  or  near 
the  surgical  neck.)  Into  the  perforation  fit  the  right-angled  beak  of  McBurney's 
traction  hook  (Figs.  1350  and  1351).  Make  traction  on  the  upper  fragment  by 
means  of  the  hook  and  at  the  same  time  press  with  the  fingers  on  the  head  of  the 
bone  and  so  reduce  it.  Treat  the  fracture  secundum  artem.  Farquhar  Curtis 
has  found  McBurney's  hook  tear  out  during  the  necessary  traction  but  by  using 
leverage  with  a  periosteal  elevator  and  by  dividing  obstructing  bands  he  suc- 
ceeded in  obtaining  reduction. 

Schlange's  Operation. — ("Archiv  fiir  kUn.  Chir.,"  Ixxxi,  II,  Theil).  Abduct 
the  arm.  Make  a  43^^  inch  incision  along  the  axillary  margin  of  the  pectoralis 
major  and  coraco-brachialis.  Retract  these  two  muscles  forwards,  retract  the 
axillary  vessels  and  nerves  backwards  and  protect  them.  Incise  the  joint 
capsule  or  enlarge  (if  necessary)  any  tear  which  may  involve  the  capsule  and  so 
expose  the  heads  of  the  bone.  Remove  any  splintered  fragments  of  bone. 
Reduce  the  dislocated  humeral  head  by  direct  manipulation  with  the  fingers  and 
by  prying  with  blunt  instruments.  Schlange  operated  in  this  manner  on  one 
case  of  fracture  of  the  anatomical  and  in  one  of  the  surgical  neck.  In  the  former 
case  the  question  of  resection  presented,  as  the  head  of  the  bone  was  separated 
from  almost  all  its  connections;  "the  good  result  obtained  demonstrates  that  one 
dare  to  and  ought  to  act  very  conservatively  just  as  in  the  case  of  a  dislocated 
astragalus."  This  advice  of  Schlange's  is  good  when  the  patient  is  in  the  hands 
of  a  first-class  surgeon  and  in  proper  surroundings,  but  there  are  circumstances 
in  which  resection  is  much  safer  and  will  give  an  excellent  functional  result, 
especially  if  the  upper  end  of  the  humerus  be  covered  with  Murphy's  flap  of  fatty 
fibrous  tissue. 

Codman's  (Sabre-cut)  method  of  exposing  the  shoulder  is  described  on  p.  1108. 

Arthrodesis  Shoulder. — When,  as  a  result  of  paralysis,  the  shoulder-joint 
becomes  flail-like  and  yet  the  muscles  of  the  elbow  and  of  the  hand  and  those 


IIOO  SHOULDER 

uniting  the  scapula  to  the  trunk  are  not  paralyzed,  the  operation  of  arthrodesis 
may  be  useful.  If  the  elbow  muscles  are  also  paralyzed  but  those  for  the  hand 
remain  active,  artificially  produced  anchylosis  (arthrodesis)  of  both  shoulder  and 
elbow  may  be  of  service. 

Step  I. — Exposure  of  the  joint.  Owing  to  the  degeneration  of  the  deltoid 
and  of  the  circumflex  nerve  in  cases  of  paralytic  luxation  it  is  useless  to  pay 
much  attention  to  these  structures,  hence  incision  may  be  made  where  con- 
venient ("Bothezat,  Rev.  de  Chir.,"  June,  1901). 

From  a  point  a  little  internal  to  the  acromio-clavicular  joint  make  an  incision 
downwards  to  the  outer  side  of  the  pectoro-deltoid  groove  for  a  distance  of  i^'^  to 
4  inches. 

Step  2. — The  deltoid  being  practically  absent,  it  is  very  easy  to  open  the 
joint  by  cutting  the  capsule  along  the  bicipital  groove. 

Step  3.— Excise  as  much  of  the  synovialis  as  possible  and  scrape  with  the 
spoon  every  accessible  part  of  the  remainder. 

Step  4. — Push  the  head  of  the  humerus  out  of  the  wound.  This  is  easy 
because  all  the  tissues  are  relaxed  and  the  muscles  paralyzed.  Remove  all 
cartilage  from  the  head  of  the  bone.  Vivify  the  glenoid  cavity  by  removing  the 
cartilage.     Vivify  an  appropriate  surface  of  the  acromion  process. 

Step  5.— Let  an  assistant  steady  the  scapula  in  good  position.  Place  the 
humeral  head  in  contact  with  the  glenoid  cavity  and  the  acromion  process. 
The  most  useful  position  (Bothezat)  is  one  of  slight  internal  rotation  with  the 
arm  at  an  angle  of  45°  to  the  external  border  of  the  scapula.  Fix  the  bone  in 
position  by  means  of  two  wires,  one  uniting  the  humerus  to  the  upper  part  of  the 
glenoid,  the  other  uniting  the  humerus  to  the  acromion. 

Step  6. — Close  the  wound  by  deep  and  superficial  sutures,  being  careful 
to  "take  up  the  slack"  in  the  capsule.  Immobilize.  After  the  wound  has 
completely  healed  treat  the  muscles  by  means  of  massage  and  electrical  stimu- 
lation, but  keep  up  immobilization  for  two  months,  i.e.,  until  consoHdation  has 
had  time  to  take  place. 

Habitual  Dislocation  Shoulder.- — Burrell  operates  by  excising  a  portion  of 
the  capsule  in  the  following  manner: 

Make  Ollier's  anterior  incision. 

Expose  the  coraco-brachialis,  short  head  of  the  biceps,  and  upper  part  of  the 
tendon  of  the  pectoralis  major  below;  divide  the  upper  three-fourths  of  the 
tendon  of  the  pectoralis  major  at  its  insertion  and  so  expose  the  head  of  the 
humerus  and  part  of  its  shaft. 

Rotate  the  arm  outwards  and  push  the  elbow  a  little  backwards,  exposing 
the  tendon  of  the  subscapularis  stretehed  over  the  head  of  the  bone.  Divide 
the  upper  portion  of  this  tendon.  Abduct  the  arm  to  an  angle  of  45°;  press  the 
head  of  the  bone  backwards  so  as  to  relax  the  capsule  anteriorly.  Excise  a  strip 
of  capsule  about  %  inch  long  by  %  inch  wide.  Suture  the  wound  in  the  capsule. 
Close  the  wound.  Dress.  Immobilize.  A.  I.  Mackinnon  improves  Burrell's 
operation  by  avoiding  excision  of  the  capsule  and  by  closing  the  wound  in  an 
overlapping  fashion.  The  operation  consists ' '  in  doing  an  open  arthrotomy ;  the 
muscles  are  well  retracted  and  the  capsule  is  opened  from  the  coracoid  process 
downwards.     Mattress  sutures  are  introduced  1  io  lYi  inches  from  one  margin 


HABITUAL  DISLOCATION    SHOULDER  IIOI 

of  the  incision  in  such  a  manner  that  when  they  are  tied  one  flap  slides  under  the 
other.  By  this  process  there  is  a  double  layer  of  capsule  over  what  is  ordi- 
narily the  weakest  point,  and  increased  protection  against  recurrence  is  given  the 
joint.  A  running  suture  closes  the  exposed  margin  of  the  capsule,  and  the  ex- 
ternal wound  is  closed  in  the  usual  manner."  In  similar  cases  Robert  Jones  often 
cuts  down  to  but  not  into  the  capsule;  seizes  the  capsule  with  two  forceps,  twists 
it  tight  and  with  sutures  fixes  the  folded  or  twisted  capsule  so  that  it  cannot  relax. 

Turner  Thomas  ("journal  A.  M.  A.,"  March  12,  1910)  performs  capsulor- 
rhaphy  through  an  incision  in  the  axilla. 

Step  I. — Make  a  cut  in  the  axilla  along  the  coraco-brachialis  muscle  from 
the  side  of  the  chest  downwards  for  about  5  inches.  Retract  outwards  the 
coraco-brachialis,  biceps  and  pectoralis  major.  Retract  inwards  the  axillary 
vessels  and  nerves  as  well  as  the  musculo-cutaneous  nerve.  Doubly  ligate 
and  divide  the  anterior  circumflex  vessels  and  expose  the  latissimus  dorsi  in 
the  floor  of  the  wound.  Locate  and  protect  the  circumflex  nerve  and  the 
posterior  circumflex  vessels  as  they  pass  backwards.  On  a  grooved  director 
divide  about  half  the  width  of  the  subscapular  muscle,  thus  exposing  the 
capsule. 

Step  2. — Open  the  capsule  by  a  cut  about  i}4  inches  in  length,  in  the  line  of 
the  anterior  glenoid  margin  and  about  3^  inch  below  it.  Explore  the  joint  for 
any  obstruction  to  reduction. 

Step  3. — Close  the  wound  in  the  capsule  by  the  overlapping  method.  Repair 
the  wound  in  the  subscapularis.  Close  the  wound.  Bind  the  arm  to  the  side 
and  support  the  wrist  in  a  sling. 

After-treatment. — On  the  ninth  day  the  patient  may  put  his  arm  through 
the  sleeve  of  his  coat.  For  three  weeks  keep  the  arm  bound  to  the  chest  during 
the  night.  After  which  time  forcible  movements  may  be  begun.  Thomas  finds 
that  patients  become  able  to  raise  their  arms  straight  above  their  heads  in  from 
six  to  fifteen  weeks  after  operation. 

Clairmont-Ehrlich  Operation. — Make  an  incision  over  the  anterior  portion  of 
the  deltoid  and  parallel  to  its  fibres.     Split  the  muscle. 

Make  an  incision  over  the  posterior  portion  of  the  deltoid  and  reflect  upwards 
a  flap  of  deltoid  preserving  intact  the  branches  of  the  axillary  nerve  supplying  it. 

From  the  anterior  incision  pass  a  closed  forceps  through  the  split  in  the 
deltoid  around  the  inner  side  of  the  humeral  neck  to  emerge  at  the  posterior  del- 
toid wound.  Grasp  the  mobilized  flap  of  muscle,  pull  it  through  the  tunnel, 
which  has  been  su£5ciently  dilated  to  accommodate  it,  and  suture  it  to  the 
anterior  deltoid  wound.     The  whole  operation  is  extra-capsular. 

Clairmont  and  Ehrlich  obtained  good  results  in  two  cases. 

In  three  cases  of  Lameris  the  immediate  results  were  good  but  in  two  of 
them  there  was  recurrence  after  eleven  months.  Seidel  found  that  the  longest 
muscle  flap  obtainable  might  be  too  short  to  reach  to  the  anterior  deltoid  wound, 
so  in  one  case  he  lengthened  it  by  a  graft  of  fascia  with  unfavorable  result. 

Kirschner's  Operation. — Step  i. — Beginning  ^  inch  below  the  middle  of  the 
spine  of  the  scapula  make  a  23^-3  inch  incision  along  the  posterior  margin  of 
the  deltoid.  Expose  the  posterior  margin  of  the  deltoid  and  retract  it  upwards 
and  outwards. 


II02  SHOULDER 

Step  2.- — ^Recognize  the  circumflex  nerve  and  vessels.  Using  these  as  a 
guide  find  the  quadrilateral  space  bounded  above  by  the  teres  minor;  below  by 
the  teres  major;  internally  by  the  long  head  of  the  triceps;  and  externally  by  the 
humerus.  Retract  the  circumflex  nerve  and  vessels  downwards;  bluntly  pene- 
trate the  quadrilateral  space. 

Step  3. — Push  the  finger  or  a  forceps  forwards  and  upwards  under  the  del- 
toid to  the  posterior  edge  of  the  acromion  near  its  point.  At  this  place  make  the 
forceps  penetrate  the  deltoid  and  lift  up  the  skin.  Incise  the  skin  over  the  point 
of  the  forceps. 

Step  4. — Make  an  incision  along  the  anterior  margin  of  the  deltoid  and  expose 
its  border.  With  finger  and  forceps  burrow  under  the  muscle  to  the  anterior 
margin  of  the  acromion  near  its  point  and  perforate  the  muscle.  Push  the  per- 
forating forceps  through  the  skin  incision  made  in  Step  3. 

Step  5. — Through  the  anterior  incision  pass  the  fingers  or  forceps  around  the 
neck  of  the  humerus,  hugging  the  bone,  to  emerge  at  the  posterior  incision. 

Step  6. — From  the  thigh  excise  a  strip  of  fascia  lata  about  8  inches  long  by 
i}4:  inch  wide.  Pull  this  through  the  tunnels  which  have  been  made  around  the 
shoulder.  The  course  of  the  implant  as  it  is  pulled  into  place  is  (a)  through  the 
posterior  incision,  (b)  through  the  quadrilateral  space  between  the  teres  major 
and  minor,  (c)  under  the  neck  of  the  humerus  to  the  anterior  incision,  (d)  under 
the  deltoid  to  the  perforation  in  that  muscle  just  in  front  of  the  acromion,  (e) 
over  the  acromion  (f)  from  without  inwards,  through  the  perforation  in  the 
deltoid  and  so  under  the  deltoid  to  the  posterior  incision  again,  where  it  is 
fixed  by  a  few  sutures. 

The  result  is  a  strip  of  fascia,  outside  the  joint  capsule,  which  slings  the  neck 
of  the  humerus  to  the  acromion  process. 

Payr's  Operation  (Kleinschmidt,  "Ergeb.  d.  Chir.  u.  Orthop.  "  viii,  229). — 
Expose  the  joint  capsule  through  Ollier's  incision.  Suture  the  base  of  a  triangu- 
lar flap  of  fascia  lata  by  several  rows  of  sutures  to  the  insertion  of  the  pectoralis 
major. 

Under  tension  suture  the  apex  of  the  flap  to  the  coracoid  process.  Through 
a  suitable  incision  behind  expose  the  posterior  margin  of  the  deltoid  and  retract 
it  upwards  and  outwards.  Suture  the  apex  of  a  triangular  flap  of  fascia  lata 
to  the  joint  capsule  above  the  head  of  the  humerus.  Suture  the  base  of  this  flap, 
under  tension,  to  the  surface  of  the  infra-spinatus  and  teres  minor.  Several 
rows  of  suture  should  be  used. 

Perthes  ("Deutsche  Zeitschrift  fiir  Chir.,"  Ixxxv)  beUeves  habitual  disloca- 
tion of  the  shoulders  is  generally  due  to  fracture  of  the  upper  end  of  the  humerus 
or  of  the  scapula.  Owing  to  muscular  action  or  to  direct  violence  the  greater 
tuberosity  is  often  fractured  or  the  tendons  give  way  near  their  insertion  there, 
and  are  likely  to  unite  to  the  capsule.  In  other  cases  the  glenoid  may  be  injured, 
giving  rise  to  foreign  bodies  in  the  joint.  Sometimes  the  trouble  is  due  to  re- 
laxation of  rupture  of  the  capsule.  The  capsule  is  normally  so  large  that  it  is 
capable  of  holding  two  humeral  heads  or  of  permitting  subcoracoid  dislocation 
(Perthes).  It  may  be  enlarged  uniformly  or  the  anterior  part  may  be  enlarged 
and  form  a  sort  of  hernia. 

In  operating  always  open  the  joint  to  look  for  damage  to  the  bones  and  ten- 


ARTHROPLASTY  SHOULDER  II03 

dons.  If  the  tuberosity  is  fractured  or  the  tendons  torn  off  from  it,  the  injury 
must  be  repaired,  or  the  joint  will  not  be  secure.  The  best  method  of  joining 
the  ruptured  tendons  to  the  bone  is  by  double-pointed  steel  tacks  (Perthes) 
which  are  either  driven  through  the  tendons  into  the  bone  or  are  first  driven 
into  the  bone  and  the  tendons  then  secured  to  them.  The  glenoid  ligament 
may  be  fastened  to  the  neck  of  the  scapula  in  the  same  fashion.  Perthes  ex- 
poses the  joint  by  turning  backwards  and  upwards  a  flap  of  skin  and  of  the  whole 
deltoid  muscle.  This  exposes  the  joint  very  well  and  the  muscle  is  said  not  to 
suffer  from  the  disinsertion,  if  sewed  in  place  firmly.  The  joint  may  be  reached 
from  in  front  by  an  incision  along  the  border  of  the  deltoid,  the  anterior  portion 
of  which  is  severed  near  the  clavicle.  The  tendon  of  the  pectoralis  major  is  cut 
and  this  muscle  is  drawn  towards  the  breast.  The  end  of  the  coracoid  process  is 
removed  with  a  Gigli  wire  saw  and  the  coraco-brachialis  and  short  head  of  the 
biceps  drawn  down.  The  upper  border  of  the  subscapularis  may  be  drawn  back 
or  severed.  After  suturing  the  tendons  of  the  scapular  muscles  and  repairing 
the  glenoid  ring,  the  capsule  is  drawn  up  with  sutures  so  placed  as  to  strengthen 
it.  The  muscles  cut  during  the  operation  are  then  restored  and  the  skin 
closed. 


Fig.  1357. — Arthroplasty.     (Payr.) 

Arthroplasty  of  Shoulder. — The  general  principles  governing  the  operation  of 

arthroplasty  are  described  on  page  1052. 

Step  I. — Expose  the  joint  through  OUier's  incision. 

Step  2. — Overcome  the  anchylosis.  In  bony  anchylosis  resection  and  model- 
ling of  the  head  of  the  humerus  will  be  necessary.  See  that  motion  is  even  more 
than  normally  free. 

Step  3. — Method  A. — Through  an  incision  parallel  to  its  fibres,  expose  the 
surface  of  the  middle  portion  of  the  pectoralis  major.  Mobilize  a  flap  from 
the  pectoralis  major,  the  pedicle  of  the  flap  being  formed  by  its  humeral  inser- 
tion (Fig.  1357,  Payr).  Make  a  subcutaneous  tunnel  from  the  wound  on  the 
chest  to  that  opening  the  joint  and  pull  the  pectoral  flap  through  the  tunne 
into  this  joint.  Wrap  the  flap  over  the  head  of  the  humerus  and  fix  it  in  position 
by  a  few  sutures. 

Method  B. — Exactly  the  same  as  method  A  but  the  flap  is  formed  of  the  fat 
and  fascia  covering  the  pectoralis  major  instead  of  muscular  tissue. 

Method  C. — Carefully  wrap  the  head  of  the  bone  in  Baer's  membrane  (see 

p.  1055)- 

Step  4. — Close  the  wounds.     Apply  dressings. 


II04  CLAVICULO-HUMERAL  NEARTHROSIS 

CHAPTER  XCIII 
CLAVICULO-HUMERAL  NEARTHROSIS 

It  is  interesting  and  valuable  to  know  that  a  useful  new  joint  can  be  es- 
tablished after  excision  of  the  scapula  and  of  the  upper  end  of  the  humerus 
even  when  a  useless  flail-like  articulation  has  been  present  for  a  long  time. 
Ollier's  case  presents  so  many  points  of  interest  and  his  treatment  of  it  is  so 
suggestive  in  many  ways  that  no  apology  is  necessary  for  discussing  it  at  some 
length. 

The  patient  was  wounded  in  the  shoulder  in  187 1.  He  subsequently  under- 
went many  operations — sequestrotomies,  typical  resection  of  the  humeral 
head,  complete  removal  of  the  scapula,  etc.,  etc.  ("Revue  de  Chir.,"  July, 
1899).  Figure  1358  shows  the  appearance  of  the  patient.  The  outer  end  of 
the  clavicle  was  pulled  upwards  by  the  trapezius  and  was  connected  with  the 
humerus  merely  by  skin,  fibrous  tissue,  and  some  atrophied  bands  of  muscle. 
The  arm  itself  drooped  because  of  its  own  weight.  The  limb  was  useless 
though  the  muscles  of  the  forearm  and  hand  were  well  nourished.  The  upper 
end  of  the  humerus  was  thin,  pointed,  surrounded  by  scar  tissue,  and  about 
2^^  inches  distant  from  the  clavicle.  The  muscles  of  the  shoulder  were  so 
atrophied  that  only  with  difficulty  could  remnants  of  them  be  found  among 
the  scars  of  the  incisions  existing  where  the  scapula  had  been.  The  deltoid 
had  lost  all  its  clavicular  connections  except  its  inner  fibres  which  were  stretched 
and  atrophied.  The  rest  of  the  deltoid  had  retracted  to  its  lower  insertion, 
curling  itself  up  in  a  bunch  over  the  upper  end  of  the  humerus.  The  pectorahs 
major  formed  the  principal  support  of  the  arm. 

Oilier  operated  as  follows: 

(i)  Antero-lateral  incision  from  the  outer  end  of  the  clavicle  downwards. 

(2)  Vivification  of  the  under  surface  of  the  clavicle  for  an  area  of  about 
1 3^  square  inches.     This  was  done  by  turning  aside  a  flap  of  periosteum. 

(3)  Extension  of  the  incision  sufficiently  to  permit  the  formation  of  a  cavity 
through  which  the  humerus  could  be  brought  into  contact  with  the  clavicle 
(care  was  here  required  to  avoid  injuring  the  vessels  and  nerves.  It  was 
necessary  to  excise  some  of  the  scar  tissue  before  the  humerus  could  be  brought 
into  proper  position. 

(4)  Cutting  off  the  pointed  extremity  of  the  humerus  in  order  to  obtain  a 
surface  large  enough  to  unite  to  the  clavicle.  When  removing  the  bone  Oilier 
preserved  its  periosteum. 

(5)  Drilling  of  two  holes  through  the  clavicle  and  two  holes  (from  before 
backwards)  through  the  humerus.     Wiring  of  the  humerus  to  the  clavicle. 

(6)  Suture  of  the  periosteum  of  the  humerus  to  that  of  the  clavicle  (i.e., 
the  reflected  flaps  of  periosteum). 

(7)  Dissection  and  straightening  out  of  the  periarticular  muscles  so  that 
they  could  be  sutured  where  they  would  do  most  good,  e.g.,  the  deltoid  which 
was  curled  up  on  itself  was  freed  from  adhesions  and  then  sutured  to  the  trape- 
zius which  was  separated  from  the  clavicular  insertion;  such  portions  of  the 


CLAVICULO-HUMERAL   NEARTHROSIS 


1 105 


Fig.  1358.— (0//Jer.) 


Fig.  1359. — {Oilier.) 


70 


IIo6  OPERATION   FOR   SUBACROMIAL  BURSITIS 

deltoid  as  did  not  correspond  to  portions  of  the  trapezius  were  sutured  to  the 
periosteum  and  tissues  around  the  clavicle. 

(8)  Closure  of  the  wound.  The  limb  was  immobilized  for  four  months, 
but  during  that  time  the  deltoid  was  stimulated  by  electricity  applied  through 
a  window  cut  in  the  dressings.  After  the  above  time  no  bony  union  had  taken 
place.  In  time  a  useful  and  movable  joint  formed.  Figure  1359  shows  the 
patient  twenty-five  months  after  operation. 


CHAPTER  XCIV 

OPERATION  FOR  SUBACROMIAL  BURSITIS  AND  FOR  RUPTURE  OF 
THE  SUPRA-SPINATUS  TENDON 

Codman's  Bursitis  is  more  common  than  any  other  lesion  of  the  shoulder 
or  inflammation  of  any  other  bursa.  Normally,  a  bursa  exists  between  the 
deltoid  and  acromion  and  the  short  rotators  which  form  the  capsule  of  the 
shoulder.  When  the  arm  hangs  at  rest  a  small  portion  of  the  bursa  extends 
under  the  acromion  process  and  the  coraco-acromial  ligament.  When  the  arm 
is  abducted  the  base  of  the  bursa  which  is  on  the  tuberositv  of  the  humerus 


Fig.   1360. — Codman's  bursitis.     (Codman.) 

passes  upwards  under  the  acremion  and  the  coraco-acromial  ligament.  When 
bursitis  is  present  abduction  and  likewise  external  rotation  become  impossible. 
In  chronic  inflammation  the  normally  thin  and  pliable  bursal  walls  become 
thickened,  and  if  simpler  means  of  treatment  fail,  excision  becomes  necessary. 

The  Operation. — Step  i. — From  a  point  midway  between  the  coracoid 
and  the  acromion  make  a  2  to  23^-inch  incision  parallel  to  the  fibres  of  the 
deltoid  (Fig.  1360).  Split  the  deltoid  and  enter  the  bursa  as  if  it  were  the 
peritoneum. 

Step  2. — Excise  the  adherent  or  thickened  portion  of  the  bursa. 


C'ODMAN  S   BURSITIS 


IIO7 


Step  3. — Attend  to  hemostasis.  Close  the  wound  in  the  deltoid  with  fine 
catgut  sutures.  Close  the  skin  wound.  Apply  dressings.  Begin  motion  in 
about  ten  days. 

Brickner  ("Am.  J.  Med.  Sc,"  March,  191 5)  notes  that  contusions  or  tears 
of  the  supra-spinatus  tendon,  even  when  the  trauma  is  mild,  are  sometimes 
followed  by  single  or  multiple  deposits  of  lime  salts  in  the  tendon  or  on  its 
surface.  When  such  are  present  and  cause  disability  their  removal  is  necessary. 
Brickner  operates  for  Codman's  bursitis  as  follows:  Open  the  bursa  through  an 
incision  which  splits  the  deltoid  from  the  outer  border  of  the  acromion  down- 
wards over  the  greater  tuberosity,  i.e.,  towards  the  external  condyle.  With 
retractors  open  the  bursa.  Divide  all  adhesive  bands.  Excise  any  papilloma- 
like  masses.  Explore  the  whole  bursa  rotating  and  putting  traction  on  the  arm 
as  may  be  necessary  to  facilitate  palpation.  Incise  the  floor  of  the  bursa,  in 
the  same  line  as  the  skin  incision,  over  the  greater  tuberosity  and  supra-spinatus 


Bid  of  c7ai/icte^ 


Acromion    divided. 
Comcvid,-'"' 


J^i^tiired  supra-spincdizs 
Nobili7ed  segment 


Flap 
co?Uamin^ 


I    .^T-Ioffy^ead  Mceps 


Codmans  sabre-cut  incision 

Fig.  1361. 

insertion  and  dissect  it  up  from  the  tendon.  If  any  deposit,  fluid  or  solid  is 
found,  remove  such.  If  the  tendon  shows  any  superficial  injury  or  tear  within 
which  is  more  of  the  solid  or  cheesy  material  clear  such  away  and  trim  and  suture 
the  rent  in  the  tendon.  If  the  X-ray  has  shown  calcareous  material  in  the  ten- 
don, completely  remove  such  through  an  axial  split  in  the  tendon  and  suture 
the  wound  with  catgut.  Close  the  wound  in  the  floor  of  the  bursa  with  fine 
catgut  stitches.  Smear  the  inside  of  the  bursa  with  vaseline  but  leave  no 
small  lumps  of  the  lubricant.  Suture  the  roof  of  the  bursa.  Close  the  wound. 
Dress.  Immobilize  the  arm  in  a  position  of  abduction  (120°)  until  healing  has 
taken  place. 

Injury  to  the  Supra-spinatus  Tendon. — Codman  has  shown  that  the  deltoid 
can  act  ejficiently  as  an  abductor  only  after  the  supra-spinatus  has  pulled  the 
head  of  the  humerus  firmly  against  the  scapular  portions  of  the  articulation; 
thus  rupture  of  this  tendon  causes  great  disability  and  must  be  repaired.  The 
operation  is  best  carried  out  through  Codman's  sabre-cut  incision  which  is  very 
valuable  for  exploration  of  the  joint  and  for  the  treatment  of  fracture — dis- 


II08  ELBOW 

location  or  of  irreducible  dislocations.     The  operation  is  not  suitable  for  tuber- 
culosis or  inflammatory  lesions. 

The  Sabre -cut  Operation. — Split  the  deltoid  exactly  as  in  exposing  the 
subacromial  bursa.  Continue  the  incision  directly  back  over  the  shoulder  at 
the  root  acromion  process.  Divide  the  acromio-clavicular  joint.  With  a 
Gigli  saw  divide  the  base  of  the  acromion  avoiding  injuring  the  supra-scapular 
nerve  as  it  passes  through  the  great  scapular  notch.  (Fig.  1361).  Divide  a  few 
fibres  of  the  trapezius  and  retract  outwards  the  acromion  along  with  the  deltoid 
and  the  whole  outer  half  of  the  wound  just  as  if  one  opened  the  upper  part  of 
the  seam  of  a  coat  sleeve  and  looked  in  at  the  top  of  the  shoulder.  If  the  supra- 
spinatus  has  been  torn,  the  articular  surface  of  the  joint  is  visible;  otherwise  (if 
the  operation  is  exploratory)  that  muscle  must  be  divided  before  proper  ex-posure 
is  attained.  It  is  easy  to  repair  the  tendon  with  sutures  and  to  suture  the 
acromio-clavicular  joint  by  means  of  the  surrounding  firm  fibrous  tissue.  The 
acromion  may  be  united  either  by  wiring  or  by  suture  of  the  surrounding  soft 
parts. 


CHAPTER  XCV 
ELBOW 


Intra-articular  Injection. — The  technic  of  intra-articular  injections  has 
been  so  fully  treated  elsewhere  that  it  is  sufficient  to  mention  the  point  of 
puncture  of  the  elbow-joint.  Recognize  by  palpation  the 
head  of  the  radius.  From  the  outer  side  of  the  arm  in- 
troduce a  trocar  at  right  angles  to  the  long  a.\is  of  the 
hmb,  immediately  above  the  radial  head,  and  penetrate 
into  the  joint. 

Arthrotomy. — The  remarks  made  on  arthrotomy  and  on 
the  treatment  of  wounds  and  infections  of  the  knee  (p.  1030) 
apply  equally  to  the  elbow.  The  incisions  for  arthrotomy 
should  be  ample.     The  best  incisions  are  lateral.     To  gain 

i'';.  .)  I  free  exposure  of  the  joint,  division  of  the  external  lateral 
[  '{  \  ligament  is  necessary  and  does  not  interfere  with  function 
if  well  sutured.  Willems  principle  of  active  motion  begun 
immediately  after  operation  (pp.  1030,  1031)  is  of  great  im- 
portance for  drainage  and  function. 

Resection  or  Excision  of  the  Elbow.  Posterior  Vertical 
Median  Incision. — Step  i. — Have  an  assistant  hold  the  arm 
Fig.  1362. — Exci-  firmly  in  a  position  of  partial  flexion.  Make  a  longitudinal 
sion  of  elbow.  jncision  from  a  point  2  inches  above,  to  a  point  2  inches 
below,  the  tip  of  the  olecranon  (Fig.  1362).  The  cut,  following  the  middle  line 
of  the  olecranon  and  lower  part  of  the  humerus,  penetrates  at  once  to  the 
bone  and  opens  the  posterior  part  of  this  joint. 

Step  2. — With  a  periosteal  elevator  or  knife  separate  all  the  soft  parts 
(including  periosteum  and  inner  portion  of  triceps  tendon)  from  the  olecranon 
process  on  the  inner  side  of  the  vertical  wound.     In  doing  this,  if  one  uses  the 


ARTHROTOMY   ELBOW 


1 109 


knife,  one  must  strongly  retract  the  tissues  inwards  with  the  nail  of  his  left 
thumb  and  cut  with  short  decided  movements  of  the  knife  on  to  the  hone.  As 
such  a  manner  of  cutting  is  essential,  but  soon  renders  the  knife  as  blunt  as 
the  proverbial  ploughshare,  it  is  well  to  have  several  knives  prepared. 
In  all  the  cutting  practised  in  resection  of  the  elbow  the  edge  of  the  knife  must 
be  directed  against  the  bone  (Fig.  1363). 

Continue  the  separation  inwards  until  not  only  is  the  inner  part  of  the 
olecranon  bare  of  covering,  but  the  same  is  true  of  the  inner  part  of  the  lower 
end  of  the  humerus  and  the  internal  epicondyle  can  be  protruded  into  the 
wound. 


Fig.  1363. 
Figs.  1363  and  1364.- 


Fig.  1364. 
-Excision  of  elbow.     {Sc/iwartz.) 


The  ulnar  nerve  lying  in  the  groove  between  the  olecranon  and  the  internal 
condyle  is  raised  up  and  retracted  inwards  with  the  rest  of  the  soft  structures 
(Fig.  1364).  It  should  not  be  seen.  The  structures  on  the  outer  side  of  the 
elbow  are  to  be  treated  in  the  same  way  as  those  on  the  inner  side.  The  man- 
oeuvres described  effect  a  complete  decortication  of  the  posterior  and  lateral 
surfaces  of  the  bones  forming  the  elbow. 

Step  3. — Flex  the  elbow  completely.  Push  the  lower  end  of  the  humerus 
out  of  the  wound  and  separate  it  from  the  soft  structures  in  front  to  the  desired 
extent.  With  a  flat  piece  of  metal  (retractor  or  spatula)  protect  the  soft  parts 
in  front  of  the  elbow.  Seize  the  lower  end  of  the  humerus  with  lion-jawed 
forceps  and  remove  with  a  saw  as  much  of  it  as  seems  desirable  (Fig.  1365). 
Any  operating  saw  is  suitable.  (Some  surgeons  use  a  Butcher's  saw  with  its 
sawing  edge  turned  towards  the  bow  of  the  instrument.  The  sawing  ribbon 
is  placed  in  front  of  the  bones  while  the  bow  is  behind  them,  the  bone  is  sawed 
through  backwards,  and  all  danger  to  the  vessels  anterior  to  the  joint  is  averted.) 

With  the  elbow  still  flexed,  make  the  upper  ends  of  the  radius  and  ulna 
protrude  through  the  wound  and  saw  them  off  with  the  same  precautions. 

Step  4. — Review  the  wound  to  see  if  all  osteal  disease  has  been  removed. 
Any  diseased  synovialis  which  may  be  seen  must  be  cautiously  and  thoroughly 
removed  bv  dissection. 


mo 


ELBOW 


How  much  bone  ought  to  be  removed?  The  line  of  section  of  the  ulna 
should  permit  removal  of  the  greater  and  lesser  sigmoid  cavities  with  the 
olecranon.  The  radius  should  be  divided  at  the  same  level  just  below  its  head, 
above  the  biceps.  Jacobson  writes,  regarding  section  of  the  humerus:  "An 
insufficient  amount  is  usually  removed  here,  and  limitation  of  subsequent 
movement  thereby  invited.  It  is  generally  considered  sufficient  to  remove 
all  the  articular  cartilage,  the  section  being  made  to  pass  through  the  lower  part 
of  the  coronoid  and  olecranon  fossae,  and  below  the  level  of  the  epitrochlea  on 
the  inner,  and  through  the  epicondyle  on  the  outer  side.     This  is  not  enough. 


Fig.  i365.^Excision  of  elbow. 


The  saw  should  pass  at  a  higher  level,  i.e.,  above  the  level  of  the  epicondyle, 
and  through  the  highest  part  of  the  epitrochlea,  removing  quite  the  lower  two- 
thirds  of  this  process.  This  is  the  very  lowest  level  at  which  the  surgeon 
should  hold  his  hand  if  he  desires  to  obtain  good  movement.  And  before  he 
is  satisfied  on  this  point  he  should  place  the  fingers  of  the  affected  limb,  not 
only  on  the  opposite  shoulder  and  mouth  (as  is  often  done),  but  on  the  shoulder 
of  the  same  side,  and  behind  the  back  to  the  angle  of  the  opposite  scapula. 
Unless  these  movements  are  perfectly  free,  he  should  take  another  thin  slice 
off  the  humerus,  removing  the  whole  epitrochlea.  This  step  may  seem  to 
my  younger  readers  a  needless  shortening  of  the  limb,  and  likely  to  lead  to  a 
flail-joint.  I  can  assure  them  that  it  is  not  so.  As  long  as  the  elbow-joint 
is  freely  movable,  shortening  of  the  bones  matters  very  little.  If  attention 
has  been  paid  to  the  advice  given  and  the  soft  parts  separated  very  carefully 
and,  as  far  as  possible,  subperiosteally  from  the  epicondyle  and  epitrochlea, 
the  joint  will  become  sufficiently  steady  laterally  as  well  as  freely  movable, 
although  these  bony  prominences  have  been  freely  removed.     Another  test 


EXCISION    ELBOW 


nil 


Fig.  1366. — Splint  im- 
mobilizing elbow-joint,  al- 
lowing access  to  it.  (Robert 
Jones,  British  Med.  Journ.) 


which  the  surgeons  should  always  apply  before  considering  the  section  of  the 
bones  completed  is  the  interval  between  the  sawn  ends.     Prof.  Annandalc 
considers  that  i^^  inches  should  intervene  between   them  when    the   bones 
are  extended."     This  valuable  advice  of  Jacobson 
does  not  apply  when  one  covers  the  sawn   surfaces 
of  the  bone  with  a  flap  of  fascia  and   fat.     If   the 
operation  has  been  undertaken  for  tuberculosis,  rub 
iodoform    into    all   raw   surfaces.     Suture.     Provide 
drainage.     Dress.     As  an  alternative,  fill  the  wound 
cavity  with  iodoform  emulsion  or  its  equivalent  and 
close  without  drainage.     It  is  generally  recommended 
to  place  the  partially  flexed  limb  in  a  metal  splint 
provided  with  an  adjustable  joint  opposite  the  elbow. 
The  young   surgeon,  especially  in  the  country,  will 
generally   be   without   such    apparatus,   but   in   the 

author's  experience  a  starch  or  light  plaster  bandage  strengthened  with 
strips  of  pasteboard  or  wire  netting  answers  all  purposes.  Jones'  metal  splint 
Fig.  1366  is  convenient  and  excellent.  The  after-treatment  is  the  same  as  that 
described  in  the  chapter  on  the  operative  treatment  of  old  dislocations  of  the  elbow. 
Kocher's  Method. — Kocher  is  true  to  his  principle  that  in  arthrectomy 
it  is  far  better  to  make  a  complicated  skin  incision  than 
a  simple  one,  if  by  so  doing  one  can  preserve  intact  not 
merely  the  muscles,  but  their  nerve  supply.  Flex  the 
arm  to  an  angle  of  150°.  From  a  point  i3^  to  2  inches 
above  the  articular  line  make  an  incision  downwards 
along  the  outer  edge  of  the  humerus  to  the  head  of  the 
radius  (Fig.  1367).  Continue  the  incision  downwards 
along  the  outer  margin  of  the  anconeus  to  the  ridge  of 
the  ulna  about  2  inches  below  the  tip  of  the  olecranon. 
The  incision  is  curved  and  should  end  a  little  to  the 
inner  (ulnar)  side  of  the  ulna.  At  the  upper  end  of  the 
incision,  penetrate  to  the  outer  edge  of  the  humerus  by 
separating  the  supinator  longus  and  the  extersor  carpi 
radialis  longior  in  front  from  the  triceps  behind.  From 
the  external  condyle  downwards  penetrate  between  the 
extensor  muscles  (extensor  carpi  ulnaris,  etc.)  in  front 
and  the  anconeus  behind,  until  the  ulna  is  reached.  In 
doing  this  the  lower  fibres  of  the  anconeus  must  generally 
be  divided.  The  rest  of  the  operation  requires  no  special 
description. 

Ollier's  Bayonet  Incision. — From  a  point  2)4,  inches  above  the  joint-line 
make  a  vertical  incision  along  the  outer  margin  of  the  humerus  between  the 
triceps  and  supinator  longus  to  the  tip  of  the  external  condyle.  From  the 
tip  of  the  condyle  continue  the  incision  downwards  and  inwards  to  the  base 
of  the  olecranon,  then  change  the  direction  of  the  incision  once  more  so  as 
to  make  it  follow  the  posterior  border  of  the  ulna  downwards  for  I'^i  to  2 
inches  (Fig.  1368).    Make  a  second  incision,  i  inch  long,  over  the  internal  condyle. 


Fig.  1367. — Kocher's 
incision. 


III2 


ELBOW 


Posterior  Flap  Operation. — Morison  operates  as  follows:  From  a  point 
over  the  internal  condyle  make  an  incision  upwards  for  about  2  inches,  corre- 
sponding to  the  inner  intermuscular  septum.  Make  a  similar  incision  on  the 
outer  side  of  the  limb  (Fig.  1369).  Join  the  upper  ends  of  the  two  vertical 
cuts  by  a  curved  transverse  incision,  the  upper  convexity  of  which  is  3  inches 
above  the  olecranon.  Expose  the  ulnar  nerve  through  the  inner  incision  and 
protect  it.  Turn  down  the  skin  flap  outlined  for  a  distance  of  i  inch.  Divide 
the  triceps  transversely.  Turn  the  skin  flap  and  triceps  tendon  downwards. 
The  rest  of  the  active  operation  requires  no  special  description.  Close  the 
wound  by  suturing  the  divided  triceps  and  then  the  superficial  wound.  Morison 
permits  no  motion  for  two  weeks,  after  which  time  he  keeps  the  limb  extended 
at  night  and  fully  flexed  during  the  day. 


Fig.  1368. — Ollier's  incision. 


Fig.  1369. — Rutherford-Morison's 
incision. 


Bardenheuer's  Operation  (Lossen,  "Deutsche  Zeitschrift  fur  Chir.,"  xcii, 
120).    Extra-capsular  Arthrectomy. 

Step  I. — Reflect  a  horseshoe-shaped  flap  of  skin,  having  its  pedicle  above, 
from  the  posterior  aspect  of  the  joint. 

Step  2. — Divide  the  triceps  tendon  above  the  olecranon. 

Step  3. — By  dissection  lay  bare,  but  do  not  penetrate,  the  posterior  and 
lateral  surfaces  of  the  articular  capsule. 

Step  4. — Divide  the  humerus  and  retract  its  articular  end  downwards  (Fig. 
1370),  thus  exposing  the  anterior  surface  of  the  joint. 

Step  5. — Separate  the  overlying  soft  structures  from  the  anterior  surface  of 
the  capsule. 

Step  6. — Divide  the  ulna.  At  a  lower  level  divide  the  radius.  (The  section 
of  the  radius  at  a  lower  level  than  that  of  the  ulna  is  important  for  the  preserva- 
tion of  pronation  and  supination.)  The  articular  ends  of  the  bones  plus  the 
whole  joint  cavity  can  now  be  removed  in  one  piece. 

Step  7. — With  chisel,  forceps,  or  saw  cut  a  V-shaped  notch  in  the  humerus 


RESECTION    ELBOW 


III3 


(Fig.  1370).  Trim  the  upper  end  of  the  ulna  so  as  to  fit  into  the  notch  in 
the  humerus  while  the  forearm  is  held  in  a  position  of  a  little  less  than  a 
right  angle  to  the  upper  arm.  Unite  the  ulna  to  the  humerus  by  means  of  a 
nail  (Fig.  1371). 

Step  8.- — Close  the  wound. 


Fig.  1370.  Fig.  1371. 

Figs.  1370  and  1371. — Bardenheuer's  operation.     {Lossen.) 
Fig.    1370. — I.   Anconeus.     2.   Ext.    digitorum.    3.    Division    musculo-spiral    nerve.    4.   Ext.   carpi 
radialis  longior.    5.   Supinator  longus.    6.  Musculo-spiral  nerve.    7.  Pronator  radii  teres.    8.  Brachialis 
anticus.     9.  Flexor  muscles  divided.     10.  Ulnar  nerve.     11.  Tendon  of  triceps. 

Fig.  1371. — I.  Anconeous.  2.  Extensor  com.  digitorum.  3.  Division  musculo-spiral  nerve.  4.  Ext. 
carpi  radialis  longior.    s.  Supinator  longus.    6.  Musculo-spiral  nerve. 

Atypical  Resection  of  the  Elbow.- — Access  to  the  joint  is  obtained  through  the 
posterior  longitudinal  incision  already  described.  The  base  of  the  olecranon 
process  is  cleared  of  its  coverings  and  divided  transversely  either  from  without 
inwards  with  a  chisel,  or  from  within  outwards  with  a  Gigli  wire  saw.  The 
olecranon  is  reflected  upwards  with  the  attached  triceps  tendon.  Examine  the 
olecranon  carefully  as  it  is  the  most  common  site  of  osseous  foci  of  disease  in 
tuberculosis  of  the  elbow.  With  a  chisel  or  sharp  spoon  remove  diseased  bone 
wherever  found.  With  forceps  and  knife  or  scissors  excise  diseased  soft  struc- 
tures. Thoroughly  cleanse  the  joint  cavity.  Reunite  the  olecranon  to  the  ulna 
with  bone  pegs,  steel  nails  (the  ends  protruding  through  the  wound),  silver  wire, 
or  chromicized  catgut.  Close  the  wound,  provide  for  drainage,  and  dress. 
]\Iany  surgeons  advise  that  the  limb  be  kept  in  an  extended  position  for  two 
weeks.  The  after-treatment  is  practically  the  same  as  that  for  other  elbow-joint 
resections. 

Fritz  Konig  ("Zent.  f .  Chir.,"  xiii,  June,  1914)  uses  various  methods  by  which 
to  gain  access  to  the  elbow-joint  for  the  treatment  of  strictly  localized  disease 
(synovial  tags;  floating  cartilages;  osteochondrolysis;  fractures)  and  has  had 
no  trouble  from  subsequent  ankylosis,  (i)  If  the  widest  possible  exposure  is 
required  use  the  posterior  transverse  incision  with  division  of  the  olecranon 
(Trendelenburg).  Avoid  injurmg  the  ulnar  nerve.  This  method  gives  the 
least  good  functional  results. 

(2)  Anterior  median  incision  along  the  median  nerve.  To  avoid  injuring  the 
nerve  branch  going  to  the  pronator  teres  Konig  opened  between  the  pronator  and 
the  flexor  dig.  subUmis  and  removed  a  large  loose  cartilage  from  in  front  of  the 
trochlea. 


III4 


ELBOW 


(3)  Internal  lateral  incision  separating  the  flexor  muscles  from  the  condyle 
and  retracting  them  forwards.  This  gives  good  access  to  the  inner  portion  of 
the  joint. 

(4)  Anterior  lateral  incision  between  the  supinator  radii  longus  and  the 
brachialis  anticus.  Retract  the  musculo-spiral  (radial)  nerve  outwards. 
Separate  the  upper  capsular  attachment.  This  gives  the  most  clearly  defined 
anatomic  access  to  the  joint;  through  it  Konig  removed  a  traumatic  loose  car- 
tilage from  beside  the  trochlea  and  the  capitulum  humeri. 

(5)  External  lateral  incision  (humero-radial  incision).  Separate  the  upper 
capsular  attachment  to  the  external  condyle.  This  gives  excellent  access  to  the 
most  common  site  of  osteochondrolysis  and  synovial  tags.  Through  this  inci- 
sion it  is  also  easy  to  resect  the  head  of  the  radius  or  even  to  excise  the  elbow- 
joint. 

Arthrodesis.— Occasionally  after  very  extensive  removal  of  bone  in  excision 
of  the  elbow  a  flail-joint  results.  If  exercises,  etc.,  or  the  use  of  some  supporting 
apparatus  do  not  lead  to  tolerable  results,  it  becomes  necessary  to  operate.  The 
operation  is  practically  that  for  ununited  fracture  and  requires  no  special 
description.  The  endeavor  must  be  to  obtain  bony 
union  with  the  elbow  flexed  to  such  an  angle  that  the 
lingers  may  be  brought  up  to  or  nearly  up  to  the  mouth. 
In  cases  of  paralysis  when  the  most  careful  treatment 
has  failed,  and  when  no  hope  exists  of  obtaining  a  useful 
joint  by  means  of  tendon  transplantation  or  of  nerve 
anastomosis,  it  becomes  necessary  to  operate  for  the 
relief  of  the  resultant  and  useless  flail-joint.  The  joint 
must  be  exposed  as  in  excision;  a  thin  shell  of  bone 
must  be  removed  from  the  humerus  and  the  forearm 
bones;  the  sawn  surfaces  must  be  brought  into  good 
apposition  and  kept  there  until  bony  union  has  taken 
place.  Of  course  care  must  be  taken  to  insure  a  useful 
position  of  the  elbow. 

Robert  Jones  does  not  consider  the  hip,  WTist,  and 
elbow-joints  fitted  for  bony  fixation.  In  that  uncommon 
type  of  paralysis  in  which  the  muscles  of  the  hand  are 
acting,  but  the  shoulder  and  elbow  are  flail,  it  is  neces- 
sary to  fix  the  arm  in  acute  flexion  so  that  the  function- 
ing hand  may  be  of  use.  Jones  does  this  ' '  by  the  exci- 
sion of  the  skin  flaps,  fixing  the  forearm  to  the  arm,  which 
is  infinitely  preferable  to  an  arthrodesis  of  the  elbow." 
—Step  I. — At  the  junction  of  the  middle  and  lower  thirds 
of  the  anterior  surface  of  the  upper  arm  choose  the  point  A  (Fig.  1372).  At  the 
junction  of  the  middle  and  upper  thirds  of  the  forearm  choose  the  point  B. 
Between  A  and  B  remove  a  diamond-shaped  area  of  skin  A  B  C  D. 

Step  2." — Attend  to  hemostasis.  With  sutures  unite  the  raw  surface  A  C  D  to 
the  raw  surface  B  C  D  in  such  a  fashion  that  A  is  united  to  B  and  the  cut  edge 
A  C  to  C  B,  etc.  Apply  dressings.  Use  a  sling  for  some  months,  i.e.,  until 
contraction  is  well  advanced. 


1372. — R.  Jones' 
arthrodesis. 

Jones'  Operation.- 


OLD    DISLOCATION    OF    ELBOW 


III 


CHAPTER  XCVI 


OLD  DISLOCATION  OF  THE  ELBOW 


The  common  causes  which  impede  reposilion  of  a  dislocated  elbow-joint 
are:  (i)  Fragments  of  bone  separated  from  the  articular  ends.  (2)  Contraction 
and  malposition  of  torn  portions  of  capsule  and  ligament.  (3)  Organization  of 
blood-clot.  (4)  The  filling  up  and  obliteration  of  the  olecranon  and  coronoid 
fossae.  WTien  sufiiciently  good  results  cannot  be  obtained  by  means  of  non- 
operative  treatment,  operation  is  generally  justifiable.  The  operation  of  choice 
is  "Operative  Reposition;"  if  this  proves  impossible  or  inadvisable,  it  is  easy  to 
proceed  to  excise  and  interpose  a  flap  of  fat  and  fascia  between  the  divided 
bones. 

Operative  Reposition. — Bunge  ("Archiv  fiir  klin  Chir.,"  Ix,  557)  gives  an 
excellent  account  of  the  operation  as  practised  in  von  Eiselberg's  clinic.  The 
following  is  based  largely  on  Bunge's  article: 

Apply  an  elastic  constrictor.  On  the  outer  side 
of  the  elbow-joint  make  an  incision  about  4  inches 
in  length  (Fig,  1373).  This  cut  in  part  of  its 
course  lies  between  the  extensor  carpi  radialis 
longior  and  the  extensor  communis  digitorum. 
Expose  the  dislocated  head  of  the  radius  and 
lateral  part  of  the  humerus.  Divide  all  tense 
bands  of  scar  tissue  and,  subperiosteally,  lay  bare 
the  whole  upper  end  of  the  radius  and  the  outer 
side  of  the  humerus  at  least  as  far  as  the  origin  of 
the  joint  capsule.  This  is  done  with  scissors  and 
periosteal  elevator.  Through  the  above  incision 
inspect  the  condition  of  the  olecranon  and  coronoid 
fossae  and  the  articular  end  of  the  ulna.  Remove 
all  abnormal  masses  of  tissue  until  the  fossae  are 
clear  and  the  normal  configuration  is  displayed, 
remove  any  displaced  fragments  of  bone.  The  articular  ends  of  the  bone  can 
now,  occasionally,  be  luxated  through  the  wound;  the  median  side  of  the  joint 
cleared  of  scar  tissue  and  the  soft  parts  separated  from  the  humerus  and  ulna 
in  the  same  manner  as  already  described. 

Replace  the  bones.  Test  the  mobility  of  the  joint.  If  movement  seems  to 
be  at  all  impeded,  make  a  longitudinal  incision  about  4  inches  in  length  along  the 
inner  side  of  the  joint.  Remember  the  location  of  the  ulnar  nerve  and  avoid 
injuring  it.  The  cut  is  made  a  little  in  front  of  the  internal  epicondyle.  Through 
this  wound  subperiosteally  separate  the  soft  parts  from  the  bones  until  free 
motion  is  obtained.  Remove  the  tourniquet  and  attend  to  hemostasis  with  the 
most  minute  care.  This  is  of  extreme  importance,  as  the  occurrence  of  a  hem- 
atoma interferes  with  the  after-treatment.  The  articular  capsule,  the  covering 
soft  parts,  and  the  skin  are  each  separately  sutured  with  catgut.     Dress  and  put 


Fig. 


1373. — Dislocation  of 
elbow. 


Carefully  hunt  for  and 


iii6 


OLD    DISLOCATION    OF    ELBOW 


up  in  a  starch  bandage  strengthened  by  strips  of  pasteboard  or  wire  netting. 
The  joint  is  to  be  fixed  at  an  obtuse  angle  and  fully  pronated. 

After-treatment. — The  sooner  the  after-treatment  is  begun,  the  better  the 
result  will  be.  As  early  as  the  third  or  fifth  day  begin  making  daily  passive 
movements.  As  soon  as  the  wound  has  healed  the  movements  must  be  supple- 
mented by  massage  and  warm  baths  to  the  arm.  At  an  early  date  some  form 
of  pendulum  apparatus  may  be  used  (sand-bag  fixed  to  the  wrist)  as  a  means  of 
exerting  continuous  passive  motion.  Active  movements  should  be  begun  early. 
If  any  signs  of  inflammation  appear,  restrict  or  stop  all  exercises  until  danger  has 
passed.     If  a  hematoma  forms,  it  must  be  emptied  at  once. 

Schlange  considers  that  the  hindrance  to  reduction  is  usually  a  fracture  of  the 
articular  end  of  the  humerus  which  has  not  been  properly  corrected  or  in  which 
there  is  an  excess  of  callus.     He  operates  as  follows: 

I.  Make  an  incision,  on  each  side,  from  the  points  of  the  epicondyles  down- 
wards, inwards  and  backwards  to  the  ulna  about  i  inch  below  the  base  of  the 


Fig.  1374.  Fig.  1375. 

Figs.  1374  axd  1375. — Schlange's  operation. 

olecranon.  Unite  these  converging  incisions  by  a  transverse  cut  across  the  back 
of  the  ulna  (Fig.  1374).  Remember  the  location  of  and  protect  the  ulnar  nerve. 
The  more  or  less  horseshoe-shaped  incision  described  penetrates  to  the  bone. 

2.  With  a  saw  introduced  through  the  transverse  portion  of  the  incision 
divide  the  ulna  obliquely  upwards  and  forwards  so  as  to  separate  the  olecranon 
process  and  a  wedge-shaped  portion  of  the  shaft  from  the  ulna  (Fig.  1375). 

3.  Reflect  upwards  the  flap  of  skin,  triceps  tendon,  and  bone,  and  thus  freely 
expose  the  whole  interior  of  the  joint. 

4.  Remove  any  excessive  callus  and  correct  any  defect  which  interferes  with 
reduction.     Reduce  the  dislocation. 

5.  Replace  the  osteoplastic  flap.  Unite  the  sawn  surfaces  of  the  ulna  by 
means  of  a  nail  which  penetrates  the  skin  and  thus  can  be  subsequently  removed. 
Suture  the  periosteum.  Close  the  wound.  Dress.  Immobilize  with  the  elbow 
extended.  Remove  the  nail  from  the  bone  in  about  ten  days.  Begin  passive 
motion  early  (Schlange,  "Archiv.  fiir.  klin.  Chir.,''  Ixxxi,  Part  II). 

The  head  of  the  radius  may  be  dislocated  forwards,  the  ulna  remaining  in 
situ,  and  the  remains  of  the  orbicular  ligament  may  be  so  placed  between  the 


ANCHYLOSIS    ELBOW  III7 

bones  that  reduction  becomes  impossible;  under  these  circumstances  operation 
may  be  necessary.  Open  the  joint  by  Kocher's  external  incision  (see  p.  11 11). 
Pick  up  the  torn  ends  of  the  orbicular  ligament.  Reduce  the  dislocation.  Re- 
pair the  ligaments  by  means  of  sutures.  Close  the  wound.  Apply  dressings. 
C.  C.  P>lliott  (China  Med.  J.,  July,  1916  and  personal  communication) 
finds  many  cases  of  old  dislocation  in  China.  In  posterior  dislocation  of  the 
elbow  he  operates  as  follows:  Split  the  insertion  of  the  triceps  tendon  and  sepa- 
rate the  two  halves  from  the  olecranon  along  with  the  periosteum.  Divide  the 
base  of  the  olecranon  and  remove  that  process.  Pass  a  lever  (the  curved  handle 
of  a  dental  forceps  is  good)  into  the  joint  and  lever  the  bones  into  position  after 
flexing  the  forearm  to  or  beyond  a  right  angle. 


CHAPTER  XCVII 
ANCHYLOSIS  ELBOW 

Anchylosis  of  Elbow. — The  treatment  of  fibrous  anchylosis  consists  in 
breaking  down  the  adhesions,  under  an  anesthetic,  and  in  keeping  them  from 
reforming  by  means  of  proper  passive  and  active  exercises.  Occasionally 
in  very  stubborn  cases  it  may  be  necessary  to  operate  in  the  same  manner  as  for 
osseous  anchylosis.  When  osseous  anchylosis  is  present  treatment  may  or  may 
not  be  necessary.  If  the  elbow  is  fixed  at  such  an  angle  that  the  patient  gets  fair 
use  of  the  limb  and  if  elbow  immobility  does  not,  for  the  individual  affected, 
entail  much  disability,  then  no  treatment  is  demanded.  If  however,  owing  to 
faulty  position  plus  immobility,  there  is  distinct  disabiHty,  operation  is  indi- 
cated. Until  recently  the  operative  treatment  was  principally  directed  against 
the  faulty  position  rather  than  against  the  immobility. 

This  treatment  consisted  in  ordinary  excision  which  was  made  very  extensive 
if  the  endeavor  was  to  obtain  motion.  Thanks  to  hints  thrown  out  by  Verneuil 
(in  1863),  Oilier,  Helferich,  Rochet,  etc.,  Nelaton  (in  1902)  proposed  a  general 
method  of  treatment  of  bony  anchylosis  by  interposition  of  flaps  of  muscle. 
J.  B.  Murphy  (in  1904)  showed  that  fat  and  fibrous  tissue  was  more  suitable 
than  muscle  for  this  purpose  as  it  is  from  such  tissue  that  the  synovialis  is 
originally  formed.  For  bony  anchylosis  of  the  elbow  it  is  no  longer  essential  to 
make  a  very  extensive  resection;  it  is  only  necessary  to  remove  enough  bone  to 
permit  of  free  motion  after  the  sawn  surfaces  have  been  recovered  with  a  proper 
flap  of  muscle  or  fascia  and  after  the  wounds  in  the  soft  parts  have  been  closed. 

Method  A.— The  author  devised  and  successfully  used  the  following  method : 
Render  the  limb  bloodless.     Apply  an  elastic  constrictor. 

I.  To  the  outer  side  of  the  middle  line  make  a  vertical  incision  from  a  point 
2  inches  above  to  one  3  inches  below  the  tip  of  the  olecranon. 

.2.  Reflect  outwards,  by  dissecting  against  the  bone,  all  the  soft  parts  exter- 
nal to  the  incision,  laying  bare  the  outer  edge  of  the  lower  end  of  the  humerus  and 
the  outer  side  of  the  olecranon,  but  leaving  the  annular  ligament,  if  possible, 
intact.  Do  the  same  on  the  inner  side  of  the  wound.  Remember  the  ulnar 
nerve. 

With  an  osteotome  separate  the  olecranon  from  the  humerus.     Remove 


iii8 


ANCHYLOSIS    ELBOW 


most  of  the  olecranon.  Divide  the  bony  tissue  uniting  the  humerus  to  the  ulna 
and  radius.  Completely  divide  the  lateral  ligaments.  Flex  the  elbow  acutely. 
With  the  Gigli  wire  saw  remove  a  small  portion  of  the  lower  end  of  the  humerus. 
Remove  the  articular  surface  of  the  ulna  and  model  a  new  sigmoid  cavity.  If 
necessary,  remove  part  of  the  head  of  the  radius.  Divide  any  bony  tissue  uniting 
the  radius  to  the  ulna,  if  possible  preserving  part  or  all  of  the  annular  ligament. 
Smooth  and  properly  shape  the  opposing  surfaces  of  the  radius  and  ulna.  It 
is  usually  easy  to  find  enough  soft  structures  (fat,  fascia,  muscle)  to  interpose 
between  the  radius  and  ulna  where  they  normally  articulate  without  formally 
fashioning  a  flap  for  the  purpose.  Trim  the  edges  of  the  sawn  surface  of  the 
humerus. 

4.  Remove  the  elastic  constrictor.  Attend  to  hemostasis.  Pack  the  deep 
wound  with  hot  gauze.  Replace  the  soft  parts  in  position  over  the  gauze. 
5.  On  the  outer  side  of  the  original  wound  reflect  the  skin  from  the  fat  and 
deep  fascia  for  a  great  distance  (Fig.  1376).     Outline  and  dissect  up  a  flap 

having  its  pedicle  above  the  joint-line.  The  flap 
consists  of  fat,  fascia,  and  some  of  the  superficial 
fibres  of  the  subjacent  muscles  (Fig.  1376)  (an- 
coneus, ext.  carpi  ulnaris,  etc.),  and  must  be  large 
enough  to  completely  cover  the  lower  end  of  the 
humerus  and  i  inch  of  its  anterior  and  posterior 
surface. 

6.  Remove  the  pack  from  the  deep  wound. 
Wrap  the  flap  over  the  lower  end  of  the  humerus, 
fixing  it  with  a  few  stitches  of  fine  catgut. 

7.  Flex  the  arm  to  about  a  right  angle.  Re- 
place the  tissues  as  well  as  possible  into  their 
normal  positions.  Most  of  the  triceps  tendon  is 
intact  (on  the  inner  side  of  the  original  wound)  and 
continuous  with  the  periosteum  of  the  ulna.  Close 
the  deep  wound  with  catgut  sutures.  Provide 
drainage  (rubber  tissue).  Close  the  skin  wound. 
Dress.  Apply  a  right-angled  anterior  splint. 
After-treatment:    Remove    the    drain    in    about 

twenty-four  hours.     Begin  motion  in  about  eight  days. 
Method  B.- — Expose  the  joint  as  in  Method  A. 

2.  Rupture  of  the  Anchylosis.* — First  try  to  rupture  the  anchylosis  by  man- 
ual force.  If  this  fails,  introduce  a  rugine  between  the  olecranon  and  the 
humerus  as  a  lever  or,  better,  divide  the  olecranon  near  its  base,  and  after  having 
cut  the  fibrous  bands  uniting  the  humerus  to  the  forearm  bones,  once  more  try 
to  break  the  anchylosis  by  manual  force. 

If,  as  is  rare,  the  above  means  fail,  one  must  separate  the  bones  with  chisel 
and  mallet. 

3.  Divide  the  humerus  at  a  point  where  its  diameter  begins  to  diminish  (Fig. 
1377).     Fashion  the  sawn  surface  so  that  it  is  convex  from  before  backwards. 

*  The  description  of  this  and  the  following  method  is  based  on  Huguier's  Traitement  des 
Ankyloses. 


Fig.   1376. — Arthroplasty, 
author's  method. 


ARTHROPLASTY   ELBOW 


III9 


4.  Resect  the  olecranon  at  its  base.  Fashion  the  bone  as  shown  in  Figs. 
1378  and  1379.  Resect  that  portion  of  the  head  of  the  radius  which  projects 
above  the  sawn  surface  of  the  ulna.  If  anchylosis  exists  between  the  radius 
and  ulna  separate  these  bones  with  a  fine  chisel. 

5.  Remove  the  elastic  constrictor.     Attend  to  hemostasis  with  usual  care. 

6.  Interposition  of  Muscle. — (a)  Flex  the  forearm  acutely.  Divide  the 
anterior  articular  capsule  transversely  at  its  ulnar  insertion;  continue  this 
incision  into  the  brachialis  anticus,  so  as  to  form  the  muscular  flap  (Fig.  1379) 
(Quenu).  With  the  flap  cover  the  sawn  surface  of  the  humerus.  The  rest  of 
the  operation  is  as  in  Method  A. 

(b)  Berger  obtains  the  muscular  flap  from  the  anconeus.  Figure  1380 
sufficiently  explains  the  operation. 


--.-A 


Fig.  1377. — {Huguier.)        Fig.  1378. — (Huguier.) 


Fig.  1379. — Arthroplasty.  (Huguier.) 

b,  Brachialis  anticus;  h,  humerus;  c, 
ulna;  t,  triceps;  /,  anterior  ligament 
turned  in  with  flap. 


Method  C. — ^Lateral  Incisions  (Ombredanne) . — Make  a  5-inch  vertical 
incision  on  the  inner  side  of  the  elbow.  Isolate  and  protect  the  ulnar  nerve. 
Denude  the  epitrochlea.  .  Divide  the  lateral  ligament.  Denude  the  anterior 
surface  of  the  humerus.  On  the  outer  side  of  the  elbow  make  a  vertical  incision 
downwards  from  a  point  2}/^  inches  above  the  joint-line.  If  it  is  necessary  to 
carry  this  cut  more  than  i}4  inches  below  the  joint-line  it  ought  to  incline 
backwards  so  as  to  avoid  injury  to  the  radial  nerve.  Denude  the  epicondyle 
with  a  knife,  the  anterior  surface  of  the  condyle  with  a  rugine.  Divide  the 
external  lateral  ligament.  Rupture  the  anchylosis  as  already  described. 
Make  the  lower  end  of  the  humerus  protrude  through  the  internal  \yound  and 
divide  it  transversely  immediately  below  its  lateral  tuberosities.  Figure  1381, 
in  conjunction  with  what  has  already  been  written,  sufficiently  describes  the 
remainder  of  the  operation. 

Transplantation  of  Cartilage  in  the  Treatment  of  Anchylosis. — Weglowski's 
operation  ("Zentralblatt  fiir  Chir.,"  1907,  No.  17).  This  operation  has  been 
performed  successfully  by  Weglowski  and  by  Diakonow  in  bony  anchylosis  of 
the  elbow. 


II20 


ANCHYLOSIS   ELBOW 


Step  I  .—Expose  the  elbow.  Remove  all  excess  of  bone.  Model  the  ends  of 
the  bone  so  as  to  form  proper  articular  surfaces. 

Step  2. — Expose  the  cartilage  of  the  sixth  and  seventh  ribs  and  from  them 
remove  two  plates  of  cartilage  with  perichondrium  the  full  length  and  width  of 
the  costal  cartilage  and  about  one-half  its  thickness. 

Step  3. —  Place  these  strips  of  cartilage  between  the  new-formed  articular 
surfaces  of  the  elbow.  The  strip  laid  against  the  articular  surface  of  the  hu- 
merous  must  have  its  perichondrial  surface  directed  towards  that  bone.  It  is 
unnecessary  to  fix  the  cartilage  in  position  with  sutures. 


li 


W    / 


?'p 


^p 


Fig.  1380.  Fig.  1381. 

Figs.  1380  and  1381. — Arthroplasty.     (Huguier.) 

Fig.  1380. — a.  Anconeus  interposed;  r,  radius;  c,  ulna;  Ic,  flap  of  ext.  ulnaris;  cp,  interposed;  /,  triceps; 
t"  tendon  triceps;  ca,  flexor  ulnaris;  cs,  supinator  brevis;  ap,  aponeurosis. 

Fig.  1381. — h.  Humerus;  c,  ulna;  U,  external  muscle  flap;  li.  internal  muscle  flap;  r,  radius,  re,  extensor 
carpi  radialis  longior. 


Step  4. — Close  the  wound.  Immobilize.  After  ten  days  begin  active  and 
passive  motion.  In  both  cases  the  result  was  good.  One  patient  died  of  pleuro- 
pneumonia five  weeks  after  operation,  thus  giving  opportunity  for  anatomical 
examination  which  showed  that  the  transplanted  cartilage  hved  and  was  adapt- 
ing itself  satisfactorily  to  its  new  surroundings  and  functions. 

Bony  Anchylosis  Elbow, — Buchmann's  Operation. — Transplantation  of  an 
Entire  Joint, — P.  Buchmann  has  operated  as  follows  in  two  cases  of  bony  anchy- 
losis of  the  elbow  ("Zentralblatt  fiir  Chir.,''  1908,  No.  19). 

Step  I. — Make  a  posterior  longitudinal  incision  down  to  the  triceps  tendon 
and  the  olecranon.  At  the  outer  side  of  the  olecranon  divide  all  soft  parts 
longitudinally.  With  an  elevator  separate  and  push  inwards  the  triceps  tendon, 
remnants  of  capsule,  and  the  periosteum. 


JOINT    TRANSFLAXTATIOX 


II2I 


Step  2. — Divide  the  olecranon  at  the  level  of  the  joint.  Divide  the  lateral 
remnants  of  capsule.  Divide  the  bony  union  between  the  humerus,  ulna  and 
radius. 

Step  3.— Flex  the  elbow.  From  the  trochlea  cut  out  a  niche,  wider  in  front 
than  behind  and  narrower  above  than  below.  Remove  a  very  thin  slice  from 
the  lower  end  of  the  humerus. 


Fig.  1382.  Fig.  1383. 

Figs.  1382  antj  1383. — Buchmann's  transplantation  of  joint.     (Buchmann.) 

Step  4. — Separate  the  brachialis  anticus  from  its  insertion  into  the  coronoid 
process.  Cut  a  quadrangular  niche  in  the  ulnar  epiphysis  (Figs.  1382,  1383). 
Remove  the  head  of  the  radius  and  separate  the  radius  from  the  ulna. 


Fig.   1384. — Result  of  transplantation  joint.     {Buchmann.) 


Step  S-' — Excise  the  first  metatarso-phalangeal  articulation  without  opening 
the  joint  itself.  Remove  with  the  joint  sufficient  metatarsus  and  phalanx  to 
fit  into  the  niches  cut  in  the  humerus  and  ulna. 

71 


I  I  22  WRIST 

Step  6. — Implant  the  excised  joint  into  the  wound  at  the  elbow  in  such  a 
manner  that  its  plantar  surface  faces  backwards.  Fit  the  end  of  the  metatarsus 
and  the  phalanx  into  the  corresponding  niches  cut  in  the  humerus  and  ulna. 

Step  7. — Close  the  elbow  wound  and  immobilize  in  the  extended  position. 
Close  the  wound  in  the  foot. 

Figure  1384  shows  a  skiagram  of  one  of  Buchmann's  cases  ten  and  one-half 
week?  after  the  operation. 

Myositis  Ossificans  Traumatica.- — Occasionally  as  a  result  of  injury,  bone 
develops  inside  a  muscle.  Examples  of  such  lesions  are  "drill  bone,"  "rider's 
bone,"  etc.  Probably  the  commonest  site  of  the  trouble  is  the  brachialis  an- 
ticus  muscle.  Operative  treatment  consists  in  exposing  the  bone  through  a 
suitable  incision  and  excising  it.     No  precise  description  is  necessary. 

Auvray  writes  ("La  Presse  Med.,"  July  3,  191 2)  concerning  osteomata  situ- 
ated in  muscle  but  unattached  to  the  bone:  "  it  is  certain  that  their  extirpation  is 
only  exceptionally  followed  by  recurrence  (in  92  cases  collected  by  Chabrol 
there  were  75  cures,  15  improvements  and  only  2  failures).  On  the  other  hand, 
when  the  osteomata  are  consecutive  to  articular  traumata,  recurrence  is  much 
more  frequent  and  the  results  of  treatment  much  less  satisfactory  (in  23  cases, 
7  cures,  7  improvements,  9  failures)." 


CHAPTER  XCVIII 
WRIST 

Anatomically,  the  wrist-joint  is  formed  between  the  radius  and  the  triangular 
fibro-cartilage  above  and  the  first  row  of  carpal  bones  below.  Below  the  ana- 
tomical wrist-joint  there  are  the  carpal  and  the  carpo-metacarpal  joints.  These 
joints  are  surrounded  by  many  ligaments.  Surgically,  the  series  of  joints  and 
bones  between  the  radius  and  the  metacarpal  bones  may  be  considered  as  one 
structure,  completely  surrounded  by  one  periosteo-ligamentous  investment,  an 
investment  which  is  here  thicker,  there  thinner;  here  more  firmly,  there  less 
firmly  united  to  its  contents.  Numerous  tendons  pass  over  or  are  inserted  into 
this  ligamentous  investment,  so  that  if  the  latter  is  separated  from  its  contained 
bones  the  tendons  also  are  separated  or  raised  from  them  without  being  injured. 

Wounds  and  infections  of  the  wrist  should  be  treated  on  the  principles  laid 
down  on  p.  1030. 

Typical  Subperiosteal  Resection  of  the  Wrist. — Ollier's  Operation. 

Step  1. — Incision  through  the  Skin  and  Ligamentous  Investment. — Note 
the  position  of  the  styloid  processes  of  radius  and  ulna  and  imagine  a  line  join- 
ing these  two  points  (interstyloid  line).  Note  the  tendon  of  the  extensor  indicis, 
or  if  this  cannot  be  made  out,  the  base  of  the  second  metacarpal  bone. 

Beginning  at  the  middle  of  the  dorsal  aspect  of  the  second  metacarpal  bone, 
make  an  incision  upwards  and  inwards  a  little  to  the  radial  side  and  following 
the  line  of  the  tendon  of  the  extensor  indicis  (Fig.  1385).  This  obhque  incision 
reaches  the  middle  point  of  the  interstyloid  line  where  its  direction  is  changed 
to  that  of  the  axis  of  the  forearm. 


EXCISION    CARPAL  BONES 


II23 


Recognize  and  retract  inwards  the  tendon  of  the  extensor  indicis,  without 
opening  its  sheath.  This  exposes  the  insertion  of  the  extensor  carpi  radiahs 
brevior.  Incise  the  periosteum  of  the  head  of  the  third  metacarpal  to  the  inner 
side  of  the  insertion  of  the  extensor  carpi  radiahs  brevior.  Continue  the  peri- 
osteal incision  upwards,  dividing  the  joint  capsule  and  the  posterior  annular 
ligament  between  the  extensor  indicis  and  the  long  extensor  of  the  thumb. 

On  the  ulnar  side  of  the  wrist  make  an  incision  from  a  point  i]/^  inches 
above  the  point  of  the  ulnar  styloid  process  to  a  point  ^  inch  above  the  base 
of  the  fifth  metacarpal  bone.  The  incision  is  to  the  inner  side  of  the  extensor 
carpi  ulnaris,  and  is  carried  directlv  to  the  bone. 


Fig.  1385. — OUier's  operation.     {After  Farabeuf.) 
/?',  Radius;  C,  ulna;  Sc,  scaphoid;  t,  trapezoid;  i-i',  tendon  ext.  carpi  radialis  long.-  2-2'   ext    caroi 
radialis  brevior;  3-3',  ext.  ossis  metacarpi  pollicis;  4-4',  ext.  brevis  pollicis;  5-5'.  ext.  longus  pollici's-  6-8-g-io 
ext.  communis;  7-7'.  ext.  indicis;  ii-ii',  ext.  minim,  dig.;  12-12',  ext.  carpi  ulnaris.  '  ' 

Step  2.— Removal  of  the  Carpal  Bones.— Through  either  the  dorsal  or  ulnar 
incision  separate  the  ligamentous  investment  from  the  underlying  structures 
seize  the  individual  bones  in  forceps  and  dissect  them  out.  If  the  ligamentous 
investment  is  properly  separated,  the  tendinous  insertions  will  be  preserved 
and  the  least  possible  amount  of  damage  inflicted.  The  pisiform  bone  may  or 
may  not  be  removed.  The  unciform  process  may  be  divided  while  its  bone 
is  being  removed  and  if  not  diseased  it  may  be  left  in  situ. 

Step  3. — After  the  removal  of  the  carpal  bones  it  is  easy  to  resect  the  lower 
end  of  the  radius  and  ulna  and  to  remove  the  triangular  cartilage.  The  carpal 
ends  of  the  metacarpal  bones  are  readily  excised  with  rongeur  forceps. 


II24 


WRIST 


Step  4. — Review  the  whole  wound  and  excise  with  forceps  and  scissors  any 
diseased  tissue.  Unite  by  suture  the  divided  annular  ligament.  In  cases 
of  tuberculosis  rub  the  wound  cavity  with  iodoform.  Provide  drainage. 
Close  the  wounds  with  sutures.  Some  surgeons  pack  the  wound  with  iodoform 
gauze  and  suture  after  the  lapse  of  a  few  days,  or  they  apply,  but  do  not  tie,  the 
sutures  on  the  completion  of  the  operation,  pack  with  gauze,  remove  the  pack 
after  a  few  days,  and  tie  the  sutures  already  in  place.  Instead  of  the  above 
dressings  the  wound  may  be  filled  with  iodoform  or  bismuth  paste  and  closed 
with  or  without  drainage.  After  the  dressings  have  been  applied  the  member 
must  be  fixed  with  the  hand  in  a  position  of  dorsal  flexion.  For  this  purpose 
Robert  Jones'  'cock  up'  sphnt  is  good.  Whatever  means  of  immobilization  is 
adopted,  the  fingers  and  thumb  must  be  left  uncovered  so  that  they  may  be 
exercised  as  early  as  possible. 

After-treatment.- — At  the  earUest  date  possible  practise  passive.  Active 
movements  of  the  fingers  and  thumb  must  be  early  attempted  and  the  patient 
told  to  make  "piano-playing"  movements.  All  these  movements  are  of 
extreme  importance  so  that  fibrous  union  of  the  tendons  may  be  avoided.  The 
limb  must  be  kept  immobilized  until  the  wrist  has  solidified  considerably. 
This  may  take  six  months  or  even  longer.  When  the  wound  is  healed  a  light 
splint,  e.g.,  Ollier's  wire  splint  or  some  leather  device,  should  replace  the  original 
splints.  The  extensor  and  flexor  muscles  of  the  wrist  should  be  kept  in  ' '  con- 
dition" by  applications  of  electricity.  The  splint  should  be  removed  several 
times  daily  and  movements  of  the  wrist  practised.  Much  patience  is  required 
before  a  good  result  can  be  obtained. 

The  operation  is  usually  performed  for  tuberculous  disease.  Miiller  has 
excised  the  wrist  in  arthritis  deformans  with  good  results.  In  one  case  of 
arthritis  deformans  the  author  obtained  a  result  which  was  only  fair,  but  this 
he  thinks  partially  due  to  want  of  completeness  in  the  operation  done. 


Fig.   1386. — Taj'lor's  operation.     (Taylor.) 

Wm.  J,  Taylor's  Operation  ("Annals  of  Surgery,"  xxxii,  360). — This  is  a 
modification  of  an  operation  suggested  by  Studsgaat  and  carried  out  by  IMynter. 

Apply  an  elastic  constrictor  above  the  elbow. 

Step  I. — Make  a  longitudinal  dorsal  incision  from  the  lower  end  of  the  radius 
downwards  along  the  line  corresponding  to  the  space  between  the  second  and 
third  metacarpal  bones  (Fig.  1386).  Through  this  incision  penetrate  between 
the  metacarpal  bones  to  their  palmar  surface,  but  be  careful  not  to  injure  the 
soft  tissues  of  the  palm.  (Mynter  made  a  small  palmar  as  well  as  a  long  dorsal 
incision.)     Split  the  carpal  bones.     This  splitting  is  easy,  as,  when  operation  is 


ANCHYLOSIS    WRIST  1 1 25 

required  because  of  tuberculosis,  the  bones  affected  are  softened  or  destroyed 
by  the  disease. 

Step  2. — Remove  all  diseased  tissue.  Clean  thoroughly.  Lessen  the  size 
of  the  deep  wound  by  means  of  a  few  sutures.  Loosely  pack  with  gauze. 
Partially  close  the  skin  wound.     Dress.     Apply  a  suitable  splint. 

Bardenheuer's  Operation.- — Through  a  suitable  incision  remove  the  carpus 
en  masse.  If  possible,  preserve  the  trapezius  so  as  to  retain  the  mobility  of  the 
thumb.  Obliterate  the  dead  space  left  by  the  removal  of  the  carpus  in  the 
following  manner:  Divide  the  three  middle  metacarpal  bones  so  as  to  form 
a  wedge  whose  apex  is  formed  by  the  third  metacarpal.  Fashion  the  forearm 
bones  so  as  to  form  a  V-shaped  surface  and  into  this  V  place  the  metacarpal 
wedge.  Nail  the  third  metacarpal  to  the  radius,  the  fifth  metacarpal  to  the 
ulna,  and  the  trapezius  to  the  outside  of  the  radius.  Any  tendons  which  have 
been  resected  because  of  involvement  in  the  disease  are  now  reunited  by  suture. 

At3rpical  Resection  of  the  Wrist. — In  tuberculosis,  limited  foci  of  disease 
may  be  safely  reached  through  small  incisions  on  any  part  of  the  dorsum  of  the 
wrist  if  care  is  taken  to  avoid  division  of  tendons.  In  more  advanced  carpal 
disease  access  may  be  obtained  through  Ollier's  incisions  and  the  affected 
structures  removed  with  the  sharp  spoon,  forceps,  and  scissors.  After  such 
operations  the  wounds  are  carefully  cleaned,  iodoformized  and  either  packed 
with  iodoform  gauze  or  closed  by  suture  after  drainage  is  provided. 


CHAPTER  XCIX 
WRIST  ANCHYLOSIS 

Method  A.— Nelatons'  Operation.  ("Rev.  d'orthopedie,"  1905,  Nelaton; 
"Traitement  des  Ankyloses,"  Huguier). 

1.  Expose  the  wrist-joint  by  a  longitudinal  incision  along  the  radial  side 
of  the  extensor  tendons  of  the  index  linger.  Extend  the  incision  upwards  so  as 
to  freely  expose  the  lower  portion  of  the  extensor  communis  digitorum.  Re- 
tract the  extensors  of  the  thumb  outwards,  those  of  the  fingers  inwards. 

2.  Break  down  the  anchylosis  by  manipulation  or  with  the  chisel.  Excise 
the  first  row  of  carpal  bones,  except  the  pisiform.  Resect  sufi&cient  of  the  second 
row  of  bones  in  a  curve,  to  give  them  the  shape  of  a  condyle. 

3.  From  the  outer  side  of  the  fleshy  body  of  the  extensor  communis  digitorum 
cut  a  flap  having  its  pedicle  below.  The  flap  must  be  about  3^^  inch  wide 
by  2  inches  long.  Place  the  flap  transversely  in  the  gutter  formed  by  the  re- 
moval of  the  carpus  and  fix  its  end  to  the  fibrous  tissue  at  the  inner  side  of  the 
joint  (Fig.  1387). 

4.  Stop  all  bleeding.  Close  the  wound  after  providing  for  drainage.  After 
tw^o  weeks  begin  motion.  Nelaton  operated  successfully  in  this  fashion  in  a 
case  of  anchylosis  from  arthritis. 

Method  B. — The  author  suggests  the  following  method  as  simpler  and  at 
least  as  efficacious  as  Nelaton's;  it  is  almost  identical  with  an  operation  for 
anchylosis  of  the  first  carpo-metacarpal  joint  which  he  performed  successfully. 


II26 


WRIST   ANCHYLOSIS 


1.  Expose  the  wrist-joint  by  a  longitudinal  incision  along  the  radial  side  of 
the  extensor  of  the  index  finger.  Divide  the  skin,  fascia,  etc.,  so  as  to  open  the 
joint.  Do  not  cut  the  fascia  upwards  any  farther  than  is  absolutely  necessary. 
Break  down  the  anchylosis  and  excise  bone  from  the  carpus  to  the  extent 
necessary  for  free  motion,  as  in  Nelaton's  operation. 

2.  Extend  the  original  incision  upwards  dividing  the  skin  alone  (Fig.  1388). 
Expose  a  large  surface  of  the  fascia  of  the  forearm.     From  the  fascia  dissect 


exc 


Fig.  1387. — Arthroplasty.     {Huguier.) 

r,  Radius;  c,  ulna;  m,  metacarpus;  exc,  ext.  com- 
munis digitonim;  t,  tendon  ext.  indicis;  Icp,  ext.  long 
pollicis. 


Fig.  1388. — Arthroplasty. 

E,  Deep  fascia;  F,  flap   of   fascia;    D,   carpal 
bones. 


downwards  a  flap  of  fascia,  fat,  and  a  few  muscle  fibres  (pedicle  below  and 
sufficiently  above  or  to  the  side  of  the  opening  made  in  the  fascia  for  the 
arthrectomy  to  permit  of  good  nutrition). 

3.  Turn  the  flap  of  fascia  downwards,  tuck  it  into  the  deep  wound  so  that  it 
completely  envelops  the  articular  surface  of  the  radius.  Fix  the  flap  in  position 
with  fine  catgut  sutures. 

4.  Close  the  wound  after  providing  for  drainage.  Apply  dressings  and  a 
splint.  Remove  the  drain  in  twenty-four  to  forty-eight  hours.  Begin  motion 
as  soon  as  the  wound  is  healed. 


WEBBED    FINGERS  I I 27 

CHAPTER  C 
METACARPO -PHALANGEAL  DISLOCATIONS 

Dorsal  dislocations  of  the  first  metacarpo-phalangeal  joint  are  occasionally 
irreducible  by  manipulation  and  demand  operation.  Stimson  (Fractures  and 
Dislocations,  p.  707)  writes:  "The  cause  of  this  difficulty,  in  all  the  cases  in 
which  I  have  exposed  the  joint,  has  been  the  torn  edge  of  the  anterior  ligament 
closely  drawn  across  the  back  of  the  metacarpal  behind  its  head,  and  a  slight 
nicking  of  that  edge  made  reduction  easy." 

The  Operation.- — ^Make  a  longitudinal  incision  over  the  palmar  surface  of 
the  prominent  head  of  the  metacarpus.  As  soon  as  the  head  is  exposed,  retract 
the  edges  of  the  wound  and  note  that  the  anterior  ligament  (capsule)  has  been 
torn  from  its  metacarpal  insertion  and  its  edge  can  be  seen  above  it  and  close  to 
the  phalanx.  Longitudinally  divide  or  nick  the  capsule,  and  reduction  becomes 
easy. 

Frequently  the  capsule  curls  tightly  over  the  articular  surface  of  the  phalanx 
in  this  condition.  The  nicking  of  the  capsule  makes  it  easy  to  pull  the  offending 
membrane  out  of  its  false  position  by  means  of  hooks.  Close  the  wound  in  the 
capsule  with  fine  catgut.  Close  the  skin  wound.  Dress.  Begin  movements 
in  about  one  week. 

In  cases  of  old  unreduced  dislocations  of  one  or  other  of  the  metacarpo- 
phalangeal joints,  Friedrich  recommends  resection  of  the  head  of  the  metacar- 
pus, but  gives  warning  that  pain  on  motion  may  persist  for  a  long  time. 

C.  C.  EUiott  (China  Med.  J.,  July,  1916)  finds  that  a  median  incision  over 
the  palmar  surface  of  the  joint  gives  good  access  without  danger  to  the  tendons 
which  have  been  pushed  aside  by  the  head  of  the  metacarpal.  A  lever  passed 
into  the  joint  until  its  tip  is  well  beneath  the  base  of  the  dislocated  phalanx, 
permits  stretching  of  the  shortened  tendons,  etc.,  so  that  the  dislocation  can 
be  reduced. 


CHAPTER  CI 
SYNDACTYLISM.    WEBBED  FINGERS 

The  easiest  way  in  which  to  operate  for  webbed  fingers  is  merely  to  divide 
the  web  and  suture  the  resulting  wounds.  Unfortunately  there  always  results 
a  contraction  of  the  wound  near  the  root  of  the  fingers  and  the  condition  recurs 
to  a  large  extent.  The  following  are  the  principal  operations  devised  to  prevent 
recurrence : 

I.  Perforate  the  web  at  its  apex.  Through  the  perforation  pass  a  stout 
silver  wire.  Keep  the  wire  in  situ  until  the  perforation  is  thoroughly  healed 
when  the  rest  of  the  web  may  be  divided  and  the  wounds  sutured. 

XL  On  the  dorsal  surface  of  the  web  make  the  triangular  incision  ABC 
(Fig.  1389)  and  reflect  the  flap  A  C  D,  which  should  be  thick  and  well  nourished. 


1121 


OPERATIONS    ON    THE    TENDONS    OF    THE   FINGERS 


Divide  the  web  uniting  the  fingers.  Turn  the  flap  A  C  D  between  the  divided 
fingers  and  suture  the  apex  D  of  the  flap  to  the  palmar  side.  Either  suture  the 
wounds  caused  by  the  division  of  the  web  or  bring  them  together  with  adhesive 
strips  and  dress  with  an  ointment  containing  Scharlach  red.  Schreiber 
("Zentralblatt  fiir  Chir.,''  1910,  No.  29)  claims  much  for  this  operation. 


VJ 


// 


u 


Fig.  1391. 


Fig.  1392.  Fig.  1393. 

Figs.  1389  to  1393. — Syndact\-lism.  , 

in.  Didot's  operation. 

Step  1. — On  the  dorsum  of  the  fingers  and  web  make  the  incisions  B  A  C  D 
(Fig.  1390)  and  reflect  the  flap  outlined. 

Step  2. — On  the  palmar  aspect  make  the  incision  F  E  H  G  (Fig.  1391) 
and  reflect  the  flap  outlined. 

Step  3. — Divide  the  rest  of  the  web. 

Step  4. — Make  the  flap  B  A  C  D  envelop  the  finger  to  which  it  is  attached 
(Fig.  1392)  and  suture  it  in  place.  Similarly  envelop  the  other  finger  with  the 
flap  F  E  H  G.     Figs.  1392  and  1393  are  self-explanatory. 


CHAPTER  CII 


OPERATIONS  ON  THE  TENDONS  OF  THE  FINGERS 

Occasionally  after  a  finger  is  flexed  until  its  tip  touches  the  palm  it  can  only 
be  extended  by  a  considerable  muscular  effort  or  by  the  aid  of  the  other  hand. 
"  In  overcoming  the  hitch  by  the  action  of  the  extensor  muscles  the  finger  springs 
back  suddenly  and  usually  with  more  or  less  pain."  The  cause  of  the  trouble 
is  either  an  enlargement  or  nodulation  of  the  tendon  or  a  narrowing  of  the 
tendon  sheath.  When  trauma  is  the  exciting  cause,  the  lesion  is  usually  found 
in  the  fingers;  in  other  cases  the  obstruction  is  almost  always  in  the  short  space 
between  the  digito-palmar  fold  and  the  first  fold  or  wrinkle  of  the  palm.  If 
the  trouble  does  not  soon  disappear  under  bloodless  treatment  and  if  it  is  very 
annoying  or  disabling,  operation  is  indicated.     The  principle  of  operation  is 


SNAPPING    FINGERS 


I129 


Fig.  1394.  Fig.  1395. 

Needle  in  tendon.     Payer's  case.  Split  tendon.     Haegler's  case. 

Figs.  1394  and  1395. — Snapping  fingers.     (Weir.) 


Fig.  1396. — {Weir.) 
Tumor  causing  trigger  finger. 


Fig.  1397. — (Weir.) 

Enlargement  deep  flexor. 


II30 


OPERATIONS   ON    THE    TENDONS    OF   THE   FINGERS 


free  exposure,  removal  or  repair  of  any  vertical  evident  lesion  (Figs.  1394,  1395, 
1396,  1397),  and  closure  of  the  wound. 

When,  as  is  commonly  the  case,  there  is  a  fusiform  swelling  of  the  tendon  or 
merely  a  thickened  sheath,  Weir  recommends  that  the  sheath  be  split  (Fig.  1398) 
and  left  open,  the  superficial  wound  being  closed  (Weir,  "Journ,  A.  M.  A.," 
Oct.  5,  1907). 

Abbe  considers  "snapping  finger"  to  be  due  to  a  crumpling  up  of  the  con- 
joined fle.xor  tendon  by  a  transverse  band  of  fascia  situated  beneath  the  distal 
flexure  crease  of  the  palm.  .A  longitudinal  incision,  about  3^  inch  long,  through 
the  fascia  at  the  flexure  crease  is  sufficient  to  cure  in  some  cases. 


Fig.  1398. — {Weir  from  Spalleholz.) 

Tendon  Transplantation. — When  the  flexor  tendons  of  one  or  more  fingers 
have  been  destroyed,  e.g.,  by  necrosis'due  to  phlegmon,  function  may  be  restored 
by  transplantation.  This  is  one  of  the  many  good  things  for  which  E.  Lexer 
is  responsible  ("Archiv  fiir  klin.,  Chir.,"  xcviii,  Hft.  3). 

1.  Obtain  the  graft  (a)  from  a  suitable  tendon  in  a  recently  amputated  limb 
(X.B.:  The  researches  of  Carrel  and  others  show  that  tissues  and  organs  may 
be  preserved  in  suitable  solutions,  e.g.,  Ringer's,  in  cold  storage  for  days  and  then 
be  successfully  implanted),  (b)  from  a  segment  of  the  palmaris  brevis,  (c)  from 
a  slip  cut  out  of  the  rectus  femoris  tendon,  the  tendo  Achillis,  or  any  suitable  and 
convenient  source. 

2.  Make  short  incisions  in  the  natural  transverse  folds  at  the  base  of  the 
first  phalanx,  in  the  palm  or  at  the  wrist,  as  may  be  required  to  find  the  stump 
of  the  destroyed  tendon. 

3.  Through  one  of  these  incisions  introduce  a  strabismus  hook  and  with 
it  find  and  pick  up  the  desired  tendon  stump  (the  flexor  profundus).     Separate 


TENDON   TRANSPLANTATION  II31 

the  tendon  from  acquired  adhesions.  With  a  suitable  instrument  introduced 
through  the  incision  bore  a  subcutaneous  tunnel  to  the  ungual  phalanx.  From 
the  side  or  from  the  tip  of  the  finger  cut  down  upon  the  end  of  the  tunneling 
instrument.  This  cut  must  be  made  as  a  sort  of  flap  as  sufficient  exposure  is 
necessary  and  the  wound  must  not  lie  directly  over  the  implanted  graft. 

4.  Suture  one  end  of  the  graft  to  the  tendon  stump  and  pull  the  other  end 
of  the  graft  through  the  tunnel  by  means  of  an  eyed  probe  or  a  thread.  Suture 
the  distal  end  of  the  graft  to  the  periosteum  of  the  ungual  phalanx  or,  better,  to 
the  vivified  bone  itself. 

5.  If  it  is  desired  to  replace  the  destroyed  superficial  flexor  at  the  same  time 
it  may  be  accomplished  somewhat  similarly  as  follows:  Find  the  proximal 
stump  of  the  tendon  and  suture  to  it  one  end  of  a  graft.  Split  the  other  end  of 
the  graft  and  conduct  each  of  the  two  slips  of  the  graft  through  the  tunnel  to 
the  middle  phalanx.  Make  a  small  cut  on  each  side  of  the  middle  phalanx 
(preserving  vessels  and  nerves  from  injury)  and  through  these  cuts  suture  the 
tendon  slips  one  on  each  side  to  the  phalanx. 

6.  Close  the  wound.  Apply  dressings.  Begin  movements  on  the  sixth  day 
after  operation.  The  early  motion  is  imperative,  otherwise  connective  tissue 
penetrates  and  substitutes  itself  for  the  tendon  which  becomes  a  hard,  immobile, 
fibrous  mass.  Unfortunately  fingers  requiring  tendon  transplantation  have 
usually  been  the  seat  of  severe  inflammation  and  have  deposits  of  scar  tissue 
which  in  themselves  cause  deformity  and  prevent  motion.  In  these  cases 
preliminary  operations  are  necessary.  Thorough  excision  of  the  scar  tissue  and 
plastic  repair  (by  skin  flaps,  etc.)  are  absolutely  requisite  before  the  tendon 
transplantation  may  be  attempted. 

E.  Lexer  reports  the  following  case:  "As  the  result  of  injury  and  sup- 
puration the  hand  was  severely  crippled  and  entirely  useless;  the  thumb  was 
claw-like,  immobile  and  flexed  into  the  palm  due  to  complete  loss  of  its  tendons; 
an  extensive  scar  above  the  wrist-joint  produced  moderate  flexion  of  the  fingers 
which  retained  a  mere  trace  of  motion.  It  was  necessary  to  resect  the  ankylosed 
first  metacarpo-phalangeal  articulation  and  produce  a  pseudarthrosis  by  the 
interposition  of  fat.  Then  the  thumb  had  to  be  straightened  by  means  of  an 
H-shaped  incision  and  the  resultant  defect  covered  with  skin.  Three  weeks 
later  a  segment  of  tendon  was  implanted  as  a  substitute  for  the  lost  deep  flexor. 
This  was  accomplished  after  excision  of  the  scar  at  the  wrist,  by  tunneling 
through  the  sclerosed  muscles  of  the  ball  of  the  thumb  up  to  the  ungual  phalanx, 
drawing  the  implant  through  the  tunnel  and  fixing  its  end  to  the  phalanx.  But 
as  it  was  impossible  to  find  the  flexor  tendon  of  the  thumb  above  the  wrist  in 
spite  of  having  separated  all  the  tendons  from  the  scar  (it  must  have  been  dis- 
charged as  a  sequestrum),  I  split  a  slip  from  the  flexor  carpi  radialis  and  united 
this  to  the  implant.  Subsequent  adhesion  of  the  other  flexor  tendons  was 
prevented  by  surrounding  and  separating  them  with  free  {i.e.,  non-pedunculated) 
fatty  tissue.  Although  the  result  was  but  moderate,  it  was  most  satisfactory 
because  of  the  exceedingly  unfavorable  condition  encountered.  The  fingers 
gained  one-half  of  their  active  function  and  could  be,  passively,  flexed  com- 
pletely. Best  of  all  the  thumb  remained  straight  and  could  be  flexed  so  that  its 
point  could  press  firmly  against  the  index  finger." 


II32 


OPERATIONS   FOR   INFECTWE    LESIONS    OF    THE    HAND 


CHAPTER  cm 
OPERATIONS  FOR  INFECTIVE  LESIONS  OF  THE  HAND 

From  the  standpoint  of  practical  surgery  the  vast  majority  of  standard 
works  on  Anatomy  are  wofuUy  unsatisfactory  in  their  description  of  the  anatomy 
of  the  hand.  Poirier  and  Charpy,  in  their  colossal  "Traite  d'  Anatomie  Hu- 
raaine,"  give  much  information  regarding  the  tendon  sheaths  of  the  palm, 
while  Allen  B.  Kanavel  deserves  much  thanks  for  an  encyclopedic  article  or 
series  of  articles  on  the  hand  and  its  infections  ("Surg.,  Gyn.,  Obstetrics," 


I 

Superficial  palmar  arch \. ^^----^"^--VfcS^ 

Deep  palmar  arch  •-..•.•-y / ^\^. 

Superficialis  voice 

Radial  artery j j^j  ^ 


Fig.  1399. — {Morris.) 

Relation  of  the  palmar  arches  to  the  folds  of  the  palm. 


Inferior  fold 
. ..  Middle  fold 

Superior  fold 


—  ■Clnar  artery 


Sept.,  1905;  Nov.,  1907;  Jan.,  and  Feb.,  1909;  "Infections  of  the  Hand,"  1912. 
These  publications  are  freely  used  in  the  preparation  of  this  chapter.  In  order 
to  operate,  with  any  degree  of  precision,  for  the  relief  of  infective  lesions  of 
the  hand  a  fair  knowledge  of  anatomy  is  requisite. 

Figure  1399  shows  the  position  of  the  palmar  arches. 

Figures  1400,  1401,  and  1402  show  the  usual  arrangements  of  the  synovial 
sheaths  of  the  flexor  tendons  of  the  hand  and  how  the  sheaths  in  the  fingers  do 
or  do  not  communicate  directly  with  the  palmar  sheaths  or  bursae.  The  syno- 
vial sac  surrounding  the  more  internal  of  the  common  fle.xors  lies  on  the  ulnar 
side  of  the  palm  and  wrist  (Fig.  1403).  As  this  sac  forms  a  pouch  in  front  of 
the  superficial  flexors,  separates  the  superficial  from  the  deep  flexors  and  forms 
a  pouch  behind  the  deep  flexors,  it  may  be  considered  as  consisting  of  three 
pouches  (pre-,  inter-,  and  retro-tendinous),  all  opening  into  a  common  pouch — 
the  ulnar  or  cubital  bursa.  The  importance  is  evident  of  recognizing  this 
complicated  arrangement  when  it  is  necessary  to  drain  pus  from  the  ulnar 
bursa.     The  other  palmar  bursae  are  not  so  complicated. 


ANATOMY    OF   HAND 


^^33 


Fig.  1400.  Fig.  1401.  Fig.  1402. 

Figs.  1400,  1401  and  1402. — Synovial  sheaths  of  flexors  of  fingers.     (Poirier  and  Cliarpy.). 


Pretendinous 
pouch 


Intertendinous 
pouch 


Retrotendinous 
pouch 


Fig.  1403. — Sj^no vial  sheaths  of  palm,     {Poirier  and  Charpy.) 


Fig.  1404. — Synovial  sheaths  of  back  of  hand.     (Poirier  and  Charpy.) 


II34 


OPERATIONS    FOR   INFECTIVE    LESIONS    OF    THE    HAND 


The  synovial  sheaths  of  the  extensor  tendons  about  the  wrist  are  compara- 
tively simple  (Fig.  1404).  Besides  the  synovial  sheaths  and  bursae  there  are 
certain  well-defined,  uniform  spaces  upon  the  fingers,  palm,  and  dorsum  of  the 
hand  in  which  pus  can  accumulate.  A  section  (Fig.  1405)  made  through  the 
hand  i^s  inches  (3.5  cm.)  proximal  to  the  metacarpo-phalangeal  joints  shows  a 
number  of  these  spaces  admirably,  while  a  section  (Fig.  1406)  taken  a  little 
higher  up  through  the  distal  part  of  the  thenar  area  shows  another  view  o^ 
these  same  spaces.  Kanavel,  in  a  recapitulation  of  some  of  his  findings,  writes: 
"We  note  that  we  have  five  great  spaces,  with  their  tributaries,  in  which  pus 
can  accumulate. 


T5         ATP  fLf 


Fig.  1405. — (Kanavel.) 

Cross  section,  3?^  cm.  proximal  to  joint,  ss,  Synovial  sheath;  DSCS,  dorsal  subcutaneous  space;  dsas, 
dorsal  subaponeurotic  space;  ect,  extensor  communis  tendon;  ft.  flexor  tendon;  lm,  limbrical  muscle; 
IM,  interossei  muscle;  m,  metacarpal  bone,  bv,  blood  vessels;  N,  nerves;  TS,  thenar  space;  MPS,  middle  palmar 
space;  atp,  adductor  transversus  pollicis;  dim,  dorsal  interosseous  membrane;  pi.m,  palmar  interosseous 
membrane;  UB,  ulnar  bursa;  is,  space  between  adductor  transversus  and  first  dorsal  interosseous;  DIM, 
dorsal  interosseous  membrane;  flp,  flexor  longus  pollicis  in  its  synovial  sheath;  hm,  hypothenar  muscles 
with  intermuscular  spaces;  rv,  interosseous  vessels  and  nerves. 


"First,  the  dorsal  subcutaneous,  which  is  an  extensive  area  of  loose  tissue, 
without  definite  boundaries,  allowing  pus  to  spread  over  the  entire  dorsum  of 
the  hand. 

"Second,  the  dorsal  subaponeurotic,  limited  upon  its  subcutaneous  side  by 
the  dense  tendinous  aponeurosis  of  the  extensor  tendons,  upon  the  deep  side 
by  the  metacarpal  bones,  having  the  shape  of  a  truncated  cone,  with  the  smaller 
end  at  the  wrist  and  the  broader  at  the  knuckle.  Laterally  the  aponeurotic 
sheet  shades  oflF  into  the  subcutaneous  tissue. 

"  Third,  the  hypothenar  area,  a  distinctly  localized  space. 

"Fourth,  the  thenar  space,  occupying,  approximately,  the  area  of  the  thenar 
eminence,  to  the  flexion  adduction  crease  of  the  thumb,  not  going  to  the  ulnar 


INFECTIOUS    HAND 


II35 


De.CS    PIM 


jyfe''l>^\\         MPS     TMF 


UV.~.|v 


Fig.  1406. — (Kanavel.) 

Cross  section,  through  distal  part  of  thenar  area.  See  Fig.  1352  for  common  lettering  its,  indefinite 
thenar  spaces;  tmf,  tendon  of  middle  finger;  tm,  thenar  muscles;  pf,  palmar  fascia;  ra,  radial  artery; 
DP.\.  deep  palmar  arch — digital  branches  beginning;  dia,  dorsalis  indicis  artery. 


Fig.  1407.  Fig.  1408. 

Figs.  1407  and  1408. — Sites  for  incisions.     (Kanavel.) 


1136 


OPERATIONS    FOR    INFECTIVE    LESIONS    OF   THE   HAND 


side  of  the  middle  metacarpal.     It  should  be  remembered  that  this  space  lies 
deep  in  the  palm,  just  above  the  adductor  transversus. 

''Fifth,  the  middle  palmar  space,  with  its  three  diverticula  below  along  the 
lumbrical  muscles,  limited  by  the  middle  metacarpal  bone  upon  the  radial  side, 
overlapped  by  the  ulnar  bursa  upon  the  ulnar  side,  and  separated  from  the 
thenar  space  by  a  partition  which  is  very  firm  everywhere  except  at  the  proximal 
end,  where  it  is  rather  thin.  A  small  isthmus  can  be  found  leading  from  the 
proximal  end  of  the  space  under  the  tendons  and  ulnar  bursa  at  the  wrist  up  into 
the  forearm." 


Fig.  1409. — Drainage  of  palm.     {KauavcL; 

Figures  1407,  1408,  and  1409  show  the  best  sites  for  incisions  in  infections 
of  the  hand  and  the  best  route  for  securing  drainage  of  the  midpalmar  and 
thenar  spaces.  In  any  case  of  extensive  or  deep  suppuration  of  the  hand 
when  operation  has  been  decided  on,  it  is  well  if  possible  to  administer  a  gen- 
eral anesthetic,  apply  an  elastic  constrictor  to  the  upper  arm  and  operate 
deliberately  with  a  precision  rendered  possible  by  a  knowledge  of  anatomy 
and  an  absence  of  blood. 

After  providing  for  drainage,  apply  liberal  dressings  and  use  Bier's  hyper- 
aemia  by  means  of  an  elastic  constrictor.  As  an  alternative  one  may  evacuate 
the  pus  by  appropriate  incisions  and  apply  h\-peraEmia  by  Klapp's  suction 
method  which  has  given  the  author  very  gratifying  results. 


WOUNDS    OF    HAND  II37 

Inciskd  Wounds  of  the  Hand  must  be  treated  on  ordinary  surgical  princi- 
ples, tendons,  if  divided,  must  be  repaired  and  cleanliness  sought.  Many  wounds 
of  the  hands  are  very  much  lacerated  and  have  much  dirt  ingrained  into  them. 
Two  methods  of  treatment  are  possible:  (A)  Cleanse  as  thoroughly  as  possible, 
repair  injured  tendons,  close  the  wound,  providing  for  drainage  by  means  of 
rubber  tissue.  If  infection  develops  later,  treat  it.  Bier's  hyperaemia  is  of 
much  value  in  warding  off  the  consequences  of  infection.  (B)  Cleanse  the 
wound  as  thoroughly  as  possible.  Swab  the  wound  with  spirits  of  turpentine 
which  may  act  in  three  ways;  (c)  as  a  solvent  of  grease,  (b)  as  an  antiseptic, 
(c)  as  an  excitant  of  local  leucocytosis.  Pack  the  wound  loosely  with  gauze. 
Apply  abundant  moist  dressings  loosely.  Apply  Bier's  constrictor  to  produce 
hvperaemia.  Immobilize.  Immobilization  is  of  special  importance  to  prevent 
spreading  of  infection.  George  Gray  (who  has  unusual  experience  in  the  treat- 
ment of  filthy  lacerated  wounds  of  the  hand)  treats  his  patients  as  above,  and 
after  the  lapse  of  about  forty-eight  hours,  if  infection  has  not  developed,  re- 
moves the  dressings,  repairs  injured  tissues,  and  closes  the  wound,  providing 
for  drainage  by  means  of  rubber  tissue. 

Infection  has  entered  through  a  wound  in  the  finger.  Suppuration  has 
taken  place.  How  ought  the  principles  of  treatment  outlined  in  the  preceding 
pages  be  carried  out? 

Make  the  first  incision  at  the  site  of  known  infection.  Open  the  tendon 
sheath,  if  involved,  at  the  side.  This  applies  to  the  middle  and  proximal 
phalanges.  Do  not  cut  the  tissues  over  an  articulation  unless  it  is  necessary  to 
drain  the  joint.  If  necessary  incise  on  both  sides  of  the  finger.  If  the  infection 
involves  the  palmar  end  of  the  sheath,  but  has  evidently  not  spread  farther,  incise 
in  the  middle  line  "from  the  flexion  crease  at  the  base  of  the  proximal  phalanx 
for  about  three-fourths  of  an  inch  into  the  palm.  If,  however,  there  is  some 
question  whether  the  lumbrical  spaces  at  the  side  have  begun  to  be  involved 
the  incision  is  made  upon  the  side  most  affected,  opening  the  space  and  the  ten- 
don sheath  at  the  same  time."  When  the  index  finger  is  affected  and  the  in- 
fection has  passed  into  the  lumbrical  space  on  the  radial  side,  then  it  may 
extend  into  the  thenar  space.  Under  these  circumstances  incise  so  as  to  open 
the  tendon  sheath  and  lumbrical  space  just  external  to  the  tendon — find  if  pus 
is  present  in  the  thenar  space.  If  pus  is  present  continue  the  incision  parallel 
to  and  on  the  radial  side  of  the  metacarpal  of  the  index  finger.  This  cut  must 
run  dorsal  to  the  web  of  the  thumb.  Through  the  wound  push  a  sinus  forceps 
(hemostat)  (Fig.  1409)  across  the  palmar  surface  of  the  metacarpal  bone  into 
the  thenar  space.  Open  the  blades  of  the  forceps  to  enlarge  the  deep  wound. 
Provide  rubber  tissue  drainage.  By  the  above  means  the  deep  palmar  space 
is  drained  without  the  palm  being  incised  and  without  danger  to  the  palmar 
arches.  When  introducing  the  forceps  do  noi  force  its  point  beyond  the  middle 
metacarpal,  as  it  then  would  penetrate  and  probably  infect  the  mid-palmar 
space.  W^hen  the  middle  finger  is  infected  and  the  trouble  spreads  upwards,  the 
mid-palmar  space  becomes  involved.  Incise  to  the  ulnar  side  of  the  tendon  from 
the  flexion  crease  at  the  base  of  proximal  phalanx  for  about  ^  inch  into  the 
palm.  If  pus  can  be  pressed  from  the  palm  into  the  wound  pass  a  closed  sinus 
forceps,  at  a  deeped  level  than  the  tendons,  so  as  to  penetrate  and  provide 

72 


1 138  OPERATIONS   FOR   INFECTIVE    LESIONS    OF    THE    HAND 

drainage  for  the  mid-palmar  space.  It  is  easy  to  open  the  mid-palmar  space 
from  the  ulnar  side  of  the  flexor  tendon  of  the  ring  finger  by  pushing  a  forceps 
upwards  and  inwards  under  the  tendons  (Fig.  1409). 

Of  course  infection  may  extend  irom  any  of  the  fingers  to  the  palmar  synovial 
sheaths,  but  is  very  much  more  liable  to  do  so  from  the  little  finger,  whose 
flexor  sheath  is  continuous  with  the  palmar  sheath  (ulnar  bursa)  in  50  per  cent, 
of  the  cases,  or  from  the  thumb  (Figs.  1400,  1401,  and  1402),  whose  tendon 
sheath  extends  from  the  distal  phalanx  to  the  palmar  sheath  (radial  bursa)  and 
above  the  annular  ligament  of  the  wr'st  in  95  per  cent,  of  the  cases.  When 
there  is  grave  infection  of  the  ulnar  biu-sa  very  free  drainage  is  necessary.  The 
following  method  (Kanavel's)  fulfills  the  requirements  with  the  minimum  of 
injury  to  important  structures. 

Incise  at  the  point  of  infection  and  there  open  the  tendon  sheath.  Press 
the  palm;  if  it  is  involved,  pus  will  come  into  the  wound.  Incise  at  the  distal 
flexion  crease  of  the  palm  and  enter  the  tendon  sheath.  Pass  a  director  up  the 
sheath  into  the  palm.  Guided  by  the  director  open  the  ulnar  bursa,  cutting  to 
the  ulnar  side  of  the  tendons.  "Having  arrived  at  the  anterior  annular  liga- 
ment, pressure  above  over  the  prolongation  of  the  sheath  in  the  forearm  will 
force  pus  downwards  into  the  sheath  below  the  ligament  if  the  infection  has 
extended  here,  as  it  generally  has.  If  it  is  very  early  in  the  course,  it  may  be 
justifiable  to  leave  the  anterior  annular  ligament  intact  and  incise  the  sheath 
above  the  ligament  on  the  same  line.  This  line  here  lies  about  one-half  inch  to 
the  radial  side  of  the  ulnar  artery.  Generally,  however,  the  swelling  is  such 
that  the  pulsation  of  this  vessel  cannot  be  felt.  It  is  then  necessary  to  proceed 
by  choosing  a  point  at  the  junction  of  the  middle  and  ulnar  thirds  of  the  flexor 
surface  and  incising  carefully,  layer  by  layer,  until  the  group  of  flexor  tendons  is 
reached.  These  can  be  identified  by  moving  the  fingers.  The  dissection  is 
now  carried  down  along  the  ulnar  border  of  these  tendons  in  juxtaposition  to 
them  and  immediately  above  the  anterior  annular  ligament,  since  the  sheath 
lies  to  the  ulnar  side  and  posterior  to  the  tendons.  If  infected  it  should  be 
freely  opened,  since  the  swelling  due  to  oedema  and  inflammatory  infiltration 
tends  to  a  close  small  opening.  If  the  infection  is  now  seen  to  be  at  all  severe, 
the  anterior  annular  ligament  is  split  as  far  to  the  ulnar  side  as  possible.  The 
hook  of  the  unciform  interferes  somewhat  with  the  incision.  If  it  is  determined 
at  first  when  the  palmar  part  is  incised  that  the  infection  is  at  all  severe,  I  pro- 
ceed differently.  The  incision  is  continued  from  below  upwards,  at  once  cutting 
the  anterior  ligament  and  carrying  the  incision  about  an  inch  up  on  the  forearm. 

This  latter  is  made  as  much  to  drain  the  subcutaneous  area  above  the  wrist, 
which  commonly  becomes  infected,  as  to  open  the  sheath.  This  incision  is 
always  supplemented  by  a  transverse  drainage  above  the  wrist-joint  as  follows : 
At  a  point  about  i}^i  inches  above  the  tip  of  the  ulna  an  incision  is  made 
directly  down  on  this  bone  at  its  flexor  surface;  an  artery  forceps  is  now  thrust 
across  the  flexor  surface  of  this  bone  and  the  radius  until  it  impinges  on  the 
skin  at  the  radial  side,  where  the  knife  cuts  down  upon  it.  The  incisions  in  the 
skin  are  now  enlarged  to  the  length  of  an  inch  and  a  half  or  more  and  with  the 
artery  forceps,  the  subtendinous  area  to  the  same  extent.  Especial  care  should 
be  used  here  to  make  the  incision  neither  too  far  upon  the  flexor  surface  nor 


INFECTIOUS    HAND  II39 

dorsally,  since  in  the  first  instance,  especially  upon  the  radial  side,  the  artery 
may  be  injured  either  by  the  primary  incision  or  subsequent  necrosis,  and  in  the 
second  instance,  if  the  incision  is  too  far  dorsal  it  will  not  drain  easily.  If  the 
primary  incision  is  made  low  down  and  on  the  radial  side  the  danger  of  injuring 
the  radial  is  greater.  With  the  proper  precaution,  no  anxiety  need  be  felt  (Fig. 
1408).  Having  opened  this  area  the  finger  is  now  inserted  under  the  flexor  pro- 
fundus tendons  and  if  there  is  any  infection  of  the  sheath  it  is  bulging  and  can  be 
opened  easily.  In  case  it  is  not  found  easily,  flexion  and  extension  of  the  fingers 
will  locate  the  tendons  involved  and  the  palpating  finger  is  pushed  up  among 
them,  or  an  artery  forceps  can  be  pushed  down  from  the  bursa  which  has  been 
opened  in  front.  Its  point  is  felt  plainly  by  the  finger  and  the  opening  dilated 
freely.  As  a  matter  of  fact,  the  infection  will  be  found  to  have  ruptured  into 
this  space  in  practically  every  case,  except  in  the  very  earliest  stages.  I  wish 
to  emphasize  that  it  is  this  incision  that  I  depend  on  for  drainage  of  the  upper 
end  of  the  bursa,  since  it  extends  upwards  on  the  tendons  on  their  posterior  sur- 
face. I  have  even  made  it  in  cases  where  I  had  made  no  incision  upon  the  flexor 
surface  of  the  forearm,  or  had  deemed  it  inadvisable  to  cut  the  anterior  annular 
ligament.  Particularly  in  infections  of  the  radial  bursa  do  I  do  this.  In  other 
words,  I  use  it  as  a  site  for  entering  and  draining  the  sheath  before  rupture  as 
well  as  the  site  for  incision  for  draining  the  extension  into  the  forearm." 

When  there  is  grave  infection  of  the  thumb  and  radial  bursa,  Kanavel  oper- 
ates as  follows:  "Here  it  is  my  habit  to  dissect  down  to  the  tendon  upon  the 
flexor  surface  of  the  proximal  phalanx;  having  entered  the  sheath,  the  incision 
is  enlarged  along  the  sac  through  the  thenar  eminence  separating  the  muscular 
mass  (heads  of  the  flexor  brevis  polKcis).  It  should  be  remembered  that  the 
tendon  lies  nearer  the  palm  than  one  would  be  inclined  to  think,  and  that  the 
mass  of  the  thenar  muscles  lies  to  the  radial  side  of  the  incision.  This  is  only 
carried  up  to  within  a  thumb's  breadth  of  the  lower  border  of  the  anterior 
annular  ligament,  since  I  have  previously  shown  by  observations  made  upon 
cadaver  hands,  and  reported  in  an  earlier  contribution,  that  the  motor  nerve  to 
the  thenar  muscles  passes  across  the  sheath  between  this  point  and  the  lower 
edge  of  the  anterior  annular  ligament,  and  in  my  opinion  loss  of  the  flexor  longus 
pollicis  tendon  is  to  be  preferred  to  destroying  this  nerve,  and  thus  bringing 
about  a  loss  of  the  muscles  which  it  supplies.  The  incision  begins  again  at  the 
upper  part  of  tV  ^  anterior  annular  ligament,  opening  the  proximal  end  of  the 
radial  bursa  abo\  this  ligament.  If  the  process  is  severe  and  there  is  fear  that 
the  sheath  may  have  ruptured,  incisions  are  made  laterally  above  the  wrist-joint 
as  described  under  the  ulnar  sheath  infection  and  the  tendon  sheath  drained 
from  this  site.  Exceptionally  incision  upon  the  radial  side  alone  may  be  suffi- 
cient. If  the  anterior  incision  is  made,  subcutaneous  pus  may  be  found,  lead- 
ing to  the  mistaken  notion  that  the  sheath  has  ruptured  and  is  draining  into 
•  this  area.  One  should  not  be  deterred  from  continuing  the  incision,  going  a 
quarter  of  an  inch  to  the  radial  side  of  the  median  line  of  the  flexor  surface  of 
the  forearm.  The  dissection  is  carried  down  to  the  radial  side  of  the  flexor 
sublimis  tendons,  avoiding  the  median  nerve  in  the  floor  and  to  the  ulnar  side. 
The  tendon  sheath  has  generally  ruptured  by  this  time  or  can  be  identified  by 


II40  INDICATIONS.      JOINTS 

a  grooved  director  or  fine  probe  passed  from  the  opened  sheath  below.  It  is 
entirely  safe  to  cut  the  upper  part  of  the  anterior  annular  ligament  (Fig.  1408). 

If  the  infection  has  shown  any  tendency  to  be  virulent  or  extend  rapidly 
I  feel  that  this  anterior  incision  should  be  limited  to  opening  the  subcutaneous 
accumulation,  if  there  be  any,  and  the  tendon  sheath  should  be  opened  by  the 
lateral  incisions  described  above,  for  entering  the  space  between  the  flexor 
profundus  tendons  and  the  pronator  quadratus.  Good-sized  incisions  should 
be  made  so  that  drainage  may  be  free.  In  many  cases  where  the  infection 
has  been  severe  or  the  tendon  impaired,  primary  removal  of  the  tendon  should 
be  favored.  This  is  particularly  liable  to  die  and  remain  for  many  weeks  caus- 
ing the  infection  to  persist  and  jeopardize  other  structures,  so  that  I  make  it  a 
rule  if  the  tendon  is  at  all  destroyed  or  the  infection  shows  a  slow  recovery  to 
remove  the  tendon  at  once.  I  am  also  especially  inclined  to  do  this  if  the  ulnar 
bursa  has  so  far  escaped  involvement,  since  the  preserv-ation  of  this  is  particu- 
larly to  be  sought." 

The  use  of  drainage-tubes  is  to  be  condemned.  They  are  unnecessary  if 
the  incisions  have  been  properly  made,  and  are  always  liable  to  cause  necrosis 
of  tendons.  Gauze  strips  are  useless  and  act  as  plugs  preventing  drainage. 
It  is  easy  to  keep  the  wounds  sufficiently  open  by  means  of  strips  of  rubber 
tissue  or  oiled  silk.  If  these  materials  are  not  available,  then  gauze  strips  well 
smeared  with  vaseline  or  some  sterile  unguent  will  serve  the  same  purpose. 
The  dressings  must  be  voluminous  and  )wt  tight.  The  use  of  a  dorsal  splint 
is  valuable.  Bier's  h\-peraemia  is  an  invaluable  therapeutic  aid  and  ought 
never  to  be  forgotten. 


CHAPTER  CIV 

INDICATIONS.     JOINTS 

It  is  difficult  or  impossible  to  lay  down  absolute  rules  regarding  operative 
interference  in  many  cases  of  articular  disease,  but  a  few  remarks  on  the  subject 
may  be  of  value  to  the  junior  surgeon. 

(A)  "Wounds  of  the  Joints. — (See  page  1030.) 

(B)  Simple  hydrops  articiili,  generally  of  traumatic  origin.  Only  if  the 
effusion  is  great  and  resistant  to  treatment  by  pressure,  etc.,  does  it  become 
proper  to  aspirate  and  possibly  to  inject  some  modifying  fluid,  such  as  a  5  per 
cent,  solution  of  carbolic  acid  or  2  per  cent,  formalin-glycerine.  If  the  hydrops 
is  due  to  the  presence  of  a  foreign  body  (rice  body)  or  its  equivalent,  e.g.,  dis- 
placed semilunar  cartilage,  treatment  must  be  directed  against  the  exciting 
cause. 

(C)  Arthritis  from  Pyogenic  Infection. — (I)  The  arthritis  is  not  very  acute; 
the  general  symptoms  are  not  menacing  in  character;  the  general  condition  of  the  . 
patient  is  good.  The  classical  treatment  is  absolute  rest  plus  some  active 
conservative  treatment,  e.g.,  Bier's  h\'peraemia,or  puncture  the  joint,  withdraw 
the  fluid,  douche  with  salt  solution,  and  inject  Murphy's  formalin-glycerine 
solution.  Watch  the  case  carefully  lest  more  vigorous  measures  may  be  neces- 
sar}-.     Today  arthrotomy  according  to  Willems'  principles  is  greatly  favored. 


REMARKS    OX    JOINTS  II4I 

(2)  The  arthritis  is  more  acute  or  is  accompanied  by  menacing  symptoms, 
but  yet  the  patient  is  not  in  an  alarming  condition. 

(a)  Open  the  joint  sufficiently  to  provide  free  drainage,  irrigate,  introduce 
drainage-tubes  to,  but  not  through  the  synovialis.  According  to  circum- 
stances, apply  suction  to  the  parts  by  means  of  the  Bier-Klapp  cups  (this  assists 
drainage  and  provides  hyperaemia)  or  apply  Bier's  rubber  bandage  to  produce 
obstructive  hyperaemia  and  hinder  absorption. 

(b)  Open  the  joint  freely.  Do  not  irrigate.  Apply  light  dressings.  Initi- 
ate free  active  motion  immediately  (see  p.  103 1). 

(3)  The  arthritis  is  very  extensive  and  progressive.  Use  the  Willems' 
treatment  with  very  free  arthrotomy.  If  there  is  so  much  destruction  of  tissue 
and  involvement  of  cartilage  and  bone  that  active  motion  is  contraindicated 
provide  the  most  free  drainage  possible,  lay  the  joint  open  as  thoroughly  as 
possible  and  keep  it  open  so  that  no  retention  of  discharges  may  be  possible 
(Bier's  obstructive  hyperaemia  may  benefit).  Do  not  fear  injury  to  the  subse- 
quent function  of  the  joint,  the  operation  is  a  life-saving  one  and  no  thoughts 
of  subsequent  disabilities  must  be  permitted  to  interfere  with  the  providing  of 
thorough  drainage.     Resection  of  the  joint  may  be  necessary. 

(4)  The  patient's  general  condition  is  poor  from  age,  continued  disease,  etc. 
He  will  be  unable  to  withstand  a  long  illness.  Amputation  is  the  treatment 
of  choice.  In  a  few  cases,  e.g.,  in  the  hip,  resection  of  the  joint  may  give  better 
prospects  of  recovery  than  amputation. 

(5)  The  arthritis  is  the  result  of,  or  is  complicated  by,  osteomyelitis.  The 
treatment  must  be  a  combination  of  that  for  the  bone  lesion  and  of  arthrotomy. 
Atypical  or  typical  excision  of  the  joint  will  probably  be  indicated. 

(D)  Tuberculous  Arthritis. — The  indications  for  treatment  depend,  (a) 
on  the  general  condition  and  social  position  of  the  patient;  (6)  on  the  local 
lesions  present. 

(a)  The  General  Condition  and  Social  Position  of  the  Patient.— Conserva- 
tive treatment  gives  its  best  results  in  childhood  and  youth,  during  which  periods 
the  loss  of  time  involved  is  of  comparatively  small  importance.  The  old  and 
feeble  require  treatment  which  will  give  the  quickest  possible  relief  wdth  the 
least  tax  on  their  vitality.  In  youth  it  is  more  important  to  obtain  a  function- 
ally useful  joint  than  to  save  time;  among  the  aged  and  debilitated  prompt 
recovery  is  more  important  than  functional  recovery.  The  presence  of  visceral 
tuberculosis  or  of  amyloid  disease  spells  amputation  in  most  instances,  though 
to  this  there  are  exceptions.  Amputation  often  leads  to  improvement,  some- 
times to  cure,  of  the  internal  lesions. 

(b)  Local  Lesions. 

(i)  Non-suppurative  Tuberculous  Arthritis. — In  every  case  begm  by  using 
conservative  treatment,  viz.,  rest  with  immobilization;  Bier's  hyperaemia;  as- 
piration with  injection  of  some  modifying  solution  if  hydrops  is  present. 

If  after  a  reasonable  time  (months)  there  is  no  improvement,  if  pain  persists, 
if  deformities  develop,  operation  must  be  considered.  When  skiagraphy 
shows  the  presence  of  severe  osseous  lesions,  conservative  treatment,  while 
it  may  succeed,  yet  is  not  so  likely  to  do  so.  If  the  bone  lesions  do  not  com- 
municate with  the  joint,  if  they  can  be  removed  without  opening  the  joint  and 


I  142  INDICATIONS.       JOINTS 

without  injury  to  an  active  epiphyseal  cartilage,  then  it  is  wise  to  excise  the  dis- 
eased foci.  In  deciding  between  operative  and  non-operative  treatment,  take 
into  consideration  the  individual  joint  affected,  and  the  amount  of  handicap 
anchylosis  of  that  articulation  would  impose  on  the  patient. 

(2)  Suppurative  tuberculous  arthritis  without  fistula.  (Xo  pyogenic  in- 
fection is  present.     The  disease  is  a  cold  abscess  of  the  joint.) 

Combined  with  immobilization,  the  treatment  consists  in  aspiration  followed 
by  injections  of  iodoform.  (Iodoform  in  oil,  glycerine,  ether,  or  in  formalin 
and  glycerine.)  The  results  obtained  are  better  in  children  than  in  adults, 
because  in  the  latter  sequestra  are  usually  present.  Instead  of  aspirating  one 
may  incise  the  joint,  mop  it  with  gauze,  douche  with  salt  solution,  rub  the  joint 
surfaces  with  iodoform  or  with  tincture  of  iodine,  close  the  wound  with  sutures, 
fill  the  joint  cavity  with  iodoform  emulsion  before  tightening  the  last  sutures. 
Bier  never  uses  iodoform  injections  except  in  tuberculous  hydrops  or  in  cases 
of  large  cold  abscesses  which  fill  the  articular  cavities;  in  these  hyperaemia  is 
out  of  place.  Under  other  circumstances  Bier  evacuates  the  pus  and  treats 
by  means  of  hyperaemia.  Small  multiple  cold  abscesses  around  a  joint  are 
suitable  for  puncture  and  suction  hyperaemia.  If  improvement  under  conserva- 
tive measures  does  not  manifest  itself  in  a  reasonable  time,  or  if  the  disease  shows 
progress,  one  must  resort  to  operation — -usually  typical  or  atypical  resection. 

(3)  Suppurative  Tuberculous  Arthritis  with  Fistulae. — This  means  that 
secondary  infection  is  present  as  a  complication. 

(o)  The  disease  is  not  progressing  rapidly.  On  probing  no  dead  or  diseased 
bone  is  felt.  Clean  the  fistula  with  gauze  wicks  or  with  a  curette.  Use  suction 
hyperaemia.  Sometimes  vigorous  suction  may  take  the  place  of  the  curette. 
Treat  the  main  diseases  by  the  usual  conservative  means.  If  diseased  bone  is 
found  at  bottom  of  the  fistula,  this  must  be  exposed  and  removed. 

(b)  Instead  of  treating  in  the  preceding  manner,  cleanse  the  fistula,  remove 
any  loose  sequestra,  fill  the  fistula  by  injecting  into  it  Beck's  bismuth  vaseline 
or  his  bismuth  paste.     This  frequently  leads  to  recovery. 

(c)  The  above  measures  fail  or  the  disease  appears  progressive.  Symptoms 
are  such  that  loss  of  time  is  dangerous.  Perform  either  typical  or  atypical  re- 
section. Garre  makes  a  valuable  protest  against  carelessness  in  the  treatment 
of  tuberculous  arthritis.  Unless  the  fistulae  are  kept  clean  and  well  protected 
by  dressings,  and  unless  the  soiled  dressings  are  sterilized  or  destroyed,  the 
patient  becomes  a  menace  to  the  community. 

(4)  The  presence  of  multiple  lesions  at  different  parts  of  the  same  limb 
generally  demands  amputation,  though  even  here  general  treatment,  plus  local 
care,  often  leads  to  cure  in  children. 

As  75  per  cent,  of  cases  of  tuberculous  arthritis  may  be  cured  by  conserva- 
tive means  (Hoffa),  do  not  lightly  turn  to  operation.  Remember  that  the  rules 
guiding  the  surgeon  in  his  choice  of  treatment  vary  according  to  the  social 
status  of  the  patient,  his  means  to  indulge  in  prolonged  treatment,  etc.,  and 
according  to  the  joint  involved. 

(E)  Gonorrheal  Arthritis. — Conservative  treatment  is  generally  sufficient. 
Bier's  hyperaemia  is  said  to  be  most  valuable.  In  hydrops  articuli  and  in  sero- 
fibrinous arthritis,  if  the  above  measures  do  not  give  relief  promptly,  it  is  proper 


INDICATIONS    FOR    AMPUTATION  II43 

to  aspirate  and  inject  some  modifying  solution,  e.g.,  5  per  cent,  less  carbolic  acid 
solution.  In  suppurative  arthritis  incision  and  drainage  are  necessary.  What- 
ever means  of  treatment  is  adopted,  beware  of  anchylosis  and  deformities  from 
contracture.  Remember  that  treatment  of  the  seminal  vesicles  may  be  of 
great  value. 

(F)  Typhoidal  Arthritis.— It  is  extremely  rare  that  typhoidal  arthritis 
leads  to  suppuration;  when  it  does  then  incision  and  drainage  are  necessary. 
Hydrops  of  typhoidal  origin,  when  present,  is  liable  to  cause  dislocation  espe- 
cially of  the  hip,  hence  aspiration  is  proper. 

(G)  Acute  Rheumatic  Arthritis. — O'Connor  of  Buenos  Ayres,  is  enthusi- 
astic over  the  benefits  to  be  obtained  from  incision,  irrigation,  and  drainage 
of  whatever  joints  are  affected.  He  believes  that  under  this  treatment  the 
local  lesions  recover  promptly,  pain  is  relieved  at  once,  and  secondary  heart 
troubles  are  avoided.  The  author  has  no  experience  in  the  matter,  but  O'Con- 
nor's arguments  seem  plausible  and  well  backed  by  results. 

(H)  Pneumococcal  Arthritis.- — The  indications  are  the  same  as  in  ordinary 
pyogenic  infections  of  the  joints. 

(I)  Tratmiatic  Dry  Arthritis. — Rovsing  finds  that  injections  of  sterile 
vaseline  exercise  a  favorable  influence  in  this  painful  and  disabling  disease. 


CHAPTER  CV 
AMPUTATION  OR  DISARTICULATION 

Esmarch  gives  the  following  indications  for  amputation: 

1.  Extensive  comminution  of  the  bones  and  laceration  of  large  vessels  and 
nerves. 

2.  Extensive  destruction  of  the  whole  musculature  of  a  region  even  when 
the  bones  are  not  much  damaged. 

3.  Very  extensive  destruction  of  skin  (ulcer,  burns)  if  the  Hmb  is  rendered 
useless  by  it  and  repair  by  skin  transplantation  is  impossible. 

4.  Gangrene. 

5.  MaUgnant  tumors. 

6.  Severe  septic  or  pyaemic  infection  when  removal  of  the  focus  is  impossible 
by  other  means. 

7.  Suppuration  of  long  duration  when  the  patient's  strength  is  so  lowered 
that  it  is  evident  he  cannot  withstand  a  long  illness  and  that  by  amputation 
he  is  likely  to  recover  in  a  short  time. 

8.  Amputation  of  choice.  When  the  patient  desires  to  be  rid  of  a  useless 
organ,  e.g.,  an  atrophied  or  paralyzed  limb. 

When  amputation  is  necessitated  by  gangrene,  when  ought  one  to  operate? 
Immediate  amputation  is  called  for  because  the  patient  is  constantly  absorbing 
poisons  from  the  diseased  part  and  is  constantly  losing  strength.     Immediate 


1 144  AMPUTATION    OR    DISARTICULATION 

amputation  is  improper  because  one  does  not  know  where  to  operate;  one  does 
not  know  where  the  gangrenous  process  will  stop  and  hence  too  much  of  the 
limb  may  be  sacrificed  or,  what  is  more  serious,  too  little  may  be  removed 
and  gangrene  may  appear  in  the  stump.  It  has  been  exceedingly  difficult  to 
decide  this  question  in  the  past;  if  intoxication  were  great  it  was  wise  to  run 
chances  of  recurrence  and  amputate;  if  intoxication  were  not  severe  and  the 
patient's  strength  permitted,  it  was  wise  to  delay  until  the  line  of  demarcation 
became  evident.  Mozkowicz  ("La  Presse  Med.,"  Oct.  24, 1906)  has  endeavored, 
apparently  successfully,  to  find  where  the  line  of  demarcation  will  form  in  any 
given  case,  i.e.,  to  determine  the  seat  of  arterial  obliteration.  His  method  is 
the  following:  Elevate  the  limb  for  two  or  three  minutes.  Apply  an  elastic 
constrictor  high  up  the  limb  as  if  for  amputation  and  lower  the  limb  to  the 
table.  After  five  minutes  remove  the  constrictor  quickly.  In  health  the  ar- 
terial circulation  re-establishes  itself  at  once,  a  hyperaemic  flush  passes  down  the 
limb  and  reaches  the  toes  in  about  two  seconds.  If  gangrene  is  present  the 
ruddy  flush  rapidly  passes  a  certain  distance  down  the  limb  then  pauses  so 
that  there  is  a  clear  line  of  demarcation  between  the  skin  above  (hyperaemic) 
and  that  below  (ischaemic),  then  the  flushing  passes  slowly  downward,  taking 
minutes  instead  of  seconds  to  reach  the  toes.  The  line  where  the  descending 
flush  pauses  corresponds  to  the  site  of  arterial  obliteration  and  to  the  limit 
which  the  gangrenous  process  may  be  expected  to  reach.  Several  surgeons, 
notably  v.  Eiselsberg,  have  corroborated  Moskowicz's  observations. 

Van  Buren  Knott,  when  amputating  in  certain  bad  cases  of  gangrene  or 
analogous  septic  conditions,  considers  it  of  prime  importance  first,  to  be  rapid, 
and,  second,  to  avoid  interference  with  the  nutrition  of  the  tissues  to  be  pre- 
served. He  fulfills  these  conditions  by  making  a  circular  amputation;  dividing 
the  skin,  the  muscles,  the  bone  at  the  same  level,  attending  to  hemostasis, 
applying  dressings  and  then  waiting  until  recovery  has  so  far  taken  place  that 
it  is  safe  to  fashion  the  stump  and  divide  the  bone  at  a  higher  level.  At  the 
primary  operation  there  is  no  reflection  of  the  tissues,  no  separation  of  one  tissue 
plane  from  another,  no  application  of  sutures  and  the  ligatures  are  applied  to 
the  vessels  as  precisely  as  possible  so  as  to  avoid  strangulation  of  surrounding 
structures.  This  method  under  the  name  "Guillotine  amputation"  became  very 
popular  with  many  surgeons  during  the  Great  War. 

Fitzmaurice-Kelly  ("Lancet,"  Jan.  2,  191 5)  writes  that  the  "chief  conditions 
calling  for  amputation  in  the  present  war  have  been  compound  comminuted 
fractures  and  gaseous  gangfene.  *  *  *  In  both  a  virulent  infection  is  present 
and  ordinary  amputations  are  very  frequently  followed  by  recrudescence  of  the 
infection  in  the  flaps."  He  advocates  an  operation  identical  with  Knott's  and 
claims  excellent  results  provided  that  the  nerves  are  pulled  down  and  cut  short. 
He  amputates  very  close  to  the  disease,  even  within  half  an  inch  of  gangrene, 
and  does  not  fear  spread  of  the  disease.  In  case  of  compound  fracture  of  the 
femur,  with  the  wounds  irt  the  groin  and  buttock  and  the  fracture  just  below 
the  trochanter,  he  amputated  below  the  wounds  enucleating  the  lower  frag- 
ment and  laying  open  the  sinuses  to  the  surface,  with  complete  success.  Lynn 
Thomas  (Brit.  Med,  J.,  Oct.  7,  1916)  disapproves  heartily  of  Guillotine  or  "no 
flap"  amputation  preferring  the  circular  method  with  two  lateral  incisions. 


WHEN    AND    WHERE    TO   AMPUTATE  II45 

Silk  or  linen  is  objectionable  for  ligatures  because  of  the  dangers  from  sepsis. 
He  uses  catgut  or  silkworm  gut.  The  flaps  are  pulled  downwards  "forming  a 
funnel-shaped  cavity  in  which  the  muscles  are  not  in  apposition."  This  cavity 
is  firmly  packed  with  gauze  wrung  out  of  Wright's  hypertonic  solution  and  in 
which  are  scattered  tablets  of  salt  as  advised  by  H.  M.  W.  Gray.  The  flaps  are 
scattered  tablets  of  salt  as  advised  by  H.  M.  W.  Gray.  The  flaps  are  hehl 
together  over  the  gauze  by  adhesive  straps.     Rubber  tube  drains  are  harmful. 

John  H.  Gibbon,  Joseph  A.  Blake  and  many  others  agree  with  Thomas  in 
damning  the  Guillotine  operation  as  favouring  secondary  hemorrhages,  loss  of 
time,  bad  stumps  and  re-amputations.  T.  G.  Orr  (Annals  of  Surg.,  May,  1919) 
from  experience  with  returned  soldiers  in  General  Hospital  26,  favours  the 
Guillotine  operation  but  his  statistics  are  not  entirely  persuasive. 

J.  H.  NicoU  (Brit.  Med.  J.,  Nov.  13,  1918)  recognizing  the  frequency  of 
secondary  hemorrhage  from  infected  open  stumps  after  amputations  recom- 
mends routine  ligation  of  the  common  femoral  vessels  in  such  infected  stumps 
of  the  thigh  which  are  a  week  or  more  old.  By  the  end  of  the  first  week  after 
amputation  the  collateral  circulation  is  ample  for  the  needs  of  any  stump 
down  to  the  supra-condylar  level.  In  case  of  secondary  hemorrhage  after 
amputation  below  the  knee  there  is  usually  time  for  an  attendant  to  apply 
pressure  or  a  tourniquet  until  surgical  aid  can  be. obtained. 

When  the  lesion  necessitating  ""amputation  is  old  suppurative  disease,  sinuses 
in  the  tissues  forming  the  flaps  do  not  appear  to  do  much  harm  if  they  are  well 
cleaned  by  dissection,  curettement,  and  chemical  disinfection  (H.  Barnard). 
Recognition  of  this  fact  tends  to  conserbvatism. 

Patients  who  have  lost  much  blood  bear  major  amputations  of  the  lower 
limbs  badly;  when  gangrenous  septicaemia  is  a  complication  he  outlook  is  very 
bad.  Savariaud  has  obtained  excellent  results  in  apparently  desperate  cases  as 
follows:  Anesthesia  by  ether.  Preventive  hemostasis  by  elastic  constrictor 
(if  necessary  Momberg's).  After  the  limb  has  been  amputated  and  all  bleeding 
points  clamped  or  tied,  introduce  a  cannula  (the  cannula  is  conical,  with  an 
aperture  of  2  mm.  at  its  point  while  its  base  is  about  the  size  of  a  little  finger) 
into  the  femoral  vein  and  at  once  inject  about  1500  c.c.  of  warm  saline  solution. 
The  injection  takes  only  about  2  or  3  minutes.  The  rapid  infusion  so  raises  the 
blood  pressure  that  the  small  arterioles  of  the  stump  begin  to  bleed  and  can  be 
ligated,  thus  lessening  the  danger  of  post-operative  hemorrhage. 

When  and  Where  to  Amputate  a  Limb  after  Injury. — W.  L.  Estes  has 
thoroughly  studied  this  question,  his  experience  is  vast  and  his  ideas  are  well 
worth  consideration.  The  following  paragraphs  are  based  on  Estes's  publica- 
tion ("International  Jour,  of  Surg.,"  June,  1905): 

1.  The  aged  and  very  young  are  intolerant  of  long  confinement,  hence  are 
less  suitable  to  conservative  treatment  than  other  individuals.  Chronic 
alcoholics,  diabetics,  nephritics,  etc.,  are  unsuited  to  long-lasting  conservative 
treatment.  Tuberculosis  of  moderate  degree  does  not  seriously  interfere  with 
conservatism.  The  best  subjects  for  conservatism  are  robust  individuals  of 
good  habits  in  early  adult  life  and  children  above  ten  years  of  age. 

2.  Severe  laceration  and  crushes  from  falls  or  blows  over  restricted  areas 
are  more  suitable  for  conservatism  than  when  'they  are  due  to  squeezes  or 


1 146  AMPUTATION    OR    DISARTICULATION 

pressures  of  heavy   machinery,   heavy  stones,   or   car   wheels.     These   latter 
injuries  correspond  more  or  less  to  such  as  are  produced  by  the  angiotribe. 

3.  Thick  muscular  portions  of  a  limb  stand  more  injury  than  thinner  parts. 
Crushes  of  bone  and  muscle  even  where  extensive  admit  of  conservative  efforts 
if  the  ^^skiti  is  not  fatally  injured  over  a  considerable  area,  say  half  of  the  periphery 
of  the  limb  at  the  seat  of  injury."  If  the  principal  vessels  of  the  thigh  or  upper 
arm  are  severed  and  laceration  is  extensive,  amputate.  If  in  forearm  only  one 
system  of  vessels  and  nerves  is  severed,  e.g.,  the  radial,  and  the  skin  is  not  badly 
damaged,  try  conservatism.  If  both  radial  and  ulnar  systems  are  badly 
damaged,  amputate.     The  same  principles  apply  to  the  leg. 

4.  Psychical  shock  due  to  profound  nervous  disturbance  from  fear  or  horror 
is  often  improved  under  ether,  and  hence  immediate  amputation  may  be  per- 
formed. Anaemic  shock  demands  treatment  by  means  of  salt  solution  (intra- 
venous, hypodermic,  rectal),  bandaging  of  the  extremities,  warm  bed,  morphia, 
etc.,  and  amputation  must  be  delayed  until  reaction  sets  in,  twelve,  twenty-four, 
of  thirty-six  hours.     Transfusion  of  blood  is  often  life  saving. 

5.  If  the  physical  condition  is  not  very  bad,  and  if  there  is  no  doubt  as  to 
the  necessity  of  amputation,  do  not  delay. 

6.  When  shock  from  the  operation  is  much  feared,  then  Crile's  method  of 
nerve-blocking  (p.  1186)  may  be  valuable. 

7.  When  delay  is  necessary,  hemorrhage  must  be  absolutely  controlled 
and  cleanliness  sought. 

(a)  Amputation  is  inevitable.  Apply  an  elastic  constrictor  (Estes)  over 
already  injured  tissues  just  far  enough  above  the  severed  muscles  and  bones  to 
assure  it  against  slipping.  The  tissues  compressed  by  the  tourniquet  are 
already  so  injured  that  they  must  be  sacrificed  and  hence  the  extra  constriction 
is  harmless.  The  constrictor  does  not  merely  prevent  hemorrhage;  it  also 
prevents  absorption,  a  matter  of  prime  importance  as  disinfection  of  the  lacer- 
ated wound  is  usually  impracticable.  The  constrictor  should  be  left  in  place 
until  after  the  amputation,  a  second  tourniquet  being  applied  at  a  higher  level 
during  the  operation.  The  lacerated  wound  must  be  covered  by  a  large  moist 
antiseptic  dressing.  If  in  spite  of  these  precautions  infection  reaches  above  the 
tourniquet,  immediate  operation  is  imperative. 

(b)  There  is  reasonable  doubt  as  to  the  absolute  necessity  of  amputation. 
Do  not  apply  the  elastic  constrictor  temporarily.  Clean  and  disinfect  the 
wound.  Ligate  vessels.  Pack  the  wound  with  gauze,  if  desirable,  placing  a 
sheet  of  perforated  oil  silk  between  the  gauze  and  the  tissue  to  prevent  adhe- 
sion. Possibly  introduce  one  or  two  sutures  to  keep  the  packing  in  position. 
Apply  voluminous  dressings  and  a  splint.  Bandage  snugly.  The  size  of  the 
dressings  gives  elasticity  to  the  pressure  of  the  bandage.  Elevate  the  limb. 
After  twenty-four  to  fifty-six  hours  proper  conservative  operations  or  amputa- 
tion may  be  performed.  Often  debridement  and  the  use  of  the  Carrel-Dakin 
treatment  is  good. 

8.  If  the  injury  affects  the  fingers  or  hand  the  character  of  the  amputation 
will  depend  to  some  extent  on  the  occupation  or  social  position  of  the  patient, 
e.g.,  an  irregular,  "nobby"  stump  may  be  of  vast  service  to  a  workman  (Fig. 


CHARACTER    OF    STUMP  II47 

1410);  a  neat,  smooth  one  may  be  far  more  pleasing  to  a  fashionable  lady.  As 
a  rule,  in  the  case  of  the  lingers,  hand,  and  arm,  as  much  of  the  limb  must  be 
saved  as  possible,  in  the  case  of  the  lower  extremity  several  problems  arise. 

(a)  The  patient  can  atTord  a  good  artiiicial  limb.  In  this  case  the  ideas 
of  the  artificial  limb-makers  must  be  consulted.  According  to  them  the  lowest 
favorable  point  for  section  of  the  bones  in 

amputation  of  the  leg  is  about  8  inches 
from  the  ground;  the  highest  point  is  about 
four  inches  below  the  lowest  edge  of  the 
patella;  the  lowest  point  for  section  of  the 
femur  in  amputation  of  the  thigh  is  about 
3  or  4  inches  above  the  knee-joint,  the 
highest  about  5  inches  below  the  crotch. 

(b)  The  patient  cannot  afford  a  good 
artificial  limb.  As  much  of  the  limb  must 
be  saved  as  is  possible,  and  if  possible  a 
natural  weight-bearing  surface  be  provided 
for  the  stump  as  in  Chopart's  and  Syme's  ^ig.  i4io.-{Jacobson.) 
amputations. 

(c)  Remember  that  if  amputation  be  done  through  the  upper  third  of  the 
humerus  in  children,  the  bone  left  will  grow  and  form  a  conical  stump  which 
may  require  reamputation.  A  warning  of  this  fact  given  to  the  patient's 
guardians  may  save  the  surgeon's  reputation.  Conical  stump  is  also  liable  to 
develop  after  amputation  through  the  upper  part  of  the  femur  in  children. 

9.  The  dangers  to  life  are  almost  alike  in  amputations  at  any  level  of  the 
arm  and  forearm.  Practically  all  amputations  below  the  knee  are  equal  in 
safety;  above  the  knee  the  higher  the  amputation  the  greater  is  the  danger. 

The  Character  of  the  Stmnp. — The  character  of  the  stump  is  of  importance. 
As  already  stated,  when  the  patient  cannot  obtain  a  good  artificial  Umb  the 
stump  ought,  if  possible,  to  be  covered  with  skin  and  tissue  already  accustomed 
to  bearing  weight,  and  the  scar  ought  not  to  pass  over  the  end  of  the  bone.  If 
an  artificial  limb  is  to  be  worn  a  number  of  experienced  artificial  limb-makers 
consider  the  best  site  for  the  scar  to  be  directly  over  the  end  of  the  stump  and 
not  at  the  side.  The  prime  desideratum  is  to  have  the  end  of  the  bone  well 
cushioned  with  soft  tissues  and  to  have  sufiicient  length  of  stump  for  the  appli- 
cation of  the  artificial  member.  The  osteoplastic  methods  of  amputating  are 
well  calculated  to  produce  good  useful  stumps,  but  are  more  suitable  in  cases 
when  disease  rather  than  trauma  necessitates  the  operation. 

Circular  Amputation. — Circular  amputation  is  the  basis  of  all  methods  of 
amputating. 

Example:  Amputation  of  the  arm.  Place  the  patient  on  his  back  with  the 
arm  well  out  from  the  table.  Apply  an  elastic  constrictor  around  the  limb 
near  the  shoulder. 

Step  I.— Let  the  first  assistant  pull  the  skin  of  the  arm  upwards  as  far  as 
possible.  Note  the  diameter  of  the  limb  at  the  point  chosen  for  section  of  the 
bone.     At  a  distance  below  this  point  equal  to  three-fourths  the  diameter  of 


II48 


AMPUTATION   OR   DISARTICULATION 


the  limb  make  an  incision  completely  around  the  limb  through  the  skin  and 
down  to  the  deep  fascia.  Reflect  the  skin  and  superficial  fascia  upwards  for  a 
distance  of  i  to  i}'^  inches  (Fig.  141 1).  .\t  this  level  make  a  circular  incision 
through  all  the  remaining  soft  parts  to  the  bone.  J.  N.  Jackson  insists  that  it 
is  better  to  incise  the  deep  fascia  in  the  first  cut  and  to  reflect  it  along  with  the 
superficial  structures  from  the  muscles.  The  author  agrees  with  him  in  this  as 
the  resultant  stump  is  excellent. 

Step  2. — (a)  Make  a  circular  incision  through  the  periosteum  at  the  level 
of  the  muscular  wound.  Reflect  the  periosteum  from  the  bone  for  about  3^ 
to  ^i  inch  upwards  and  divide  the  bone  at  this  level.  A  long  oval  anterior 
periosteal  flap  is  as  efficient  and  is  more  easily  made.  The  reflected  periosteum 
forms  flaps  to  cover  the  sawed  surface  of  the  bone. 


Fig.  141 1. — Circular  amputation. 


(b)  Separate  the  muscles  from  the  bone  and  periosteum  up  to  a  point  about 
}^  to  ^  inch  above  that  chosen  for  section  of  the  bone.  At  this  level  divide 
the  periosteum  and  reflect  it  downwards.  Divide  the  bone  at  the  chosen  level. 
The  result  of  this  is  that  the  distal  end  of  the  bone  in  the  stump  is  bare. 
Hirsch  and  Bunge  find  that  the  absence  of  the  periosteum  tends  to  the  produc- 
tion of  a  non-tender  stump.  Bunge  for  the  same  purpose  scrapes  out  the 
marrow  near  the  divided  end  of  the  bone.  Experience  in  the  Russo-Japanese 
war  showed  the  benefit  of  the  Hirsch-Bunge  methods. 

Siep  3. — ^Look  for  vessels  in  their  normal  locations  and  tie  them.  The  main 
vessels  run  in  the  intermuscular  septa,  but  many  muscular  vessels  also  require 
attention.  Nerve  trunks  ought  to  be  pulled  out  of  their  sheaths  as  far  as 
possible  and  divided;  this  precaution  often  saves  much  after-pain.  Dean  Lewis 
finds  that  injection  of  60  per  cent,  alcohol  into  the  nerve  end  prevents  the  forma- 
tion of  painful  neuromata. 

Apply  hot  pads  to  the  wound.  Remove  the  elastic  constrictor.  Bit  by 
bit  remove  the  hot  pad  from  the  wound;  pick  up  with  forceps  any  bleeding 
vessels;  ligate  the  vessels.  Apply  to  the  wound  pads  wrung  out  of  hot  water 
until  the  oozing  stops. 

Step  4. — Obliterate  all  dead  spaces  by  means  of  buried  catgut  sutures  or  by 


FLAPS 


1 149 


relaxation  sutures.  Close  the  skin  wound  by  sutures  converting  the  circular 
into  a  transverse  wound.  If  it  is  impossible  to  obliterate  the  dead  spaces,  if 
oozing  is  expected  or  if  asepsis  is  not  sure,  provide  drainage  either  by  tube, 
rubber  tissue,  or  cigarette.     Apply  dressing  and  a  splint. 

Crede  (""Archiv  fur  klin.  Chir.,"  xlviii,  514)  advocates  the  abolition  of 
sutures  after  amputation.  In  place  of  them  he  uses  a  sort  of  capeline  bandage 
of  wide-meshed  gauze,  applied  directly  to  the  stump.  After  one  or  two  layers 
of  the  bandage  have  been  applied  it  is  easy  to  see,  through  them,  if  the  edges 
of  the  wound  are  in  correct  apposition  and  if  the  compression  exercised  by 
the  bandage  is  too  severe.     Outside  the  bandage  he  applies  the  usual  dressings. 

When,  owing  to  the  conical  shape  of  a  limb,  it  is  impossible  to  reflect  the 
tissues  upwards  to  a  sufficient  extent  through  the  circular  incision,  it  is  easy  to 


Fig.  1412. 


make  one  or  two  lateral  incisions  through  the  soft  parts  and  so  facilitate  the 
work  (Fig.  141 2).  If,  instead  of  making  the  original  circular  incision  exactly 
transverse,  it  is  made  oblique,  the  result  is  an  oval  incision  or  practically  an 
amputation  by  a  single  flap  and  the  resultant  scar  is  not  over  the  middle  of 
the  stump.  Thus  we  have  the  racquet  incision  and  amputation  by  two  equal 
flaps.  By  means  of  lateral  longitudinal  incisions  (Fig.  141 2)  the  oval  amputa- 
tion may  be  converted  into  one  having  unequal  flaps. 

When  the  surgeon  desires  to  amputate  by  the  flap  method  he  of  course 
would  never  dream  of  making  the  flaps  in  the  indirect  method  described  above, 
but  would  trace  them  out  directly  and  fashion  them  either  by  cutting  first 
through  the  skin  and  then  through  the  musculature  or  by  transfixion. 

Amputation  by  transfixion  is  performed  as  follows. 

Example,  amputation  of  the  lower  third  of  the  thigh: 

Bring  the  patient  so  as  to  rest  with  his  buttocks  on  the  lower  edge  of  the 
table.  Have  an  assistant  hold  the  limb  well  free  from  the  table.  Apply  the 
elastic  constrictor  after  elevating  the  limb  to  render  it  anaemic. 

Step  I. — Retract  the  skin  upwards.  At  the  middle  of  one  side  of  the  thigh 
opposite  the  point  where  the  bone  is  to  be  divided,  pass  a  long  amputating 
knife  through  the  limb  immediately  in  front  of  the  femur  and  make  its  point 
emerge  through  the  skin  at  a  place  directly  opposite  the  point  of  insertion 


II50 


AMPUTATION    OR    DISARTICULATION 


Fig.  1413. — Amputation  by  transfixion.     {Burghard.) 


Fig.  1414. — Amputation  by  lateral  skin  flaps.     (Farabeuf.) 


AMPUTATION    LEG 


II^I 


(Fig.  1413).  Cut  downwards  and  forwards  so  as  to  make  a  flap  of  sufficient 
length  and  thickness. 

Step.  2. — Through  the  original  wound  once  more  pass  the  knife,  but  make 
it  go  behind  the  bone.  Cut  downwards  and  backwards  so  as  to  make  a  posterior 
flap  of  sufficient  length  and  thickness. 

Step  3. — Retract  the  soft  parts  for  a  short  distance  up  the  femui.  Make 
a  circular  incision  so  as  to  bare  the  bone  at  the  site  where  it  is  to  be  divided. 
Divide  the  bone  with  a  saw. 

Step  4. — Attend  to  hemostasis.     Close  the  wound  as  already  described. 

How  long  ought  the  flaps  to  be?  They  ought  to 
be  long  enough  to  cover  the  end  of  the  bone  with- 
out tension,  for  this  purpose  the  length  of  the  com- 
bined flaps  should  be  equal  to  i^^  times  the  diame- 
ter of  the  limb  at  the  point  of  bone  section. 

A  combination  of  methods  is  sometimes  useful, 
e.g.,  the  skin  and  superficial  fascia  may  be  fashioned 
into  flaps  and  the  deep  structures  divided  in  the  cir- 
cular fashion. 

Example. — Amputation  of  the  leg:  Support  the 
leg  free  from  the  table.     Apply  the  elastic  constrictor. 

Step  I. — Witli  a  scalpel  trace  out  a  flap  on  the 
inner  side  of  the  leg.  The  incision  outlining  the  flap 
begins  in  the  middle  line  in  front  and  ends  at  a  cor- 
responding point  behind  after  running  a  horseshoe- 
shaped  course  (Fig.  1414).  Beginning  and  ending 
at  the  same  points  trace  out  an  indentical  flap  on 
the  outer  side  of  the  leg.  Reflect  these  flaps,  con- 
sisting of  skin  and  superficial  fascia,  upwards  until 
their  bases  are  reached.  If  the  fascia  lata  is  included 
in  the  skin  flap  the  resulting  stump  is  liable  to  be 
more  satisfactory. 

Step  2.- — ^Make   a    circular   incision    through    the 
muscles  to  the  bone  (Fig.  141 5).     It  is  well  to  make        Fig.   141 5.— Circular  di- 
the  cut  through  the  muscles  posterior  to  the  bone  at  Y^sion    of    the    muscles. 

,  111  111,  .  1       {Farabeuf.) 

a  lower  level  than  that  through  the  anterior  muscles 

so  as  to  allow  for  their  greatest  retraction.  Divide  the  interosseous  ligament 
and  the  periosteum. 

Step  3.- — Divide  the  bones  with  a  saw.  Remove  rather  more  of  the  fibula 
than  of  the  tibia.  With  a  saw  or  bone-cutting  forceps  remove  the  sharp  angle 
formed  by  the  crest  of  the  tibia.  (Treat  the  periosteum  in  the  manner  described 
in  circular  amputation.) 

Step  4. — Attend  to  hemostasis.     Close  the  wound,  etc. 

In  cases  of  injury  the  surgeon  may  be  compelled  to  combine  various  methods 
to  suit  the  case.  For  example:  The  tibia  and  fibula  are  badly  comminuted 
up  to  a  point  about  6  inches  below  the  knee;  the  skin,  muscles,  vessels,  etc.,  are 
badly  lacerated  and  contused  to  the  same  level  on  the  outer  side  of  the  leg,  the 
soft  parts  on  the  inner  side  of  the  leg  are  more  or  less  intact.     The  injury  is 


1 1  52  AMPUTATION    OR   DISARTICULATION 

sufficient  to  demand  amputation.  There  is  ample  tissue  to  cover  the  stump  if 
amputation  is  performed  below  the  knee,  but  none  of  the  typical  operations  are 
calculated  to  utilize  the  material  present.  In  our  example  the  surgeon  makes 
a  long  flap  from  the  structures  on  the  inner  and  posterior  sides  of  the  leg  and 
gets  a  good  result.  Much  may  be  done  by  ingenuity  in  obtaining  viable  flaps, 
to  save  a  very  useful  portion  of  a  limb  which  would  otherwise  be  sacrificed. 

In  the  pre-anesthetic  days  when  haste  was  absolutely  necessary  flap  amputa- 
tions were  especially  favored  as  they  could  be  speedily  accomplished  by  trans- 
fixing the  limb  with  a  very  long  knife  and  cutting  from  within  outwards.  To- 
day any  limb  may  be  amputated  by  means  of  a  scalpel  (preferably  with  a  blade 

2  to  3  inches  long)  and  any  cross-cut  saw,  plus, 
of  course,  the  usual  equipment  of  scissors,  for- 
ceps, etc.  Liston's  bone  forceps  or  a  rongeur 
forceps  are  useful  for  trimming  the  roughnesses 
from  the  bone  stump. 

A  lion- jawed  forceps  is  useful  for  steady- 
ing the  end  of  the  bone  while  an  additional 
slice  is  being  sawed  off,  if  the  line  of  section 
was  made  too  low. 

Some    surgeons,    instead    of    dividing    the 

,     „  .         ,  bone  after  section  of  the  soft  parts  has  been 

rig.    1410. — Retraction    of  mus- 
cles with  three-tailed  bandage  dur-   completed,  expose  the  bone  at  the  chosen  place 
ing    bone-section.     (Esmarch    and  ^y  a  longitudinal  incision,  separate  it  from 
Kowalzig.)  .  "^  .....         .f,         ,., 

its  surroundmgs,  divide  it  with  the  chisel  or 

Gigli  wire  saw,  and  then  complete  the  section  of  the  soft  parts. 

When  amputation  is  being  performed  through  the  leg  or  forearm  it  is  not 
always  easy  to  retract  the  soft  parts  out  of  danger  from  injury  by  the  saw. 
Special  metal  retractors  have  been  devised  for  this  purpose,  but  a  three-tailed 
bandage  suffices  (Fig.  14 16). 

It  would  be  useless  and  wearisome  to  describe  all  the  methods  of  ordinary 
amputation. 

SPECIAL  AMPUTATIONS 

Upper  Extremity.— Amputation  of  the  Fingers. — Except  when  a  sym- 
metrical hand  is  more  desirable  to  the  patient  than  a  useful  one,  the  absolute 
rule  must  be  to  preserve  as  much  stump  as  possible  as  long  as  that  stump  is 
provided  with  tendons. 

Disarticulation  of  Distal  Phalanx. — Flex  the  phalanx  strongly.  Make 
a  transverse  incision  on  the  back  of  the  finger  into  the  joint  (Fig.  141 7).  This 
severs  the  insertion  of  the  extensors.  Divide  the  lateral  ligaments.  From 
each  end  of  the  transverse  incision  make  lateral  incisions  down  to  the  bone  of 
the  phalanx  to  be  removed.  Separate  the  phalanx  from  the  soft  parts  on  its 
palmar  side  (Fig.  141 8)  until  sufficient  of  the  soft  parts  has  been  separated 
to  cover  stump.  Divide  the  palmar  flap  transversely  and  if  necessary  trim 
it.  Attend  to  hemostasis.  Close  the  wound  with  sutures.  The  resulting 
scar  is  dorsal. 


AMPUTATION   FINGER 


II53 


Disarticulation  of  Middle  Phalanx.^ — Identical  with  the  preceding. 

Amputation  through  the  proximal  phalanx  is  a  good  operation,  provided 
that  the  divided  tendons  are  sutured  to  the  contiguous  theca  (J.  D.  Bryant). 
For  division  of  the  bone  of  the  phalanx  Gigli's  wire  saw  is  preferable  to  bone- 
cutting  forceps  as  the  latter  causes  splintering. 


Fig.  141 7.  Fig.  1418. 

Figs.  141 7  and  141S. — Amputation  of  finger. 


Fig.  1 419. — {Koclier.) 


Fig.  1420. — (Veau.) 


In  amputating  for  injury  remember  that  any  method  is  good  which  provides 
a  well-covered  useful  stump. 

Disarticulation  at  the  Phalango -metacarpal  or  at  the  Metacarpo-carpal 
Joints. — Figures  1419,  1420,  1421,  1422,  1423,  1424,   1425,  1426,  suflSiciently 
explain  these  operations.     Note  that  none  of  the  longitudinal  incisions  are 
made  in  the  palm. 
73 


II54 


AMPUTATION    OR   DISARTICULATION 


After  metacarpo-phalangeal  disarticulation  the  resultant  stump  is  liable 
to  be  so  prominent  as  to  interfere  with  the  patient  carrying  out  handiwork,  a 


Fig.  1421. — (Veau.) 


Fig.  1422. — {Veau.) 


serious  matter  to  certain  classes  of  mechanics.     Figure  1420  shows  how  section 
of  the  distal  end  of  the  metacarpus  overcomes  this  very  real  disability. 

"WTien  removing  the  metacarpus  of  the  thumb  or  of  the  httle  finger  it  is 
of   much  importance  to  preserve  intact  the  short  muscles  of  the  thenar  and 


AMPUTATION    WRIST 


IIS5 


hypothenar  eminences,  because  by  so  doing  a  very  useful  and  movable  stump 
is  obtained,  especially  if  the  bone  is  removed  subperiosteally. 

In  disarticulating  a  finger,  with  or  without  its  metacarpal  bone,  the  trans- 
verse incision  follows  exactly  the  line  of  the  web  of  the  fingers;  incisions  must 
not  be  made  higher  up  in  the  palm"  (Kocher). 


•■^^j^^^gf^^^^^i 


Fig.  1423. — {Veau^ 


Fig.  1424. 
{Esmarch  and  Kowalzig.) 


Fig.  1425. 
{Esmarch  and  Kowalzig.) 


Fig.  1426. 
{Esmarch  and  Kowalzig.) 


Amputation  at,  or  Disarticulation  of  the  Wrist. — Do  not  make  a  typical 
amputation  here  if  it  is  at  all  possible  to  save  a  portion  of  the  hand  or  a  movable 
finger. 

Kocher  recommends  an  obliquely  circular  (oval)  incision  so  as  to  form  a 
palmar  flap  (Figs.  1427-1428).  Figures  1429-1430  show  a  method  named 
after  various  surgeons  (Poupart,  Dubrueil,  v.  Walther). 


1 1 56 


AMPUTATION'    OK    DISARTICULATION 


Amputation  through  the  Forearm  Requires  no  Special  Notice. 

Disarticulation  of  the  Elbow. 

(A)  Circular  Incision.— (i)  Make  a  circular  cut  through  the  skin  and 
superficial  fascia  about  2  inches  below  the  condyles  of  the  humerus.  Reflect 
the  skin  upwards  so  as  to  expose  the  joint. 

(2)  Strongly  extend  the  joint.  Open  the  joint  by  a  transverse  incision  in 
front.     Divide  the  lateral  ligaments. 


Fig.  1427.  Fig.  142? 

Figs.  1427  and  142S. — Kocher's  method. 


Fig.  1429. — (Esmarch  and  Kowahig.)     FiG.  1430. — {Esmarch  aiid  Kowahig.) 


(3)  Hyper-extend  the  joint  until  the  olecranon  projects  into  the  wound. 
Divide  the  tendon  of  the  triceps  at  the  tip  of  the  olecranon.  Attend  to  hemo- 
stasis.     Close  the  wound. 

(B)  Kocher's  Method. — (i)  Flex  the  elbow  to  an  angle  of  135°. 

(2)  Make  an  obUquely  circular  (oval)  incision  round  the  limb  (Fig.  1431). 
Anteriorly  the  incision  is  at  the  joint  level  {i.e.,  just  above  the  level  of  the 
head  of  the  radius),  posteriorly  it  is  a  hand's  breadth  below  the  tip  of  the 
olecranon. 


AMPUTATION    SHOULDER 


II57 


Estes  justly  criticises  this  incision  by  saying,  "the  soft  tissues  of  the  anterior 
surface  contract  very  markedly,  those  of  the  posterior  not  at  all  or  very  little, 
so  that  a  circular  incision  at  the  elbow  will  become  by  the  contraction  of  the 
tissues  an  oval  one  with  a  long  posterior  flap;  it  is  necessary  to  bear  this  fact 
in  mind  so  that  the  posterior  flap  may  be  made  sufficiently  long." 

(3)  Reflect  the  posterior  flap,  consisting  of  skin,  fascia  muscle  and  peri- 
osteum upwards  to  the  posterior  surface  of  the  humerus. 

(4)  Divide  the  ligaments.     Remove  the  limb. 

(5)  Close  the  wound  after  attending  to  hemostasis. 

(C)  Farabeuf' s  operation  is  similar  to  Kocher's  but  he  obtains  his  main 
flap  from  the  front  instead  of  from  behind. 

Amputation  of  the  Arm  Requires  no  Special  Com- 
ment. 

Amputation  at  the  Shoulder- joint  (Disarticulation). 
— Methods  of  attaining  hemostasis  before  dividing  the 
vessels : 

(a)  Pressure  by  finger  or  padded  key,  on  the  sub- 
clavian artery.  This  is  unsatisfactory  as  movements 
of  the  shoulder,  necessary  during  the  amputation,  are 
likely  to  interfere  with  its  success. 

(b)  An  elastic  constrictor  applied  above  Wyeth's 
pins,  introduced  as  in  Fig.  1432.  This  method  acts  ad- 
mirably. If  the  vessels  are  caught  in  forceps  before  the 
joint  is  disarticulated  it  is  always  efficacious. 
(c).  Preliminary  ligation  of  the  subclavian  artery  is 
valuable  in  case  of  large,  vascular  tumor  about  the  head 
of  the  humerus. 

If  the  surgeon  and  his  assistant  use  their  brains  as 
well  as  their  hands,  it  is  easy  to  control  hemorrhage  in 
the  course  of  the  operation.  A  glance  at  Fig.  1433 
shows  the  principal  arteries  which  will  be  encountered. 

(d)  Pass  an  elastic  constrictor  round  the  shoulder 
behind  or  proximal  to  the  coracoid  and  acromion  proc- 
esses. To  prevent  slipping,  pass  a  loop  of  ordinary  bandage  under  the  con- 
strictor and  have  an  assistant  pull  this  towards  the  opposite  shoulder.  This 
is  a  very  efficient  method. 

Jacobson  mentions  that  there  are  about  thirty-two  methods  for  disarticu- 
lating at  the  shoulder.  Only  a  few  types  will  be  described  here.  Remember 
that  when  there  is  much  laceration  of  the  shoulder  the  stump  may  be  covered 
by  any  available  viable  skin  and  give  a  good  result. 

Remember  also  that  it  is  imperative  when  amputating  for  malignant  dis- 
ease, to  sacrifice  too  much  rather  than  too  little,  and  that  if  all  the  tissues  which 
are  usually  employed  to  cover  the  stump  have  been  removed,  it  is  easy  to  ob- 
tain the  necessary  tissue  in  the  shape  of  flaps  taken  from  the  chest. 

Method  A. — Hold  the  arm  at  right  angles  to  the  chest. 

Step  I. — From  the  apex  of  the  axilla  make  a  4-inch  longitudinal  incision 


Fig.  1 43 1. — Kocher's 
amputation  at  elbow. 


II58 


AMPUTATION    OR    DISARTICULATION 


Fig.  1432. — (Wyeth.) 

Shoulder-joint  amputation.     Pins  and  rubber-tube  tourniquet  in  position. 


Anterior  circumfle 


Posterior  circumflei  » 


Muscular  braRCb 


Axillary  1. 


Fig.  1433. — {Deaver.) 


AMPUTATION    SHOULDER  I I 59 

down  the  arm  immediately  behind  the  anterior  wall  of  the  axilla  along  the 
inner  and  posterior  border  of  the  coraco-brachialis  (Fig.  1434).  Elevate  the 
pectoralis  major  and  under  it  divide  the  deep  fascia  so  as  to  expose  the  coraco- 
brachialis.  Pass  the  finger  between  the  coraco-brachialis  and  the  packet  of 
axillary  vessels  and  nerves. 

Separate  the  vessels  (artery  and  vein)  from  the  nerves  and  divide  them 
(the  vessels)  between  ligatures.  Pull  the  nerve  trunks  downwards  and  divide 
them  high  up. 

Step  2. — At  right  angles  to  the  original  incision  make  a  circular  cut  down 
to  the  bone  all  round  the  arm  at  the  level  of  the  insertion  of  the  deltoid.  Sepa- 
rate the  soft  parts  from  the  bone  up  to  its  head.     Disarticulate. 

Step  3. — Review  the  wound.  Trim  away  redundant  tissue.  Suture. 
Dress. 


Fig.  1434. — Amputation  at  shoulder. 

Method  B. — Spence's  operation  or  racket  method. 

Step  I. — ^Slightly  abduct  arm.  Rotate  humerus  outwards.  Beginning 
immediately  external  to  the  coracoid  process  make  an  incision  downwards 
to  the  insertion  of  the  pectoralis  major,  which  is  cut.  This  cut  divides  the 
clavicular  fibres  of  the  deltoid  and  the  pectoralis  major.  Continue  the  incision 
in  a  curve  round  the  outer  side  of  the  arm  to  the  posterior  fold  of  the  axilla. 
The  incision  penetrates  to  the  bone,  dividing  the  lower  part  of  the  deltoid. 

Step  2. — Make  a  similar  incision  round  the  inner  or  axillary  side  of  the  arm, 
but  only  divide  the  skin  and  superficial  fat.  This  inner  incision  does  not  reach 
such  a  low  level  as  the  outer  one. 

Step  3. — Separate  the  outer  flap  from  the  bone  and  joint.  Retract  the 
flap  upwards  and  backwards  together  with  the  trunk  of  the  posterior  circum- 
flex, thus  exposing  the  head  and  tuberosities  of  the  humerus. 

Step  4.- — Cutting  directly  on  the  tuberosities  and  head  of  the  humerus, 
divide  the  tendinous  insertions  of  the  capsular  muscles.  By  thorough  re- 
traction of  the  outer  flap  and  by  hugging  the  bone  with  the  knife  injury  to  the 
posterior  circumflex  artery  is  avoided;  this  is  important  as,  if  punctured,  this 
artery  is  not  easy  to  pick  up  with  forceps  and  its  obliteration  endangers  the 
nutrition  of  the  deltoid  and  skin  (Treves). 


ii6o 


AMPUTATION    OR   DISARTICULATION 


Step  5. — ^Let  the  assistant  who  is  holding  the  arm  so  manipulate  it  that  the 
head  of  the  humerus  is  thrust  upward  and  outward  to  project  well  above  the 
glenoid  cavity.  Grasp  the  head  of  the  bone  and  pull  it  outwards.  Hugging 
the  inner  side  of  the  bone,  cut  the  posterior  part  of  the  capsule.  The  arm  is 
now  connected  with  the  body  by  the  axillary  tissues  alone.  Let  the  assistant 
grasp  these  tissues  with  his  hand  so  as  to  control  the  vessels  they  contain. 
Instead  of  the  fingers  a  gastroenterostomy  clamp  may  be  used  for  this  purpose. 
Divide  the  axillary  vessels  along  the  line  marked  in  Step  2. 

Step  6. — Ligate  the  vessels.  Cut  the  a.xillary  nerves  short.  Close  the 
wound.  J.  Hutchinson,  Jr.,  advises  that  all  synovial  membrane  be  excised 
as  a  discharge  of  syno\nal  fluid  sometimes  delays  union. 

Method  C. — Amputation  by  Superior  and  Inferior  Flaps. — Bring  the  patient 
to  the  edge  of  the  table.     Raise  the  arm  enough  to  relax  the  deltoid. 

Step  I. — -Lift  the  deltoid  with  the  left  hand.  Pass  a  long,  narrow,  strong 
knife  from  a  point  just  below  the  coracoid  process  under  the  deltoid  and  close  to 

the  anatomical  neck  of  the  humerus,  to  emerge 
at  a  point  a  httle  below  the  most  prominent 
part  of  the  acromion.  (The  transfixion  may 
be  accomplished  in  the  reverse  direction  equally 
well.)  After  transfixing,  cut  downwards  and 
outwards  so  as  to  make  a  rounded  flap  well 
down  to  the  insertion  of  the  deltoid. 

Step  2. — Reflect  the  flap.  Expose  the  joint. 
Divide  the  capsule  by  cutting  on  the  head  of 
the  bone.  Vigorously  rotate  the  arm  outwards 
and  di\-ide  the  subscapularis  and  biceps.  Ro- 
tate the  arm  inwards  and  carry  it  across  the 
chest  so  as  to  expose  and  divide  the  muscles 
attached  to 
Step  3.- 
Divide  the 
humerus. 


Fig.  1435. — Control  of  vessels  in 
shoulder  amputation. 


the  great  tuberosity. 
-Dislocate   the  head  of   the  bone. 

capsule   behind   the   head   of   the 
Grasp    the    undivided    structures 


firmly  in  a  gastroenterostomy  clamp;  this  controls  the  a.xillary  vessels  (Fig. 
1435).  Slip  the  knife  behind  the  head  of  the  bone.  If  the  clamp  has  not 
been  applied  as  above,  have  the  assistant  grasp  the  soft  parts  to  be  divided 
behifid  the  knife.  Cut  along  the  shaft  of  the  humerus  and  make  an  inferior 
flap  half  the  length  of  the  superior.  The  rest  of  the  operation  is  the  same 
as  in  Method  B. 

Method  D. — ^Fumeax  Jordan's  Method. — Apply  an  elastic  constrictor  high 
up.  Divide  the  soft  parts  dowTi  to  the  bone,  as  in  circular  amputation,  3  to  4 
inches  below  the  axilla.  Secure  the  vessels.  Make  a  longitudinal  incision  along 
the  outer  and  posterior  aspect  of  the  limb  at  right  angles  to  the  circular  cut. 
Remove  the  bone.  This  method  is  capable  of  many  modifications  and  may  be 
carried  out  after  arthrotomy  has  shown  that  the  limb  cannot  be  saved.  The 
same  may  be  said  of  Spence's  operation. 

In  operations  for  malignant  disease  in  the  aged  or  in  the  presence  of  pro- 


AMPUTATION    SHOULDER 


I  l6l 


found  depression  or  shock,  Crile  blocks  the  nerve  trunks  and  operates  under 
regional  anesthesia. 

Crile's  Method  in  Shoulder  Disarticulation  (Problems  Relating  to  Surgical 
Operations,  Crile,  1901J: 

Step  I. — Under  infiltration  with  Yiq  per  cent,  cocaine  solution.  Make  an 
incision  along  the  outer  margin  of  the  sternomastoid  just  above  the  clavicle. 
Divide  the  deep  fascia. 

Step  2. — Retract  the  omo-hyoid  downwards,  the  anterior  margin  of  the 
trapezius  backwards,  the  posterior  margin  of  the  scalenus  anticus  forwards 


Fig.  1436. — Crile's  disarticulation  of  shoulder.     {Crile.) 


(Fig.  1436).  This  exposes  the  trunks  of  the  brachial  plexus  and  by  extending 
the  dissection  a  trifle  downwards  the  arching  subclavian  artery  is  seen.  When 
dissecting  look  out  for  small  nerve  twigs  in  the  connective  tissue  planes  or 
accompanying  blood-vessels.     Anesthetize  such  nerves  before  dividing  them. 

Step  3. — Inject  each  nerve  trunk  with  just  sufl5cient  cocaine  solution  (^-^  per 
cent.)  to  cause  a  localized  swelling.  The  injection  is  made  first  into  the  outer 
covering,  then  into  the  substance  of  the  trunk. 

This  "blocking"  causes  complete  loss  of  sensation  and  motion  in  the  parts 
supplied  by  the  brachial  plexus. 

Step  4. — Apply  Crile's  clamp  with  blades  protected  by  rubber  tubing,  to  the 
subclavian  artery. 

Step  5. — Amputate  by  one  or  other  of  the  methods  described.  Note  that 
cuts  on  the  outer  and  posterior  aspects  over  the  deltoid  should  be  made  low 
down  to  avoid  skin  supplied  by  the  cervical  plexus. 


Il62 


AMPUTATION    OR   DISARTICULATION 


Interscapulo-thoracic  Amputation. — J.  William  While  finds  that  the  mortal- 
ity after  this  operation  is  not  more  than  lo  per  cent.,  probably  6  per  cent.,  and 
that  about  20  per  cent,  of  the  patients  who  survive  operation  remain  well  after 
three  years.  The  indications  for  interscapulo-thoracic  amputation  are  (a) 
extensive  injury;  (b)  mahgnant  disease  of  the  humerus  or  shoulder-joint;  (c) 
Lund  has  done  this  operation  for  sarcoma  of  the  brachial  plexus  otherwise 
irremovable. 

Berger  ("Revue  de  Chir.,"  Oct.,  1898)  considers  that  disarticulation  at 
the  shoulder  does  not  give  suflScient  guarantee  against  recurrence  of  malignant 


Fig.  1437. — Interscapulo-thoracic  amputation. 
Photograph  taken  a  few  days  after  operation.     Note  the  numerous  scratches  and  shallow  incisions 
made  to  prevent  stagnation  of  fluids  in  the  flaps  which  were  under  considerable  tension.     As  shock  was 
severe  the  wound  was  hastily  closed  hence  the  imperfect  skin  coaptation.     Union  was  perfect  in  about 
three  weeks.     When  seen  three  years  later  the  patient  seemed  well. 


neoplasms  of  the  upper  end  of  the  humerus.  When  recurrence  takes  place 
after  disarticulation,  the  disease  propagates  itself  along  the  scapulo-humeral 
muscles.  Interscapulo-thoracic  amputation  removes  en  masse,  these  routes 
of  dissemination;  it  further  so  opens  the  axilla  as  to  discover  enlarged  glands 
which  would  otherwise  escape  detection. 

The  only  reservation  Berger  makes  to  the  above  doctrine  is  the  following: 
Some  relatively  benign  tumors  of  bone  do  exist  (giant-cell  sarcomata;  chon- 
dromata;  myxomata  perhaps)  and  recovery  may  follow  a  limited  resection, 
i.e.,  excision  of  the  tumor  itself.  To  justify  a  conservative  operation,  the  tumor 
must  be  clearly  circumscribed  and  encapsulated;  there  must  be  no  prolongation 
either  along  the  muscles  or  into  the  shoulder-joint;  microscopical  examination  of 
a  segment  of  the  tumor,  made  at  the  time  of  operation,  must  verify  the  diagnosis 
of  the  exact  nature  of  the  neoplasm. 


INTERSCAPULO-THORACIC   AMPUTATION  1 1 63 

Le  Conte's  Method.^ — ^Le  Conte  ("Congres  International  de  Medicine," 
1900)  gives  an  admirable  account  of  the  operation  as  performed  by  himself.  It 
is  as  follows: 

1.  The  incision  begins  over  the  sternal  end  of  the  clavicle,  is  carried  along  that 
bone  to  about  its  middle,  and  then  curved  downward  to  the  anterior  axillary 
fold.  The  skin  and  superficial  fascia  are  dissected  up,  exposing  well  the  inner 
two-thirds  of  the  clavicle. 

2.  The  clavicle  is  disarticulated  by  severing  its  attachments  to  the  sternum 
and  the  rhomboid  ligament;  the  clavicular  attachment  of  the  sterno-cleido- 
mastoid  muscle  is  cut  close  to  the  bone,  and  the  clavicular  portion  of  the  pec- 
toralis  major  is  separated  with  the  finger  from  the  costal  portion  of  the  muscle  up 
to  the  anterior  axillary  fold. 

3.  The  clavicle  is  now  pulled  upwards  and  forwards,  and  the  attachment  of 
the  subclavius  muscle  is  divided  at  the  first  rib.  The  pectoralis  minor  will 
now  be  well  exposed,  and  it  is  divided  and  the  coracoid  portion  reflected  upwards 
with  the  clavicle.  This  exposes  the  axilla  fully,  and  the  vessels  are  seen  travers- 
ing it  from  the  anterior  scalenus  muscle  down. 

4.  The  sheath  of  the  vessels  is  opened  and  the  vein  separated  from  the  under- 
lying artery.  Two  ligatures  are  passed,  about  i  inch  apart,  around  the  artery 
and  tied.  The  arm  is  then  held  up  to  empty  it  of  blood,  while  two  Hgatures  are 
passed  around  the  vein,  but  these  are  not  tied  until  the  arm  is  blanched.  This 
renders  the  use  of  an  Esmarch  bandage  unnecessary.  It  must  be  noted  that  the 
cephalic  vein  has  joined  the  axillary  below  these  ligatures,  or  else  a  separate 
ligature  of  that  vessel  is  required. 

5.  The  vessels  are  now  severed,  together  with  the  brachial  plexus  of  nerves 
and  the  costal  portion  of  the  pectoralis  major.  This  completes  the  division  of 
the  anterior  attachments  of  the  arm, 

6.  A  posterior  incision  is  now  carried  from  some  point  on  the  anterior  incision 
(as  near  the  tumor  as  it  is  deemed  advisable  to  go)  directly  backwards  and  down- 
wards to  the  inferior  angle  of  the  scapula  and  up  again  to  the  posterior  axillary 
fold.     The  skin  and  superficial  fascia  are  dissected  up  for  a  short  distance. 

7.  The  trapezius  is  severed  and  the  transversalis  colli  or  posterior  scapular 
artery  secured;  the  omo-hyoid  muscle  is  cut  and  the  supra-scapular  artery 
secured,  and  the  muscles  attached  to  the  inner  border  of  the  scapula  are  rapidly 
divided  close  to  the  bone.  Then,  the  serratus  magnus  and  latissimus  dorsi  are 
cut,  the  latter  at  the  posterior  axillary  fold.  The  arm  is  now  held  to  the  body 
by  the  skin  of  the  axilla  alone.  If  there  is  sufl&cient  flap  to  cover  the  wound, 
the  anterior  and  posterior  incisions  are  joined  through  the  axilla,  but  if  more  skin 
is  needed,  a  flap  may  be  raised  from  the  under  surface  of  the  arm.  The  wound 
is  then  closed  with  suitable  provision  for  drainage. 

Figure  1437  shows  the  appearance  of  the  wound  in  a  patient  operated  on  by 
the  author. 

Figures  1438  and  1439  show  how  Lynn  Thomas  uses  his  forceps-tourniquet 
in  interscapulo-thoracic  amputation. 

Crile's  Method. — Under  general  anesthesia  make  an  incision  over  the 
clavicle  and  resect  the  inner  half  of  the  bone  so  as  to  expose  the  subclavian  vein 


1 1 64  AMPUTATION    OR   DISARTICULATION 

and  the  trunks  of  the  brachial  plexus.  Inject  each  nerve  trunk  with  a  }i  per 
cent,  solution  of  cocaine  or  eucaine;  this  "blocks"  them.  Divide  the  brachial 
plexus.  Ligate  the  subclavian  artery  and  vein.  During  the  rest  of  the  opera- 
tion (already  sufficiently  described)  "  the  amount  of  shock  will  be  limited  to  what 
would  be  produced  by  making  the  incision  through  the  structures  supplied  by 
the  nerves  from  the  cervical  plexus,  which  is  almost  nil.'' 


Fig.   143S. — Lynn  Thomas'  forceps-tourniquet.     {Thomas.) 


Le  Conte  recommends  the  disarticulation  of  the  sternal  end  of  the  clavicle 
in  preference  to  a  resection  of  the  middle  portion  of  that  bone,  for  the  following 

reasons: 

1.  It  gives  the  widest  and  fullest  possible  exposure  of  the  vessels  and  de- 
creases the  accidents  of  ligation  to  a  minimum. 

2.  It  insures  the  securing  of  the  artery  first,  before  the  vein  is  tied,  enabling 
one  to  elevate  the  arm  and  make  a  practically  bloodless  amputation. 


CINEMATIC    AMPUTATIONS 


Il6: 


3.  The  disarticulation  is  simpler  and  quicker  than  resection  of  the  bone,  and 
there  is  less  danger  of  wounding  important  vessels. 

4.  The  suprascapular  and  posterior  scapular  vessels,  the  only  other  vessels 
that  can  bleed,  are  easily  picked  up  before  being  cut. 

5.  In  malignant  growths,  where  the  outer  end  of  the  clavicle  is  involved, 
there  is  more  hope  of  a  radical  cure  if  the  entire  bone  with  its  periosteum  is 
removed. 


Fig.   1439.— Lynn  Thomas'  forceps-tourniquet.     {Thomas J) 


0.  It  removes  everything  in  one  piece,  a  more  surgical  procedure  when 
dealing  with  malignant  growths. 

Cinematic  or  Cineplastic  Amputations. — ^Vanghetti's  Amputation. — Vang- 
hetti's  experiments  on  birds  show  that  if  a  tendon  or  muscle  is  separated  from 
its  insertion  and  some  inches  of  its  distal  end  are  mobilized  and  covered  with 
skin,  the  muscle  retains  its  power  of  voluntary  contraction.  If  the  distal  end 
of  the  tendon  is  formed  into  a  loop  or  into  a  knob  (e.g.,  by  being  tied  as  a  knot 
and  is  covered  with  skin,  it  is  possible  to  attach  a  hook  or  a  string  to  it,  and 


ii66 


AMPUTATION    OR   DISARTICULATION 


by  means  of  that  hook  or  siring  to  convey  the  power,  provided  by  the  muscle 
contracting,  to  a  proper  artificial  limb.  These  were  remarkable  experiments  to 
be  made  by  a  country  practitioner  without  hospital  connections.  Vanghetti 
has  published  a  small  volume  "  Vilalizzazione  dellc  Membra  Artificiali"  (Hoepli 
Milan,  1916)  on  the  subject  of  cinematic  ami)utalions. 

The  method  of  application  devised  by  Vanghetti  is  somewhat  as  follows: 
In  performing  an  amputation  preserve  as  great  a  length  as  possible  of  any  healthy 
tendons  or  muscles  distal  to  the  Hne  of  section  of  the  bone.  Form  the  ends  of 
these  tendons  (a)  into  loops  either  by  suturing  the  extremities  of  two  tendons 
together,  or  by  folding  the  extremity  of  one  tendon  on  itself 
and  fixing  it  as  a  loop  by  means  of  a  suture;  (b)  into  a  knob 
by  tying  the  end  of  the  tendon  into  a  knot.  In  the  case  of 
a  muscle  or  even  a  tendon,  instead  of  being  divided,  a  por- 
tion of  its  bony  insertion  may  be  chiselled  off  its  bed  and 
left  attached  to  the  tendon  or  muscle  as  a  knob.  Envelop 
the  mobilized  tendon  or  muscle  (including  the  loop  or  knob 
at  its  end)  with  a  flap  of  skin.  If  a  loop  is  used  perforate  the 
skin  so  as  to  pass  a  smooth  hook  (as  an  ear-ring)  through  the 
loop  and  by  means  of  this  hook  and  a  proper  splint  keep  up 
enough  tension  on  the  tendon  to  prevent  secondary  contrac- 
tion. If  the  tendon  is  fashioned  as  a  knob  it  is  unnecessary 
to  perforate  the  skin,  a  padded  ring  may  be  made  to  lie 
around  the  skin-covered  tendon  proximal  to  the  knob,  and 
by  means  of  this  ring  the  necessary  tension  may  be  kept  up. 
De  Francesco  ("Archiv  fiir  klin.  Chir.,"  Ixxxvii,  p.  571) 
carried  out  Vanghetti 's  ideas  in  the  case  of  a  man  who  had 
undergone  amputation  in  the  middle  of  the  forearm  five  years 
previously.  The  muscles  in  the  stump  retained  their  electric 
irritability  and  could  be  contracted  voluntarily. 
De  Francesco  made  a  longitudinal  incision  on  each  side  of  the  forearm  and 
through  them  exposed  the  radius  and  ulna  from  a  point  about  ^  inch  proxi- 
mal to  their  distal  ends,  upwards  for  about  2  inches  (5  cm.)  (Fig.  1440).  He 
divided  the  bones  ^  inch  from  their  distal  end  and  at  points  2  inches  higher, 
thus  removing  about  i  inch  of  each  bone.  When  healing  took  place,  a  padded 
ring  was  applied  around  the  stump  just  above  the  two  fragments  of  radius 
and  ulna,  and  after  a  little  practice  the  patient  was  able  to  voluntarily  flex  the 
fingers  of  an  artificial  hand  by  means  of  cords  attached  to  the  padded  ring. 
The  power  was  obtained  by  the  flexors  and  extensors  pulling  upward  the  knobby 
stump  and  with  it  the  padded  ring  (Fig.  1441  shows  De  Francesco's  patient 
enjoying  himself). 

Vredene  (Roussky  Bratch.,  ref.  "  Journ.  de  Chir.,"  i.  No.  2)  used  Vanghetti's 
method  successfully  in  a  case  of  amputation  of  the  hand  just  in  front  of  the 
carpus.  The  superficial  flexor  tendons  of  the  hand,  exposed  through  an  incision 
in  the  lower  part  of  the  forearm,  were  divided  transversely  at  the  lower  part  of 
the  wound,  and  their  proximal  stumps  sutured  to  the  deep  flexors  (Fig.  1442). 
The  tendon  loop  can  readily  be  enveloped  in  skin  flaps,  the  pedicles  of  which 
may  be  divided  after  the  lapse  of  about  two  weeks.     In  Vredene's  case  exercises 


Fig.  1440. — Cine 
malic  apparatus. 


CINEMATIC    AMPUTATIONS 


I167 


were  begun  after  about  one  month,  and  the  tendon  loop  was  able  to  exert  a  pull 
of  12  pounds.     An  artilkial  hand  was  constructed  and  its  movable  thumb,  middle 


Fig.  1 441. — Result  of  cinematic  amputation.     (Z)e  Francesco.) 


Rezor  siiblimis 


Skin  flap  sur- 
roundinff  flexor 
sublimis 

Flex,  suhlimis 
united  to 
Flexor  prdfundus 

Distal  stumps  of 
flexor  sublimis 


Fig.  1442. — Cinematic  amputation. 


Fig.  1443. — (Ashhiirst  Annals  Surg.) 


and  index  fingers  could  be  flexed  by  means  of  the  tendon  loop  to  which  they  were 
connected  by  a  metallic  hook.  The  patient  was  able  to  seize  and  hold  various 
objects. 


ii68 


AMPUTATION    OR    DISARTICULATION 


In  the  above  description  the  tendons  of  the  flexor  profundus  are  not  divided, 
but  probably  their  division  below  their  union  with  the  flexor  sublimis  would 
give  greater  mobility.  Ashhurst  (Annals  Surg.,  Dec.,  1914)  operates  on  the 
arm  as  follows: 

Step  I. — Reflect  a  longitudinal  skin  flap  as  long  as  the  diameter  of  the  limb 
and  about  one  inch  wide,  with  its  base  at  the  proposed  line  of  section  of  the 
bone.  Ligate  and  divide  the  brachial  vessels  just  above  the  site  of  bone 
section.     Divide  the  nerves  at  the  same  level  or  higher,  Fig.  1443. 

Step  2. — Make  a  longitudinal  incision  on  the  outer  side  of  the  arm  between 
the  flexor  and  extensor  muscles  and  raise  these  muscles  from  the  bone  along 
with  the  skin  from  the  line  of  bone  section  down  as  far  as  possible.  Now 
divide  the  musculo-spiral  nerve  if  it  was  not  accessible  from  the  first  incision. 
Step  3. — ^Divide  the  soft  parts  circularly  down  to  the  bone  at  the  lowest 
limit  of  healthy  tissue.  Thus  two  musculo-cutaneous  flaps  are  formed  and 
reflected  (one  flexor  flap,  and  one  extensor  flapj. 


Fig.  1444. — (Ashhurst,  Annals  Surg.) 


Fig.   1445. — (Ashhurst,  Annals  Surg.) 


Step  4.— Divide  the  bone  at  the  selected  point  and  remove  the  limb. 

Step  5. — Make  a  small  transverse  incision  through  the  skin  on  each  side 
of  the  upper  end  of  the  external  longitudinal  incision.  This  permits  the  skin 
of  each  flap  to  be  wrapped  round  the  corresponding  muscles. 

Step  6. — Cover  the  end  of  the  bone  with  the  skin  flap  made  in  Step  i.  Sut- 
ure the  end  of  the  flexors  to  the  end  of  the  extensors  and  suture  the  end  of  the 
skin  surrounding  the  flexors  to  that  surrounding  the  extensors.  Pass  a  rubber 
tube  through  the  loop  thus  formed.     (Figs.  1444  and  1445.) 

Cinematic  amputations  have  lost  much  of  their  desirabihty  since  Games 
devised  his  artificial  arms,  by  the  use  of  which  the  author  has  seen  a  man,  who 
had  lost  both  arms,  pick  coins  off  the  floor,  light  his  cigar  with  matches,  shave 
himself  and  carry  a  heavy  suit-case.  One  patient  whose  arm  was  amputated 
above  the  elbow  by  the  author,  drives  his  own  electric  motor  car. 

Krukemberg  in  1918  described  an  amputation  of  the  forearm  in  which  the 
radius  and  ulna  were  separated  for  "^i  of  their  length  and  thus  formed  a  grotesque 
pincers.  Unfortunately  the  eflScacy  of  the  "pincers"  was  low  because  while 
there  was   sufficient   muscular  power   to   strongly   separate   the  jaws,   there 


LOWER    EXTREMITY  I169 

was  too  much  destruction  of  the  muscles  cai)al:)le  of  approximating  the  jaws. 
The  grotesqueness  of  the  stump  tempted  the  patient  to  conceal  rather  than  use 
the  "pincers," 

Putti  and  Lambert  (Tuffier,  Bui.  et  Mem.  de  la  Soc.  dc  Chir.,  I'aris,  Feb.  10, 
1920)  modified  Krukemberg's  operation  as  follows: 

From  a  point  about  8  or  lo  cm.  (s/i,  to  4  in.)  above  the  end  of  the  stump 
and  well  to  the  radial  side  of  the  mid-line,  make  a  longitudinal  incision  on  the 
anterior'  surface  of  the  forearm  through  the  skin  downwards  to  the  distal  ex- 
tremity of  the  stump.  Make  a  similar  incision  on  the  posterior  surface  of  the 
forearm,  but  let  this  incision  lie  well  to  the  ulnar  side  of  the  median  line  of  the 
limb.  Join  the  distal  ends  of  these  two  incisions  by  a  transverse  cut  crossing 
the  extremity  of  the  stump.  (It  is  assumed  that  the  operation  is  secondary 
to  an  old  amputation.)  Reflect  the  skin  sufficiently  to  form  two  iJaps  exactly 
as  in  Didot's  operation  for  syndactylism  (p.  11 28).  If  the  ends  of  the  radius 
and  ulna  are  united  by  bone,  excise  the  osseous  union. 

With  retractors  pull  the  radius  and  ulna  apart.  Along  anatomic  Hnes 
divide  longitudinally  the  deep  and  superficial  layers  of  muscles  and  tendons. 
Divide  the  pronator  quadratus  and  the  interosseous  membrane.  The  flexor 
carpi  radialis  and  parts  of  the  flexors  are  thus  left  attached  to  the  radial  "finger" 
of  the  stump,  while  the  remainder  of  the  flexors  belong  to  the  ulnar  "finger." 
It  is  necessary  to  cover  the  radial  and  ulnar  fingers  or  stumps  separately  with 
skin;  to  render  this  possible  cut  away  all  superfluous  muscle  very  freely,  as  the 
only  difliculty  in  the  operation  is  the  obtaining  of  enough  skin.  In  one  case 
Lambret  was  obliged  to  insert  an  Italian  graft  at  the  inter-radio-ulnar  commis- 
sure to  insure  the  greatest  possible  mobility. 

The  result  of  the  operation  is  a  bifid  stump,  the  radial  branch  of  which  is 
mobile.  With  the  stump  the  patient  is  able  "  to  hold  a  spoon,  a  pencil,  as  well 
as  to  select  and  extract  any  object  from  his  pocket."  The  main  advantage  of 
such  a  prehensile  stump  over  any  artificial  hand  consists  in  its  sense  of  touch. 
If  an  artificial  hand  is  worn,  rotation  is  easy. 

AMPUTATIONS  AND  DISARTICULATIONS  OF  THE  LOWER 

EXTREMITY 

Amputations  and  Disarticulations  of  the  Toes.— These  are  carried  out  ex- 
actly as  in  the  case  of  the  fingers.  When  the  great  toe  is  disarticulated  at  the 
metatarso-phalangeal  joint,  remember  that  the  great  size  of  the  head  of  the 
metatarsal  bone  requires  large  flaps  to  cover  it  and  that  in  the  presence  of 
articular  suppuration  the  sesamoid  bones  ought  to  be  removed. 

Konig  writes:  "When  operating  for  injury  or  disease  of  the  anterior  part 
of  the  foot,  and  it  is  in  any  way  possible  to  retain  the  tarso-metatarsal 
articulations,  limit  operation  to  amputation  through  the  metatarsus.  A  suffi- 
ciency of  material  must  be  present  since  the  stump  must  be  covered  by  a 
plantar  flap  and  the  scar  must  be  dorsal.  The  amputation  is  performed 
exactly  like  Lisfranc's  disarticulation  except  that  the  metatarsi  are  divided. 
We  have  often  remarked  that  too  great  conservatism  is  out  of  place  in  the 
foot.     Thus  it  is  questionable  if  it  makes   much  difference  to  the  patient 


I  I/O 


AMPUTATION"    OR   DISARTICULATION 


whether  the  metatarsus  hallucis  is  amputated  or  exarticulated.  The  removal 
of  the  two  middle  metatarsi  makes  little  difference  to  the  patient,  but  trans- 
verse amputation  is  always  better  than  the  removal  of  three  metatarsi." 

Tarso-metatarsal  Disarticulation.— Lisfranc's  Amputation. — Step  i. — Put 
the  foot  in  a  position  of  plantar  flexion.  Note  the  base  of  the  first  and  of  the 
fifth  metatarsal  bone  (Fig.  1446).  On  the  dorsum  of  the  foot  make  the  incision 
ABC  down  to  the  bone  and  reflect  all  the  soft  parts  so  as  to  expose  the  tarso- 
metatarsal articulations  freely. 

Step  2. — Put  the  foot  in  a  position  of  dorsal  flexion.  On  the  sole  of  the  foot 
make  the  incision  ADC  and  reflect  all  the  soft  parts  in  one  long  plantar  flap 
until  the  articulations  are  exposed. 

Step  3. — Hold  the  foot  in  a  position  of  marked  plantar  flexion.  Retract 
both  flaps,  being  specially  careful  of  the  plantar  flap.  Carry  the  knife  (strong 
and  narrow-bladed)  round  the  base  of  the  fifth  metatarsal, 
then  cut  forward  and  inward  to  open  the  joints  of  the  three 
outer  metatarsals.  Next  open  the  joint  between  the  first 
metatarsal  and  the  internal  cuneiform.  Holding  the  knife 
firmly,  insert  it  between  the  first  two  metatarsals  and  carry 
it  backwards  and  forwards  in  the  long  axis  of  the  limb 
(Fig.  1447).  Do  the  same  between  the  second  and  third 
metatarsals.  Open  the  joint  between  the  second  metatarsal 
and  the  middle  cuneiform.  Complete  the  disarticulation. 
Jacobson  wisely  writes:  "The  method  by  disarticulation 
may  be  a  useful  test  of  a  candidate's  knowledge  and  skill  at 
an  examination.  In  practice,  sawing  through  the  meta- 
tarsals just  below  their  bases  may  nearly  always  be  sub- 
stituted, as  giving  equally  good  results  with  a  great  saving 
of  time  and  trouble." 

Step  4. — Attend  to  hemostasis.     Close  the  wound  with 
sutures.     Dress. 

The  great  objection  to  Lisfranc's  operation  is  that  the 
projection  of  the  internal  cuneiform  and  scaphoid  bones 
makes  a  stump  which  is  likely  to  be  painful. 

Hey's  Amputation. — The  author  has  no  experience  with  the  operation,  but 
Estes  recommends  it  as  much  preferable  to  Lisfranc's.  Barker  thus  describes 
Hey's  amputation:  "Position  of  Patient:  Supine,  with  the  legs  brought  well 
over  the  end  of  the  table,  the  affected  limb  being  flexed,  and  resting  on  its  heel  on 
the  edge  of  the  table.  The  surgeon  stands  facing  the  patient;  an  assistant 
steadies  the  flexed  limb,  on  the  outside  of  which  he  stands  facing  the  operator. 
Landmarks  for  Incision  and  Operation. — The  bases  of  the  first  and  fifth 
metatarsal  bones  are  the  guide  for  the  first  incision,  which  passes  with  a  good 
downward  curve  from  one  to  the  other,  across  the  dorsum  of  the  foot,  forming  a 
flap  which  should  reach  well  over  the  metatarsus  and  contain  all  the  soft  tissues. 
WTien  this  is  turned  up  the  operator  separates  the  metatarsus  from  the  tarsus  by 
forcibly  bearing  upon  the  former  while  the  heel  rests  on  the  table,  and  dividing 
the  tense  ligaments,  remembering  the  deep  setting  of  the  second  metatarsal  bone. 
The  knife  is  placed  transversely  behind  the  metatarsus  as  the  latter  is  drawn 


Fig.  1446. — Lisfranc's 
amputation. 


SYME  S    AMPUTATION 


II71 


forward  by  the  surgeon's  left  thumb,  and  is  made  to  cut  downward  to  the  roots 
of  the  toes.  The  long  plantar  flap  thus  formed  is  now  cut  across,  either  from 
side  to  side  or  by  transfixion  from  its  centre,  first  on  one  side,  then  on  the  other, 
the  knife  being  held  vertically  in  each  case.  It  should  be  a  little  longer  on  its 
inner  than  on  its  outer  side.  Some  operators  prefer  to  fashion  the  plantar  flap 
before  separating  the  bones.    Others  again  recommend  cutting  through  the 


Fig.  1447. — Lisfranc's  amputation.     {Burghard.) 


base  of  the  second  metatarsal  bone  with  a  bone-forceps  to  avoid  the  trouble  of 
disarticulating  it;  or,  again,  division  of  all  the  bones  straight  across  with  a  saw 
just  below  their  bases.  In  amputation  for  injury  the  latter  method  gives  ex- 
cellent results,  where  the  treatment  is  distinctly  aseptic." 

Sjnne's  Amputation. — Step  i. — Make  an  incision  down  to  the  bone  from 
the  tip  of  the  external  malleolus  to  a  point  3^^  inch  below  the  internal  malleolus. 
This  incision  goes  across  the  sole,  but  its  centre  is  slightly  curved  toward  the 
heel  (Fig.  1448).  Unite  the  upper  ends  of  this  incision  by  a  cut  straight  across 
the  front  of  the  ankle-joint. 

Step  2. — Bend  the  foot  downwards  so  as  to  put  much  tension  on  the  lateral 


II72 


AMPUTATION    OR    DISARTICULATION 


ligaments  of  the  ankle.  Open  the  joint  freely  and  divide  the  lateral  ligaments. 
When  cutting  the  soft  parts  on  the  inner  side  of  the  ankle  be  careful  to  cut  the 
posterior  tibial  artery  low  down  because  of  its  importance  in  nourishing  the  flaps. 


Fig.  1448. — Syme"s  amputation.     {Farabeuf.) 


ec  a 


e.p.ot 

Fig.  1449. — Syme's  amputation,     {y/ahham^ 
/,  Fibula;  /.  tibia;  t.a,  tibialis  anticus;  dh,  ext.  long,  hallucis;  a.i.a,  ant.  tib.  art.;  a.t.t.  ant.  tib.  vein;  t.c.d.. 
ext.  com.  dig.;  f>n/.,  peroneus  ongus;  pnh.,  peroneus  brevis; /./.A.  flex.  long,  hallucis;  t.  ack,  t.  achiUis;  t.p., 
tib.  post;  f.l.d.,  flex.  long,  dig;  p.t.a.  post,  tib.  art.,  dividing  into  e.p.a.  and  i.p.a..  external  and  internal 
plantar  artery;  e.c.a.  and  i.v.a.,  ext.  and  int.  calcaneal  branches  forming  blood  supply  of  thick  heel-flap. 

Step  3. — By  bending  the  foot  more  and  more,  separate  the  surfaces  of  the 
ankle-joint  and  expose  the  tendo  Achillis.  Divide  the  tendo  AchiUis  close 
to  the  OS  calcis.     Dissect  the  heel  flap  from  the  os  calcis  from  above  downwards, 


Watson's  amputation  ii73 

leaving  the  flap  as  thick  as  possible  and  not  punctured.  In  children  the  epiphy- 
sis may  come  away  with  the  heel  llap  and  if  healthy  can  be  utilized.  Remove 
the  foot  (Fig.  1440). 

Step  4. — With  the- saw  remove  both  malleoli  and  with  them  a  very  thin  slice 
of  tibia.     As  an  alternative  remove  the  malleoli  alone  (Macleod). 

Step  5. — Trim  away  any  excess  of  tendons  or  other  tissue.  Attend  to  hemo- 
stasis.     Close  the  wound. 

Watson's  Amputation  ("Brit.  Journ.  Surg.,"  ii,  390. — Step  1. — With  a 
knife  mark  the  skin  at  the  following  points:  (a)  ]^i  inch  below  and  behind  the 
tip  of  the  internal  malleolus;  {b)  l^  inch  below  the  tip  of  the  external  malleolus; 
(r)  13^^  inches  distal  to  the  midpoint  of  a  line  joining  the  malleoh  anteriorly. 
Join  these  points  by  a  curving  incision  and  reflect  upwards  the  flap  as  far  as  the 
ankle-joint.  Divide  the  extensor  tendons  and  anterior  tibial  vessels.  Divide 
and  cut  short  the  anterior  tibial  and  musculo-cutaneous  nerves.  Open  the 
ankle-joint  and  forcibly  put  the  foot  in  the  equinus  position.  Cutting  close  to 
the  bone  divide  the  internal  lateral  ligament  and  the  anterior  and  middle  fasciculi 
of  the  external  lateral  ligament.  Pass  the  knife  between  the  astragalus  and  os 
calcis  and  divide  the  interosseous  ligament.  Open  the  astragalo-scaphoid  joint 
and  free  the  head  of  the  astragalus.  With  strong  forceps  twist  the  astragalus 
from  the  posterior  ligament  of  the  ankle  and  from  the  posterior  fasciculus  of  the 
external  lateral  ligament. 

Step  2. — With  a  broad  gouge  or  chisel  remove  the  cartilage  from  the  lower 
ends  of  the  tibia  and  fibula  and  from  the  upper  surface  of  the  os  calcis.  Cut 
away  the  sustentaculum  tali.  Remove  the  soft  structures  from  the  sinus  pedi. 
Subcutaneously  divide  the  tendo  AchilHs  and  any  contracted  fibrous  tissue 
around  it. 

Step  3. — From  the  ends  of  the  primary  dorsal  incision  make  a  cut  which 
reaches  to  half  an  inch  in  front  of  the  tubercle  of  the  scaphoid  on  the  inner  side 
and  the  same  distance  in  front  of  the  base  of  the  fifth  metatarsal  bone  on  the 
outer  side;  the  cut  curves  across  the  sole  between  these  two  points.  Disarticu- 
late the  OS  calcis  from  the  cuboid  and  complete  the  separation  of  the  foot  by 
cutting  from  behind  forwards  obliquely,  through  the  soft  parts  of  the  sole  to 
the  margin  of  the  skin  flap,  keep  the  knife  as  close  to  the  bone  as  possible. 
Remove  the  anterior  articular  surface  of  the  os  calcis.  Attend  to  hemostasis. 
Cut  the  nerves  short. 

Step  4. — Wedge  the  os  calcis  between  the  malleoli  and  nail  it  there  by  means 
of  a  6-inch  steel  pin  driven  through  the  centre  of  the  heel,  through  the  os  calcis 
and  into  the  centre  of  the  tibial  shaft.  Leave  the  end  of  the  pin  projecting 
through  the  skin.  If  any  tension  remains  about  the  tendo  Achillis  relieve  it  by 
subcutaneous  section  but  do  not  injure  the  posterior  tibial  vessels.  Suture  the 
flaps.  Insert  a  small  drain.  After  two  days  remove  the  drain.  After  2  weeks 
remove  the  pin.  Immobilize  for  about  6  weeks  to  permit  of  bony  union.  The 
advantages  claimed  for  Watson's  amputation  are :  The  original  heel  pad  covers  the 
stump.  The  retained  malleoli  give  a  firm  hold  to  the  uppers  of  ordinary  high 
shoes.  There  is  only  about  one  inch  shortening  of  the  limb.  No  artificial  limb 
is  required;  an  ordinary  high  shoe  can  be  worn  if  the  sole  is  stiffened  with  metal 
and  a  block  is  used  to  fill  the  toe  space. 


1 1 74  AMPUTATION    OR   DISARTICULATION 

Roux's  Operation. — This  is  identical  with  Symes's  except  that  the  flap 
is  not  made  over  the  heel  but  on  the  inner  side  (Fig.  1450). 

Corlette's  Amputation.  No.  i. — Stepi. — From  a  point  midway  between  the 
tip  of  the  external  malleolus  and  the  tuberosity  of  the  fifth  metatarsal  make  a 
curved  incision  over  the  dorsum  of  the  foot,  crossing  the  bases  of  the  metatarsal 
bones  and  ending  a  little  behind  the  prominence  of  the  navicular  bone  internally. 
Make  a  similar  plantar  flap  a  little  longer  than  the  dorsal.  Modifications  of 
the  above  incisions  must  be  used  in  accordance  with  the  tissues  available. 
Make  the  flaps  too  large  rather  than  too  small.  It  is  easy  to  trim  down  large 
flaps. 


Fig.  1450. — Roux's  amputation.     {Stitnson.) 

Step  2. — Disarticulate  at  the  medio-tarsal  joint,  as  in  Chopart's  operation. 
Rowlands  and  Turner  describe  the  disarticulation  as  follows:  "the  anterior 
half  of  the  foot  being  strongly  depressed,  disarticulation  is  effected  by  passing 
the  knife  above  the  tubercle  of  the  scaphoid  between  this  bone  and  the 
astragalus,  and  then  between  the  concavo-convex  surface  of  the  calcaneo-cuboid 
joint.  In  effecting  this  the  position  of  the  joints  and  the  shape  of  the  astragalus 
must  be  remembered,  and  Mr.  Skey's  words  borne  in  mind:  'the  joints  should 
be  opened  with  tact  and  not  by  force:  if  the  knife  be  applied  to  the  right 
surface,  it  will  pass  without  effort  into  the  articulation;  if  in  the  wrong 
direction,  no  force  will  effect  it.'  " 

Step  3. — With  an  osteotome  cut  a  horizontal  groove  round  the  head  of  the 
talus  at  the  junction  of  the  upper  two-thirds  with  the  lower  third  of  its  convex 
articular  surface,  Fig.  145 1.  Cut  away  the  lower  third  of  the  head.  Prelimi- 
nary grooving  leads  to  accuracy  and  prevents  fragmentation  of  the  part  to  be 
retained.  By  shaving  the  under  surface  of  the  upper  part  of  the  head,  make 
the  plane  of  the  bone  slant  a  little  upwards  and  backwards. 

Step  4. — Cut  away  the  sustentaculum  tali  flush  with  the  side  of  the  calcaneus. 

Step  5. — At  the  junction  of  the  upper  third  and  lower  two-thirds  of  the 
facet  on  the  front  of  the  greater  process  of  the  calcaneus  which  articulated  with 
the  cuboid  cut  a  horizontal  sulcus  and  through  this  cut  upwards  and  backwards 
towards  the  groove  in  which  is  inserted  the  interosseous  ligament.  The  sharp 
up-curving  projection  of  the  anterior  end  of  the  calcaneus  is  now  removed. 

Step  6. — Cut  away  the  interosseous  ligament.  With  lion  forceps  pull  the 
calcaneus  away  from  the  talus.     Cut  the  lateral,  medial  and  posterior  talo- 


corlette's  amputation 


II75 


calcaneal  ligaments.  Separate  the  soft  tissues  from  the  top  and  sides  of  the 
calcaneus.  Cut  the  long  flexor  tendons  of  the  toes  and  that  of  the  hallux  as 
far  back  as  convenient. 

Step  7.— Complete  the  removal  of  the  lower  part  of  the  talus  making  the 
plane  of  the  cut  surface  of  bone  slope  upwards  and  backwards.  Do  not  injure 
the  posterior  tibio-tarsal  ligament  and  do  not  enter  the  ankle  joint.  It  is  best 
to  remove  the  bone  by  "shaving"  and  not  in  one  piece. 

Step  8. — Shave  off  bit  by  bit  the  convex  articular  prominence  of  the  calcaneus 
until  a  large  plane  surface  is  produced  with  a  moderate  slant  up  from  before 
backwards,  Fig.  145 1  a-b. 

Step  9.— Push  the  calcaneus  well  forward  so  that  its  anterior  end  projects 
a  little  in  front  of  the  talus  and  the  two  raw  surfaces  of  these  bones  are  in  good 
apposition.  To  obtain  accurate  apposition  it  may  be  necessary  to  shave  away 
some  more  bone.  If  the  projection  of  the 
anterior  end  of  the  calcaneus  is  sufficient  to 
threaten  injury  to  the  skin  flaps,  it  may  be 
shortened. 

Step  10. — Drill  a  hole  from  side  to  side 
through  the  neck  of  the  talus  fairly  high  up. 
Make  a  similar  hole  through  the  calcaneus.  Put 
a  guide  of  wire  in  each  hole. 

Step  II. — Trim  and  place  in  position  the  skin 
flaps.  Remove  the  tourniquet  and  attend  to 
hemostasis. 

Step  12. — Unite  the  talus  and  calcaneus  by 
means  of  stifl"  (2  mm.)  silver  wire  passed 
through  the  holes  already  bored. 

Step  13. — Suture  the  anterior  tendons  to  the 
plantar  flap  as  low  as  possible.  Close  the 
wound . 

Remarks. — One  of  the  great  disadvantages  of 
such  amputations  as  Chopart's  is  that  the  heel  yig. 
is  liable  to  be  pulled  up  by  the  Gastrocnemius 
thus  giving  a  poor  stump.  Corlette  seems  to  have  reason  in  claiming  that 
the  pushing  forward  of  the  Calcaneus  (Step  9)  overcomes  this  fault  by 
shortening  the  heel  levers.  The  careful  suturing  of  the  dorsal  tendons  to  the 
plantar  tissues  (advised  by  Selegarde  in  Chopart's  operation)  aids  in  securing 
a  good  stump. 

Corlette's  Amputation  No.  2.— Step  i.— Reflect  flaps  as  in  Corlette's  Ampu- 
tation No.  I,  but  make  them  shorter. 

Step  2. — Remove  the  foot  by  medio-tarsal  disarticulation.  Remove  the 
sustentaculum  tali.     Excise  the  talus. 

Step  3.— Separate  the  soft  parts  from  the  sides  and  upper  surface  of  the 
calcaneus.  Posteriorly  this  separation  need  not  extend  far  down  the  sides  of 
the  bone.  In  making  these  separations  always  hug  the  bone  with  the  rugine 
or  knife  lest  vessels  be  injured.  Remove  the  prominent  upper  and  anterior 
part  of  the  greater  process  of  the  Calcaneus. 


145 1. — Corlette's  amputation. 


II76 


AMPUTATION    OR   DISARTICULATION 


Step  4. — After  groo\  ing  ihe  bone  slice  away  the  upper  jjart  of  the  calcaneus 
(Fig.  145 1  c-d)  leaving  a  plane  of  raw  surface  sloping  upwards  and  backwards. 
This  must  be  done  in  such  fashion  that  the  normal  bearing  surface  of  the  sole 
of  the  heel  will  be  capable  of  pressing  on  the  ground  directly  under  (in  the  bear- 
ing line  of)  the  tibia  after  the  calcaneus  is  pushed  forward.  It  is  wise  to  remove 
the  upper  part  of  the  calcaneus  not  en  masse,  but  by  shaving  but  by  bit.  Note 
that  the  upper  surface  of  the  calcaneus  is  removed  to  its  posterior  extremity, 
but  the  line  of  section  does  not  involve  the  insertion  of  the  tendo  Achillis. 

Step  5. — With  osteotome  remove  the  articular  surface  of  the  tibia  between 
the  malleoli,  but  do  not  injure  the  compact  layer  of  bone  on  the  articular  sur- 
faces of  both  malleoli;  this  is  important  as  the  malleoli  are  retained  principally 
to  give  lateral  support  and  for  purposes  of  waring. 

Step  6. — Fit  the  cut  surface  of  the  calcaneus  to  that  of  the  tibia.  To  do 
this  it  may  be  necessary  to  cut  away  part  of  the  external  malleolus,  until  it 
does  not  project  downwards  more  than  the  internal.  Drill  both  malleoli  near 
their  bases  horizontally  or  slightly  upwards  and  inwards.  Drill  the  calcaneus 
from  side  to  side.  Pass  a  wire  through  the  holes  bored  in  the  malleoli  and 
calcaneus  and  thus  fasten  the  calcaneus  securely  to  the  tibia. 

Step  7. — Cut  aM'ay  any  excess  of  calcaneus  protruding  forwards. 

Step  8. — Trim  the  flaps  and  close  the  wound. 


csij^ 


.;^ 


Fig.  1452.  Fig.  1453. 

Figs.  1452  and  1453. — Pirogoff's  amputation. 
{Esmarcit  and  Kowalzig.) 


Fig.  1454. 
Fig.  1454. — Le  Fort's  amputation. 
{Esmarch  and  Kowalzig.) 


Pirogoff's  Amputation. — Steps  i  and  2  as  in  Syme's  amputation. 

Step  3. — Make  strong  plantar  flexion  until  the  astragalus  is  dislocated 
forwards  and  the  upper  surface  of  the  posterior  part  of  the  os  calcis  comes  into 
view.  With  the  saw  divide  the  os  calcis  vertically  immediately  behind  its 
articular  surface  (Figs.  1452  and  1453). 

Step  4. — Remove  the  malleoli  and  a  thin  slice  of  the  tibia  as  in  Syme's 
operation. 

Step  5. — Divide  the  tendo  Achillis  at  its  insertion. 

Step  6. — Complete  the  operation  as  in  Syme's. 

The  sawn  surface  of  the  posterior  end  of  the  os  calcis  unites  to  the  tibia, 
giving  a  good  stump. 

Pirogoff's  operation  is  very  difficult  to  perform,  and  accidents  in  healing 
may  lead  to  distortion  of  the  stump. 


OSTEOPLASTIC    AMPUTATION 


II77 


Le  Fort's  Operation,  a  modification  of  Pirogoff's  is  sufficiently  explained  by 
figure  1454.  The  incision  crossing  the  sole  lies  at  the  posterior  margin  of  the 
navicular  bone. 

Amputation  of  the  Leg. — The  paragraphs  devoted  to  amputating  in  general 
describe  sufficiently  the  usual  methods  of  removing  the  leg. 

It  may  be  remarked  that  the  ventral  decubitus  presents  some  marked  ad- 
vantage over  the  usual  dorsal  position  in  amputations  below  the  knee  in  that 
flexion  of  the  knee  permits  the  easiest  possible  access  to  the  territory  of  operation 
(Finochietto,  ''Annals  Surg.,"  May,  1915). 

Osteoplastic  Amputations. — Osteoplastic  amputations  are  less  serviceable 
after  trauma  than  after  disease. 

Bier's  Osteoplastic  Amputation  Leg. — Bier's  operation  may  be  carried  out 
either  on  the  basis  of  a  circular  or  a  flap  amputa- 
tion. The  circular  method  will  be  here  described. 
Step  I. — Make  the  usual  circular  incision 
through  the  skin  and  subcutaneous  tissue,  being 
specially  careful  not  to  injure  the  periosteum. 
Reflect  a  cuflf  of  skin  upwards  (Fig.  1455). 

Step  2.— With  a  knife  trace  out  a  periosteal 
flap  with  its  pedicle  above,  on  the  free  surface  of 
the  tibia.  With  a  fine  saw  or  chisel  (the  chisel  is 
liable  to  splinter  the  bone)  separate  a  shell  of  bone 
from  the  tibia  so  that  a  flap  is  formed  consisting  of 
periosteum  and  bone.  The  shell  of  bone  ought  to 
be  long  enough  to  cover  the  cut  surface  of  the  tibia 
and  the  fibula  (Bier's  method)  after  the  limb  is 


Fig.  1455. 

Figs.  1455  and  1456. 


Fig.  1456. 
-Bier's  osteoplastic  amputation. 


amputated,  or  to  cover  the  cut  surface  of  the  tibia  alone  (Kocher).  When 
sufficient  bone  has  been  cut  away  or  shaved  off  the  tibia  continue  the  separation 
of  the  periosteal  flap  from  the  tibia  upwards  to  the  line  where  the  bone  must 
be  divided  (Fig.  1455).    Complete  the  amputation. 

Step  3. — Turn  the  periosteal-bone  flap  so  as  to  cover  the  sawn  ends  of  the 
tibia  and  fibula  or  of  the  tibia  alone  with  the  shell  of  bone  (Fig.  1456). 
Fix  it  in  position  with  a  few  sutures. 

Step  4. — Attend  to  hemostasis.     Close  the  wound. 

This  operation  gives  a  very  excellent  stump. 

Bier's  method  may  be  modified  in  various  ways,  one  of  the  principal  modifi- 
cations being  to  construct  a  flap  of  skin,  periosteum  and  a  shell  of  bone 
instead  of  periosteum  and  bone  alone. 

Figures   1457,   1458,   1459,   1460,  from  Trzebicky  and  Frommer's  article 


II78 


AMPUTATION   OR   DISARTICULATION 


("Archiv  fiir  klin.  Chir.,"  Ixx,  472),  illustrate  this  method  admirably.  Note  in 
Fig.  1460  that  a  segment  of  bone  is  removed  at  the  base  of  the  bone  flap;  this 
is,  of  course,  to  permit  the  folding  over  of  the  flap.  Figure  146 1  shows  the 
application  of  the  same  principle  in  amputation  of  the  thigh. 

Haffter's  Osteoplastic  Amputation  of  the  Leg.— Dumont  describes  this 
operation  ("Deutsche  Zeitschrift  fiir  Chir.,"  xcii,  497). 


Fig.  1457.  Fig.  1458. 

Figs.  1457  and  1458. — Osteoplastic  amputation.     {Trzcbicky  and  Frommer.) 


Fig.  1459. 
Figs.  1459  and  1460. — Osteoplastic  amputation. 


Fig.  1460. 
{Trzcbicky  and  Frommer.) 


Step  I. — Make  an  obliquely  oval  incision  through  the  skin.  On  the  outer 
side  of  the  limb  the  incision  is  at  a  much  lower  level  than  on  the  inner  side. 

Step  2. — On  the  inner  side  retract  the  skin  upwards  in  the  usual  manner  and 
cut  through  the  periosteum  of  the  tibia  (Fig.  1462,  a).  Push  the  periosteum 
upwards  for  about  }4,  inch.     Divide  the  tibia  with  a  Gigli  saw  (Fig.  1462,  A). 

Separate  the  soft  parts  from  the  tibia  downwards.  Expose  the  fibula 
near  the  outer  level  of  the  oval  skin  incision.     Divide  the  fibular  periosteum 


OSTEOPLASTIC   AMPUTATIONS 


1179 


(Fig.  1462,  b)  and  push  it  upwards  so  as  to  form  a  cuff.     Divide  the   fibula 
(Fig.  1462,  B). 

Step  3. — Choose  a  point  on  the  fibula  near  the  level  of  the  sawed  surface  of 


Fig.  1461. — Osteoplastic  amputation. 
{Trzebicky  and  Frommer.) 


Fig.   1462. — Hafter's  osteoplastic 
amputation. 


the  tibia.     At  this  point  cut,  with  a  chisel,  a  wedge  out  of  the  fibula,  the  base 
of  the  wedge  being  directed  towards  the  tibia  (Fig.  1462,  X). 

Step  4. — Bend  or  break  the  fibula  so  that  it  may  be  laid  over  the  sawn  sur- 
face of  the  tibia.  Vivify  the  surface  of  the  fibula 
apposed  to  the  tibia.  Attend  to  hemostasis. 
Close  the  wound  with  deep  and  superficial 
sutures  in  such  a  manner  that  the  mobilized 
portion  of  fibula  is  left  in  contact  with  the  end 
of  the  tibia.  Excellent  results  have  been  ob- 
tained by  this  operation  which  seems  simple 
and  sensible. 

Author's  Amputation. — In  performing  Bier's 
osteoplastic  amputation  the  author  has  been 
struck  by  its  diflaculty  and  by  the  ease  with 
which  the  plate  of  bone  falls  off  the  periosteal 
flap  at  the  last  moment.  Little  or  no  nourish- 
ment can  reach  the  bone  fragment  through  the 
periosteum  which  really  acts  merely  as  a  hinge; 
he  therefore  operates  as  follows: 

1.  Reflect  the  soft  parts  by  the  circular  or 
flap  method  but  leave  the  periosteum  intact. 

2.  Transversely  divide  the  periosteum  of  the  tibia  along  two  lines  separated 


Fig.  1463. 


ii8o 


AMPUTATION    OR   DISARTICULATION 


from  each  other  by  a  space  about  3^^  inch  greater  than  the  diameter  of  the 
bone  (Fig.  1463). 

From  the  upper  incision  separate  the  periosteum  downwards  for  about  3<4 
inch.  From  the  lower  incision  separate  the  periosteum  upwards  for  about  ^ 
inch.  With  a  saw  cut  through  the  compact  bone  transversely  near  the  base 
of  the  periosteal  flaps.  With  an  osteotome  cut  free  the  plate  of  bone  between 
the  two  saw  cuts.  This  plate  of  bone  is  covered  by  periosteum  which  hangs 
over  its  upper  and  lower  edges  like  a  table  cloth.  Preserve  the  plate  of 
bone  in  warm  salt  solution  or  in  gauze  moistened  with  salt  solution. 

3.  Choose  the  line  of  bone  section  and  after  forming  periosteal  cufT  divide 
the  bone.     Attend  to  hemostasis. 

4.  Place  the  plate  of  bone  over  the  cut  surface  of  the  tibial  stump  (raw 
surface  to  raw  surface)  and  suture  the  periosteum  of  the  plate  to  the  periosteum 
of  the  tibia. 

5.  Close  the  wound  secundum  artem. 

In  amputation  of  the  thigh  Hayden  suggests  using  the  patella,  after  shaving 
off  its  articular  surface,  as  a  free  transplant  to  cover  the  divided  end  of  the  femur. 


Fig.  1464. 
{Esmarch  and  Kowalzig.) 


Fig.  1465. 

(Farabeuf.) 


Fig.  1466. 
{Farabeuf.) 

The  distance  from 
the  joint  to  A  is  equal 
to  the  diameter  of  the 
leg.  The  distance  of 
P  from  the  joint  is  one- 
half  the  diameter  of  the 
leg. 


Figs.  1464,  1465  and  1466. — Disarticulation  of  knee. 

Dis£irticulation  at  the  Knee. — The  ordinary  methods  of  disarticulation 
of  the  knee  require  no  special  description.  They  are  performed  by  the  circular 
(Fig.  1464),  oval  (Fig.  1465),  or  flap  (Fig.  1466)  methods.  The  patella  may 
or  may  not  be  removed. 


AMPUTATION  BESIDE  THE  KNEE 
Method    A.^ — Carden's    Intra-condyloid    Amputation. — Make     the 


skin 


incision  shown  in  Figs.  1467  and  1468.  Reflect  the  anterior  skin  tlap  upwards 
in  front  of  the  patella  and  expose  the  upper  edge  of  that  bone.  Divide  the 
quadriceps  extensor  at  its  insertion.     Divide  the  ham-strings  and  the  contents 


OSTEOPLASTIC    AMPUTATIONS 


II»I 


of  the  popliteal  space.  Clear  the  femur  immediately  above  the  articular 
cartilage  and  divide  the  femur  at  this  level  in  such  a  manner  as  to  give  a  horizon- 
tal surface  for  the  patient  to  rest  on.  It  must  be  noted,  however,  that  the  soft 
parts  posterior  to  the  knee  contract  after  section,  while  those  anterior  do  not 


Fig.  1467. — Garden's  amputation.     (Moidlln.) 

do  SO,  hence  a  circular  flap  becomes  an  oval  one  on  account  of  the  posterior 
contraction. 

Method  B.— Gritti's  Osteoplastic  Operation.— Make  the  same  skin  incision 
as  in  Method  A,  but  turn  up  the  patella  in  the  anterior  flap.     Saw  off  the  articu- 

/ 


Fig.  1468.  Fig.  1469. 

Fig.  1468. — Garden's  amputation.     {Moidlin.) 
Figs.  1469  and  1470. — Gritti's  osteoplastic  amputation.     {Stewart.) 


1470 


Figs.  14  71  and  14 


Fig.  1471.  Fig.  1472. 

72. — Sabanejeff's  osteoplastic  amputation.     {Stewart.) 


lar  surface  of  the  patella  (Figs.  1469  and  1470).  Complete  the  amputation. 
Place  the  sawn  surface  of  the  patella  (in  the  anterior  flap)  against  the  cut 
surface  of  the  femur.     Close  the  wound. 


Il82  AMPUTATION    OR    DISARTICULATION 

Method  C. — Sabanejefif's  Method. — Make  an  anterior  flap  similar  to 
Garden's  but  having  its  lowest  point  below  the  patellar  tubercle.  With  saw 
or  chisel  cut  ofif,  in  one  piece  with  the  skin  flap,  a  portion  of  the  anterior  superior 
surface  of  the  tibia  (Figs.  147 1  and  1472).  Complete  the  amputation.  In  clos- 
ing the  wound  place  the  bone  in  the  anterior  flap  in  contact  with  the  divided 
end  of  the  femur.     Both  Gritti's  and  Sabenejeff's  methods  are  valuable. 

Amputations  of  the  thigh  do  not  require  special  description. 

AMPUTATION  OR  DISARTIGULATION  AT  THE  HIP 

Method  of  Temporary  Hemostasis. — i.  Preliminary  ligation  of  external 
iliac  artery. 

2.  Compression  of  common  iliac  artery  through  an  abdominal  incision 
(McBurney,  "Annals  Surg.,"  1894,  ii,  181). 

3.  Preliminary  ligation  of  femoral  vessels  (a)  through  a  special  incision; 
(b)  at  an  early  stage  in  the  "anterior  racquet"  operation. 

4.  (a)  Trendelenburg's  pin. 

(b)  Varick's  modification  of  Trendelenburg's  pin. 

(c)  Thomas'  forceps. 

(d)  Wyeth's  pins. 

5.  Jordan-Lloyd's  tourniquet. 

6.  Digital  compression. 

7.  Macewen's  method  of  aortic  compression. 

8.  Momburg's  method, 
g.  Senn's  method. 

Trendelenburg's  Pin.- — The  pin  or  rod  is  of  steel,  15  to  16  inches  long,  ^ 
inch  wide  and  3-^2  inch  thick  in  the  centre.  The  original  pin  was  provided 
with  a  removable  lance-shaped  point  2  inches  in  length.  Wyeth's  pins  would 
answer  the  purpose.  Introduce  the  pin  13^^  inches  below  the  anterior  superior 
iliac  spine,  make  it  pass  in  front  of  and  touching  the  femur  to  emerge  at  the  pos- 
terior scroto-femoral  junction.  Remove  the  point  or  protect  it  with  a  cork. 
Aided  by  the  pin  it  is  easy  to  apply  a  rubber  tube  in  the  figure-8  fashion  so  as 
to  compress  all  the  soft  structures  in  front  of  the  hip,  between  the  pin  and  the 
rubber  tube.  Trendelenburg  operated  by  transfixing  about  ^^  inch  below  the 
pin,  cutting  a  long  anterior  flap,  ligating  the  vessels,  removing  the  pin,  dis- 
articulating the  joint,  and,  lastly,  making  the  posterior  flap. 

Varick  ("Bryant's  Op.  Surg.")  did  not  disarticulate  until  he  had  transfixed 
a  second  time  behind  the  neck  of  the  femur. 

Thomas'  Forceps. — Lynn  Thomas  has  devised  a  long  forceps,  very  like 
a  gastrectomy  clamp,  one  blade  of  which  is  passed  through  the  tissues  exactly 
hke  Trendelenburg's  pin;  the  other  blade  pressing  on  the  tissues  externally 
takes  the  place  of  the  rubber  tube.  This  forceps  did  yeoman  service  in  the 
Boer  war  and  is  a  thoroughly  practical  device  (Fig.  1473). 

Wyeth's  Pins. — Provide  two  mattress  pins  each  one  foot  long  and  ^5 
inch  thick.  The  point  should  be  bayonet-shaped.  Insert  one  pin  3^  inch 
below,  and  slightly  internal  to,  the  anterior  superior  spine;  make  it  pass  some- 


TEMPORARY    HEMOSTASIS 


1 183 


what  superficially  through  the  tissues  at  the  outer  side  of  the  hip  to  emerge  on  a 
level  with  the  point  of  entrance.  Insert  the  other  pin  through  the  adductor 
longus  }'2  inch  below  the  perineum,  to  emerge  i  inch  below  the  ischial  tuber- 


FiG.  1473- — Lynn  Thomas'  forceps-tourniquet.     (Thomas.) 

osity  (Fig.  1474).     Protect  the  points  of  the  pins  with  corks.     Apply  a  rubber 
tube  tightly  around  the  limb  above  the  pins.     The  pins  prevent  the  rubber  tube 


Fig.  1474. — Wyeth's  pins.     (Jacobson.) 


from  slipping  even  after  the  joint  is  disarticulated  and  the  limb  removed. 
The  author  has  found  this  method  very  satisfactory. 

Jordan  Lloyd's  Tourniquet  or  Elastic  Constrictor.— Double  a  two-yard 
piece  of  stout  rubber  bandage.     Pass  it  between  the  thighs  so  that  its  middle 


1 1 84  AMPUTATION    OR   DISARTICULATION 

lies  between  the  ischial  tuberosity  of  the  side  to  be  operated  on  and  the  anus. 
Lay  a  common  roller  bandage  (size  for  the  thigh)  lengthwise  over  the  external 
iliac  artery.  Pull  the  ends  of  the  rubber  bandage  upwards  and  outwards,  one 
in  front  and  one  behind,  to  a  point  above  the  centre  of  the  iliac  crest  of  the  same 
side.  There  must  be  no  pulsation  in  the  femoral  and  tibial  arteries  when  the 
band  is  in  position.  The  front  part  of  the  rubber  band  runs  parallel  to  and 
just  above  Poupart's  ligament  and,  by  means  of  the  roller  bandage,  compresses 
the  external  iliac  artery.  The  posterior  part  of  the  rubber  band  crosses  the 
great  sacro-sciatic  notch  and  controls  the  branches  of  the  internal  iliac.  The 
ends  of  the  bandage  may  be  held  by  an  assistant  or  secured  as  a  figure  8  round 
the  body.     This  method  has  not  the  safety  of  those  of  Wyeth  or  Thomas. 

Digital  compression  of  the  femoral  artery  is  unsatisfactory. 

Macewen's  Method. — Compression  of  the  Aorta. — Arrange  the  patient 
exactly  as  he  is  to  lie  during  the  operation.  Place  a  platform  or  steady  stool  by 
the  left  side  of  the  table  of  such  height  that  an  assistant  standing  on  it  can  lean 
over  sidewise  and  with  his  right  elbow  fully  extended  lay  his  closed  fist  on  the 
aorta  immediately  to  the  left  of  the  umbilicus.  The  assistant  placed  as  above, 
facing  the  patient's  feet,  stands  on  his  left  foot,  his  right  foot  crossing  the  left, 
leans  on  his  right  fist  and  so  compresses  the  aorta  with  the  minimum  of  fatigue. 
The  writer  can  vouch  for  the  simplicity  and  efficiency  of  the  method;  he  can 
also  vouch  for  the  fatigue  of  the  assistant  at  the  close  of  the  operation. 

Momburg's  method  of  controlling  the  circulation  in  the  lower  half  of  the 
body  C'Zentralblatt  fiir  Chir.,"  1908,  No.  23)  is  applicable  not  merely  to  opera- 
tions about  the  hip-joint,  but  to  interilio-abdominal  amputations  as  well. 
Apply  a  rubber  tube  (as  thick  as  a  man's  finger),  under  full  tension,  two  to  four 
times  around  the  waist  of  the  patient  between  the  iliac  crest  and  the  lowest 
ribs.  Watch  the  femoral  pulse;  as  soon  as  it  is  no  longer  palpable,  enough 
constriction  has  been  applied.  As  soon  as  the  operation  is  completed,  apply  an 
elastic  bandage  to  both  limbs  from  the  feet  up,  if  the  operation  has  been  on 
the  pelvis,  or  to  the  remaining  limb  if  one  has  been  amputated.  Elevate  the 
limb.  Remove  the  constrictor  from  around  the  waist.  Gradually  remove  the 
elastic  bandage  from  the  hmb  so  as  to  permit  the  circulation  to  be  resumed  by 
degrees  in  the  lower  part  of  the  body  lest  too  great  a  strain  be  suddenly  put  on 
the  heart.  Bier,  Axhausen,  and  others  have  used  Momburg's  method  with  suc- 
cess and  satisfaction. 

The  methods  of  performing  amputation  or  disarticulation  at  the  hip-joint 
are  innumerable,  only  a  few  will  be  described  here. 

I.  External  Racquet  Incision. — This  operation  and  its  modifications  are 
practically  identical  with 

Fumeaux  Jordan's  Method.- — Place  the  patient  on  his  back  with  the  but- 
tocks resting  on  the  extreme  end  of  the  table.  Let  the  assistant  hold  the 
leg  and  manipulate  the  limb  according  to  instructions.  If  desired,  provide 
for  temporary  hemostasis.     Slightly  adduct,  flex  and  rotate  the  thigh  inwards. 

Step  I. — Make  a  longitudinal  incision  from  a  point  about  2  inches  above 
to  a  point  about  6  inches  below  the  tip  of  the  trochanter  major.  This  incision 
runs  along  the  femur  near  the  posterior  edge  of  the  trochanter  and  penetrates 
at  once  to  the  bone  (Fig.  1475). 


wyeth's  amputation  1 185 

Step  2. — With  a  stout  knife  divide  the  muscular  attachments  of  the  tro- 
chanter major  and  expose  the  joint.  Before  dividing  the  muscular  attachments 
it  may  be  well,  in  certain  cases,  to  expose,  open,  and  explore  the  joint  so  that  the 
alternative  of  resection  may  be  adopted  instead  of  amputation,  under  proper 
circumstances. 

With  periosteal  elevator,  stout  knife  or  scissors  separate  the  soft  parts  from 
the  femur  (most  difficult  at  the  trochanter  minor  and  the  linea  aspera)  for  the 
full  length  of  the  longitudinal  wound. 

Step  3. — Method  A. — Senn's  Method. — Dislocate  the  head  of  the  femur 
and  make  it  protrude  through  the  wound.  Introduce  a  closed  forceps  through 
the  wound  and  force  it  through  the  tissues  on  the  inner  side 
of  the  thigh  so  as  to  make  a  prominence  on  the  skin.  Di- 
vide the  skin  over  the  point  of  the  forceps  and  grasp  in  its 
blades  the  middle  of  a  length  of  rubber  tubing.  Pull  the 
tubing  through  the  wound  and  divide  the  tube  where  it 
was  grasped  by  the  forceps,  thus  leaving  two  portions  of 
elastic  tubing  passing  completely  through  the  thigh.  Tie 
one  of  these  tubes  tightly  around  the  anterior,  the  other 
round  the  posterior  mass  of  tissues.  This  insures  hemo- 
stasis  during  the  completion  of  the  amputation. 

Method  B. — Dislocate  the  head  of  the  femur  and  make 
it  protrude  through  the  wound.  Pass  one  blade  of  a 
Thomas's  clamp  (a  gastrectomy  clamp  will  do)  through  the 
wound  and  make  it  perforate  the  skin  on  the  inner  side  of 
the  thigh.  Let  the  other  blade  of  the  clamp  pass  over  the  Fig.  1475. — Jordan's 
front  of  the  thigh.  Tighten  the  clamp.  This  insures  hemo-  operation.  {Bryant.) 
stasis  in  the  anterior  flap  where  the  principal  vessels  lie.  If  desired,  a  similar 
forceps  may  be  applied  to  the  posterior  side  of  the  thigh,  or  the  soft  parts  of 
the  anterior  side  ma}''  be  divided,  the  vessels  secured  and  then  the  same  forceps 
applied  to  the  posterior  tissues,  which  may  be  divided  in  turn.  This  method  of 
using  forceps  (Thomas)  seems  very  practical. 

Method  C. — From  the  lower  end  of  the  vertical  incision  make  a  circular 
or  oblique  incision  through  the  skin  and  subcutaneous  tissues  completely  round 
the  thigh  at  a  distance  of  6  to  8  inches  from  the  tip  of  the  trochanter.  Dissect 
the  skin  upwards  for  about  2  inches;  at  this  level  divide  the  muscles  and  remove 
the  limb.  As  soon  as  the  muscles  are  divided  the  vessels  must  be  secured. 
This  method  is  identical  with  the  two  preceding  ones  except  in  the  matter  of 
hemostasis. 

Step  4. — The  limb  having  been  removed,  attend  to  final  hemostasis.  In- 
spect the  acetabulum  for  disease  and  treat  such  disease  if  found.  Close  the 
wound  after  providing  for  drainage. 

Remark. — The  racquet-shaped  incision  provides  a  wound  which  lies  as 
mote  as  possible  from  the  nates  and  genitalia. 

2.  Wyeth's  Amputation.— Introduce  Wyeth's  pins  (p.  1182).  Apply  elastic 
constrictor  above  the  pins. 

Step  I. — Make  a  circular  incision  around  the  thigh  about  2  to  2^^^  inches 
below  the  lesser  trochanter,  dividing  the  skin  and  subcutaneous  tissues  alone. 
75 


ii86 


AMPUTATION   OR   DISARTICULATION 


Reflect  the  skin  upwards  to  the  level  of  the  lesser  trochanter.  At  this  level 
di\-ide  the  muscles  circularly  to  the  bone. 

Step  2. — Make  a  vertical  incision  over  the  line  of  the  external  surface  of  the 
femur  from  the  elastic  constrictor  to  the  circular  incision.  Ligate  all  the  prin- 
cipal vessels  in  the  wound. 

Step  3.- — Separate  all  the  soft  parts  from  the  femur  upwards  from  the  circular 
incision.  Disarticulate  the  hip.  To  accomplish  disarticulation  divide  the  cap- 
sular ligament,  make  a  notch  in  the  cotyloid  ligament  to  permit  air  to  enter  the 
joint,  manipulate  the  Hmb  to  expose  the  ligamentum  teres,  divide  this  ligament, 


Crural  n. 
Femoral  a. 
Femoral  v. 


Vastus  ex 


Fig.  1476. — Kochers  amputation.     (Kocher.) 


complete  the  dislocation  by  manipulation,  using  the  limb  as  a  lever.  Some  sur- 
geons di\"ide  the  femur  as  soon  as  they  make  the  circular  division  of  the  mus- 
cles; the  loss  of  the  limb  as  a  lever  makes  disarticulation  of  the  joint  needlessly 
difficult. 

Step  4. — Remove  the  limb.  If  any  vessels  are  N-isible,  ligate  them.  Re- 
move the  elastic  constrictor  or  pins.  Attend  to  hemostasis.  Provide  for 
drainage.  Close  the  wound.  Apply  dressings.  Wyeth's  operation  has  given 
great  satisfaction  to  all  who  have  used  it.     It  is  very  easy  and  safe. 

3.  Anterior  Racquet  Incision. — This  method  is  convenient  because  at  the 
ver}-  beginning  of  the  operation  the  femoral  vessels  are  exposed,  doubly  li- 


DISARTICULATION    HIP  I187 

gated  and  divided.  The  incision  encircling  the  limb  in  an  oblique  fashion  may 
be  so  arranged  as  to  form  two  practically  ecjual  flaps,  one  long  external  flap,  one 
long  internal  flap,  two  unequal  lateral  flaps  or  one  long  posterior  flap.  This 
freedom  of  choice  in  obtaining  material  to  cover  the  stump  is  of  importance,  as 
the  site  of  disease  and  skin  involvement  may  render  it  necessary  to  remove  much 
skin  and  soft  structures.  The  anterior  racquet  method  is  entirely  analogous  to 
the  removal  of  a  tumor  from  the  body,  in  this  case  the  limb  being  considered 
as  tumor. 

Step  I. — From  a  point  immediately  below  the  centre  of  Poupart's  ligament 
make  a  vertical  incision  downwards  for  3  to  4  inches.  Expose,  doubly  ligate, 
and  divide  the  common  femoral  artery  and  vein.  Divide  the  crural  nerve 
(Fig.  1476). 

Step  2.- — ^At  the  lower  end  of  the  vertical  incision  make  an  obliquely  circular 
cut  all  round  the  limb,  dividing  the  skin  and  subcutaneous  tissues.  Reflect  the 
skin  upward  for  about  2  inches,  and  divide  the  muscles  at  this  level.  Any  vessels 
divided  (obturator,  superior,  and  inferior  gluteals)  must  be  caught  in  hemostats. 

Step  3. — Separate  from  the  bone  any  soft  structures  still  attached,  and 
remove  the  limb  by  disarticulation. 

Step  4. — Attend  to  hemostasis.  Provide  for  drainage.  Close  the  wound. 
Dress. 

The  operation  as  above  described  is  suitable  in  many  cases,  but  the  remote 
results  of  disarticulation  of  the  hip  for  sarcoma  of  the  femur  cannot  be  described 
by  any  milder  term  than  vile.  This  is  due  to  the  fact  that  the  sarcoma  early 
involves  the  soft  parts — for  instance,  the  muscles — and  of  these  principally  the 
adductors  (Quenu  et  Desmarest,  "Rev.  de  Chir.,"  1903,  No.  5).  Given  a 
patient  wdth  fair  vitality,  one  should  therefore  modify  Step  2  of  the  anterior 
racquet  method  so  as  to  expose  and  divide  the  muscles  at  their  pelvic  origin. 

The  author  suggests  the  following  method  of  disarticulation  of  the  hip  as 
being  theoretically  suitable  in  sarcoma  of  the  femur. 

Step  I . — Through  a  muscle-splitting  incision  expose  the  common  iliac  artery 
preferably  extraperitoneally.  Apply  to  the  vessel  Crile's  clamp  or  a  temporary 
ligature.  Pack  and  protect  the  wound,  if  necessary  using  a  stitch  or  a  small 
volsellum  forceps  to  temporarily  close  the  wound.  Instead  of  the  above  method^ 
Momburg's  elastic  constrictor  may  be  employed  (p.  11 84). 

Step  2.— Make  a  vertical  incision  below  Poupart's  ligament;  expose,  doubly 
ligate,  and  divide  the  femoral  vessels.     Divide  the  anterior  crural  nerve. 

Step  3. — Beginning  at  the  lower  end  of  the  vertical  incision  trace  out  and 
reflect  flaps  of  skin  and  subcutaneous  tissues  sufficient  to  cover  the  wound  which 
will  be  left  by  the  operation.  These  flaps  of  skin  and  subcutaneous  tissues  must 
be  reflected  up  to  the  crest  of  the  ilium,  the  rami  of  the  pubis  and  ischium,  the 
ischial  tuberosity,  etc.,  etc.,  so  that  the  muscles  connecting  the  femur  to  the 
trunk  are  completely  exposed,  except  of  course  those  coming  from  inside  the 
belly. 

Step  4. — Separate  the  muscles  from  the  pelvis  at  or  very  near  their  origin 
and  dissect  them  downwards  until  the  hip-joint  is  exposed  all  around.  Divide 
the  muscles  coming  to  the  femur  from  inside  the  pelvis;  these  cannot  be  excised. 

Step  5. — Disarticulate.     Remove  the  limb. 


ii; 


AXirUTATION    OR   DISARTICULATION 


Step  6. — The  femoral  vessels  have  already  been  ligated.  Look  out  for  and 
ligate  the  gluteal  and  sciatic  vessels  (Fig.  147 7J.  Pick  up  and  ligate  all  visible 
vessels.     Pack  the  huge  wound  vdlh.  gauze  wrung  out  of  very  hot  water. 

Step  7. — Reopen  the  abdominal  wound.  Let  a  competent  assistant  remove 
the  Crile's  clamp  and  hold  himself  ready  to  compress  the  iliac  if  necessary. 
Review  the  amputation  wound.  Arrest  all  hemorrhage.  Provide  for  drainage. 
Close  the  wound. 


Gluteus  max. ™ 


Sup  glut.  a. 


Sciatic  a. 


Glut.  med. 


G'ut  a. 
Sup.  glut,  n 
Glut,  a 

Glut.  min. 
Sm.  Sdatic.  n. 
Int.  pud.  n. 


Fic.  1477. — (Poirier  and  Charpy.) 


Step  8. — Close  the  abdominal  wound.     Apply  dressings. 

Felix  Franke  ("Zentralblatt  fiir  Chir.,"  1897,  Xo.  45,  and  1913,  No.  3)  notes 
that  after  disarticulation  the  acetabulum  forms  a  ca\-ity  which  may  interfere 
with  healing;  therefore  in  suitable  cases  he  advocates  amputation  through  the 
neck  of  the  femur,  lea\-ing  the  head  of  the  bone  to  fill  the  cavity. 

Interilio-abdominal  Amputation  (Jaboulay's  Operation). — Step  1. — Begin- 
ning at  the  symphysis  of  the  pubis,  make  an  incision  parallel  to  and  below 
Poupart's  ligament.  Continue  the  incision  the  whole  length  of  the  crest  of 
the  ilium.  Expose  the  peritoneum  without  opening  it  and  separate  it  by  gauze 
dissection  from  the  underlying  structures  until  the  common  iliac  vessels  are 
exposed.  Doubly  ligate  and  divide  the  common  iliac  artery.  Do  the  same  to 
the  external  iliac  vein. 

Step  2. — Make  a  circular  incision  through  the  skin  and  subcutaneous  tissues 
completely  round  the  thigh  at  the  junction  of  its  middle  and  upper  thirds. 
From  a  point  in  the  middle  line  of  the  anterior  surface  of  the  thigh  make  an 
incision  upwards  and  inwards  reaching  from  the  circular  incision  to  the  pubis. 
From  the  same  point  make  a  similar  incision  up  to  the  anterior  superior  spine. 
These  two  cuts  meeting  the  cut  made  in  Step  i  surroimd  a  triangle  of  tissue 


FLAT-FOOT  I  1 89 

which  must  be  sacrificed,  and  outline  a  very  large  posterior,  cuff-like  flap. 
Reflect  the  cuff-like  flap  of  skin  and  subcutaneous  tissue  so  as  to  expose  the 
whole  base  of  the  thigh  and  its  pelvic  connections. 

Step  3. — Retract  the  spermatic  cord  (or  round  ligament)  inwards  and  up- 
wards. Separate  the  rectus  and  pyramidal  muscles  from  the  pubis  on  the 
affected  side.  With  a  stout  knife  divide  the  symphysis.  Separate  the  corpus 
cavernosum  and  the  muscles  and  fascia  from  the  ischio-pubic  rami.  Abduct  the 
thigh  forcibly  so  as  to  make  the  symphysis  gape.  Separate  from  the  bone  the 
soft  structures  arising  from  the  inner  surface  of  the  ilium,  as  the  thigh  is  more 
and  more  abducted.  If  these  structures  are  involved  remove  them  also.  Divide 
the  psoas.  Expose  and  divide  the  sacro-iliac  articulation  from  within  outwards. 
Divide  the  structures  emerging  through  the  sciatic  notches.  When  this  is  done 
it  is  easy  to  remove  the  limb  and  corresponding  portion  of  the  pelvis. 

Step  4. — After  reviewing  the  wound,  cover  it  by  the  large  cuff-like  flap. 
Various  modifications  of  the  above  operation  have  been  attempted.  At  the 
best  it  is  a  most  formidable  procedure.  If  the  disease  is  sarcoma,  recurrence  is 
almost  sure  to  take  place  shoald  the  patient  survive  the  operative  ordeal.  When 
the  operation  seems  indicated  for  tuberculous  disease  of  the  hip  involving  the 
ilium,  most  surgeons  would  operate  in  two  or  more  stages,  for  instance:  (a) 
Amputate  or  disarticulate  at  the  hip-joint.  This  per  se  might  so  increase  the 
resisting  power  of  the  patient  by  removing  a  great  source  of  absorption  that 
nature  might  possibly  cure  the  patient.  (6)  At  a  later  stage  the  surgeon  may 
remove  part  or  all  the  ilium  as  may  be  indicated 


CHAPTER  CVI 
FLAT-FOOT 


When  flat-foot  is  due  to  rupture  of  the  deltoid  Hgament  and  chronic  disloca- 
tion of  the  astragalo-navicular  joint  Katzenstein's  operation  may  be  of  value 
(see  p.  1067). 

Ogston's  Operation. — Apply  Esmarch's  bandage.  On  the  inner  side  of  the 
foot  make  an  oblique  incision  in  such  a  manner  that  the  middle  of  the  cut  crosses 
the  astragalo-scaphoid  articulation.  With  a  periosteal  elevator  expose  those 
portions  of  the  head  of  the  astragalus  and  the  scaphoid  which  are  contiguous  to 
the  joint.  With  a  chisel  remove  sufficient  of  these  bones  (especially  of  the 
astragalus)  that  when  their  cut  surfaces  are  approximated  the  sole  of  the  foot  is 
arched  in  the  normal  fashion.  Ogston  maintains  the  bones  in  apposition  by 
means  of  bone  pegs;  this  is  perhaps  unnecessary.  Close  the  wound  without 
drainage.  Dress.  Immobilize  with  plaster  of  Paris.  Place  limb  in  elevated 
position.     Remove  Esmarch's  bandage.     Treat  the  case  as  a  fracture. 

Gleich's  Operation. — Gleich  in  1893  described  his  operation  of  cuneiform 
osteotomy  of  the  os  calcis.  Brenner  modified  the  operation  in  that  he  advised  a 
mere  oblique  section  of  the  bone  in  place  of  the  removal  of  a  wedge.  It  is 
Brenner's  modification  as  performed  in  von  Eiselsberg's  clinic  that  is  here 
described.  The  results  have  been  very  good.  Riedl  reports  that  87  per  cent,  of 
Brenner's  patients  are  cured,  many  of  them  being  able  to  serve  in  the  army. 


1 1 9© 


FLAT-FOOT 


Step  I. — Apply  an  elastic  constrictor  to  the  thigh.  Place  the  foot  and  ankle 
on  a  sand-bag  in  such  a  manner  that  the  whole  inner  (tibial)  side  of  the  foot  and 
ankle  is  imbedded  in  and  steadied  by  the  sand-bag.  One  finger's  breadth 
behind  the  external  malleolus  make  an  oblique  incision  do\\Ti  to  and  through 
the  periosteum  of  the  os  calcis.  Brenner  prefers  to  operate  on  the  inner  side 
(H.  Riedl,  "Archiv  fur  Klin.  Chir.,"  xcii,  p.  416). 

Step  2. — With  an  osteotome  divide  the  os  calcis  obliquely  from  above  down- 
wards and  forwards.  It  is  well  to  use  a  broadbladed  osteotome  in  order  to 
avoid  splintering  of  the  bone  and  to  leave  a  smooth  cut  surface.  As  soon  as  the 
bone  is  di\'ided  cut  the  periosteum  on  the  inner  side  of  the  bone.  Complete 
mobility  of  the  posterior  fragment  of  bone  is  necessary-;  if  it  is  not  mobile  some 
undivided  strands  of  periosteum  must  be  looked  for  and,  when  found,  cut. 

Step  3. — Push  the  fragment  of  bone  downwards,  forwards  and  a  trifle  inwards 
to  the  desired  extent.  If  valgus  is  a  feature,  then  the  lateral  dislocation  of  the 
fragment  must  be  more  pronounced.  The  downward  displacement  should  be 
about  ^  to  %  inch.  If  the  operation  has  been  properly  performed  the  bone 
ought  to  tend  to  stay  in  its  new  position. 


Fig.  1478. — Brenner's  modification  of  Gleich's  operation,     ir.  Eiselsberg.) 

Step  4. — Hold  the  bone  in  position.  With  a  knife  or  tenotome  puncture  the 
skin  of  the  heel  over  the  end  of  the  os  calcis.  Introduce  a  drill  through  the  skin 
puncture,  and  fix  the  fragment  of  bone  in  its  new  position  by  means  of  this  drill. 
Brenner  does  not  nail  the  bone. 

Step  5. — Close  the  wound  without  drainage.  Apply  dressings.  Leave  the 
drill  in  situ.  Immobilize  with  plaster  of  Paris  in  a  position  of  slight  supination 
and  plantar  flexion.     Remove  the  elastic  constrictor. 

.■\fter  about  two  weeks  remove  the  drill  without  taking  off  all  the  plaster  of 
Paris.  About  three  weeks  after  operation  renew  the  plaster  of  Paris  so  that  the 
patient  can  move  about  without  risk  to  the  calcaneum.  Bony  union  is  generally 
complete  about  six  weeks  after  operation.  Figure  1478  shows  the  result  in  a 
patient  of  v.  Eiselsberg's  two  years  after  operation. 

Nicoladoni's  Operation. — Paralysis  of  the  gastrocnemius  is  liable  to  lead  to 
iclipes  cams,  the  arching  of  the  foot  being  caused  by  the  unrestrained  action  of 
the  short  muscles  of  the  foot.     Nicoladoni  imagined  that  if,  in  severe  flat-foot. 


FLAT-FOOT  IIQI 

the  short  muscles  were  given  free  play  by  throwing  their  antagonists  out  of  action 
their  action  would  tend  to  cure  the  deformity.  If  the  tcndo-Achillis  is  divided 
and  kept  temporarily  from  reuniting  the  above  conditions  will  be  fulfilled. 
The  following  is  Nicoladoni's  operation  with  a  trivial  modification  by  Hertle: 

Step  I. — Perform  subcutaneous  tenotomy  of  the  tendo-Achillis  at  the  clas- 
sical site. 

Step  2. — At  a  point  about  i|'^  inches  higher  than  the  puncture  of  the  teno- 
tome, make  a  longitudinal  incision  about  2  inches  long  along  the  inner  side  of 
the  tendon.  Separate  the  tendon  from  its  surroundings  and  pull  its  stump  out 
of  the  wound. 

Step  3. — Fold  the  mobilized  tendon  upwards  and  tuck  its  cut  end  under  the 
deep  fascia  of  the  leg.  Fix  the  cut  end  of  the  tendon  in  position  by  one  or  more 
sutures. 

Step  4. — Close  the  skin  wound.  Dress.  Immobilize  for  ten  days.  After 
about  ten  days  remove  all  immobilizing  apparatus  and  encourage  the  patient 
to  walk.  The  more  exercise  is  taken  the  more  likely  are  the  muscles  concerned 
to  cure  the  deformity. 

It  was  Nicoladoni's  intention  to  repair  the  tendo-Achillis  after  the  flat-foot 
was  relieved  but  neither  he  nor  Hertle  have  found  it  necessary.  Results  are 
reported  to  be  excellent  not  only  are  the  pains  permanently  relieved,  but  an 
anatomic  correction  of  the  deformity  is  often  obtained.  The  tendo-Achillis 
reforms  after  a  time. 

Ernst  Miiller's  Operation  (" Centralblatt  f.  Chir.,"  1903,  p.  40). — In  flat- 
foot,  especially  when  muscles  are  spastic,  the  tibialis  anticus  tendon  often  stands 
out  like  a  cord  and  its  site  is  marked  on  the  skin  by  a  pigmented  line.  The 
object  of  Miiller's  operation  is  forcibly  to  correct  the  position  of  the  foot  and  to 
retain  the  new  position  by  means  of  the  anterior  tibial  tendon.  In  thirteen  cases 
the  operation  gave  satisfactory  results. 

Step  I. — Tenotomy  of  tendo  Achillis  to  permit  elevation  of  arch  of  foot. 

Step  2. — From  a  point  below  and  behind  the  internal  malleolus  midway 
between  it  and  the  sole,  make  a  curved  incision  along  the  margin  of  the  arch  of 
the  sole  to  the  base  of  the  first  metatarsal  bone. 

Step  3. — Find  and  divide  the  insertion  of  the  tibialis  anticus  at  the  anterior 
end  of  the  wound.     Isolate  the  tendon  up  to  the  ankle. 

Step  4. — 'Expose  the  plantar  surface  of  the  navicular  bone  and  bore  a  hole, 
the  size  of  a  lead-pencil,  through  it  from  below  upwards  and  slightly  backwards. 

Step  5. — Pull  the  tendon  of  the  tibialis  anticus  through  this  bone  tunnel  by 
means  of  a  thread. 

Step  6. — Push  the  arch  of  the  foot  forcibly  upwards.  Pull  the  tendon 
strongly  down  and  wind  it  around  the  inner  margin  of  the  navicular  bone.  Fix 
the  tendon  to  the  bone  or  periosteum  with  wire  sutures.  Close  the  wound  with- 
out drainage.  Dress.  Immobilize  in  plaster  of  Paris  for  four  weeks,  after  which 
massage  and  passive  movements  are  begun.  The  "  flat-foot  sole  "  should  be  used 
until  there  is  complete  functional  recovery. 

Eugen  Miiller  ("Brun's  Beitrage,"  Ixxxv,  424)  writing  of  Ernst  Miiller's 
operation  says  it  is  only  suitable  in  severe  cases,  e.g.,  those  in  which  there  is  a 
complete  sinking  of  the  arch  when  weight  is  borne  on  the  foot.     If  a  flat-foot 


IIQ2  TENDON    SHEATHS   AND   TENORRHAPHY 

plate  is  used,  it  causes  great  pain.  When  the  condition  is  recent  the  bones 
involved  still  preserve  their  normal  shape  or  are  only  slightly  deformed  and  they 
retain  their  normal  mobility.  The  normal  arch  can  be  restored  by  manipula- 
tion when  no  weight  is  borne  on  it,  and  when  the  ankle-joint  is  in  a  position  of 
plantar  flexion,  i.e.,  when  the  tendo  Achillis  is  not  stretched.  If  one  tries  to 
bring  such  a  foot  to  a  right  angle  with  the  leg  or  to  flex  it  dorsally  the  flat-foot 
immediately  recurs,  the  head  of  the  astragalus  and  the  navicular  bone  becoming 
prominent  in  the  sole.  In  such  cases  the  tendo  Achillis  is  short.  The  tendon 
shortness  hinders  the  calcaneum,  and  with  it  the  astragalus,  from  being  brought 
to  a  right  angle  to  the  leg — if  one  attempts  to  attain  such  a  position  the  motion  is 
not  accomplished  at  the  ankle  but  between  the  tarsal  bones  and  is  combined  with 
pronation,  thus  giving  rise  to  flattening  of  the  arch  and  prominence  of  the  head 
of  the  astragalus  and  navicular  bone.  In  some  cases  a  marked  looseness  of 
the  tarsal  joints  develops  and  the  achillotomy  plus  transplantation  of  the  tibialis 
anticus  are  insufficient.  Weight  on  the  foot  causes  it  to  become  pronated  to  such 
an  extent  that  the  inner  margin  of  the  sole  still  touches  the  floor.  In  such  condi- 
tions arthrodesis  of  Chopart's  or  the  talo-tarsal  joint  ought  to  precede  tendon 
transplantation.  In  a  few  bad  cases  pronation  may  be  combatted  by  shortening 
of  the  tibialis  posticus.  Eugen  Mliller  reports  many  remarkably  good  results. 
According  to  Vulpius  ("Die  Sehneniiberpflanzung"),  weakness  or  paralysis 
of  the  tibialis  anticus  and  posticus  and  of  the  gastrocnemius  is  the  principal 
cause  of  paralytic  flat-foot  (pes  abductus  pronatus).  The  appropriate  treat- 
ment therefore  consists,  first,  in  overcorrecting  the  existing  deformity;  and, 
second,  in  preventing  recurrence  by  strengthening  the  affected  muscles,  and  if 
necessary  shortening  their  tendons.  The  after-treatment  includes  exercise  of 
the  adductors,  supinators,  and  dorsal  flexors;  and  the  use  of  an  articulated  sup- 
port to  the  sole  until  sufficient  muscular  strength  is  developed.  One  example  of 
Vulpius'  method  of  treatment  will  sufl&ce: 

K.  K.,  four  years.  Paralysis  in  second  year.  Marked  equinus  and  flat-foot.  Tib.  ant. 
and  post,  completely  paralyzed.  The  other  muscles  in  good  condition.  Shortening  of  the 
Achilles  and  peroneal  tendons.  Operation:  Rectification  of  deformity.  Tenotomy  of  tendo 
Achillis.  Transplantation  of  peroneus  longus  on  to  tibialis  posticus,  of  the  extensor  hallucis 
and  a  good  portion  of  the  ext.  digitorum  on  to  the  tibialis  anticus.  Result:  After  two  month- 
foot  was  in  good  position  and  all  movements  possible.  After  one  year  adduction  and  supinas 
tion  could  be  carried  out  with  power. 


CHAPTER  CVII 
TENDON  SHEATHS  AND  TENORRHAPHY 

Operation  is  most  commonly  performed  on  the  sheaths  of  tendons  for  the 
removal  of  tuberculous  disease. 

Apply  a  tourniquet  above  the  site  of  disease.  Make  an  incision  over  the 
swelling,  following  the  course  of  the  tendon.  Split  the  sheath  of  the  tendon  wide 
open.  Retract  the  edges  of  the  sheath  wound  with  sharp  hooks  or  volsellae. 
Dissect  away  all  diseased  tissues.  If  possible,  do  not  touch  the  wound  with  the 
fingers  unless  gloves  are  worn.  Rub  into  the  whole  wound  sterile  iodoform. 
Close  the  wound  by  sutures.     Apply  dressings  and  splint. 


TENORRHAPHY 


1 193 


Tendon  Suture:  Tenorrhaphy.^ — To  avoid  unnecessary  cutting  it  is  well 
to  use  a  round  needle,  such  as  is  used  in  intestinal  work,  but  this  is  not  of  much 
importance.     All  the  ordinary  suture  materials  are  used,  viz.,  catgut,  silk,  hemp, 


Fig.  1479.  Fig.  1480. 

silkworm-gut,  silver  wire,  kangaroo  tendon,  etc. 


Fig.  1 48 1. 
If  catgut  is  chosen,  it  ought 


to  be  of  the  chromicized  variety. 

The  accompanying  figures  elucidate  the  various  methods  of  applying  sutures 
better  than  any  number  of  words  (Figs.  1479  to  1488).     Note  in  figure  1483  the 


Fig.  1482. 


Fig.  1483. 


Fig.  1484. 


Fig.  1485. 


supporting  suture,  and  in  figure  i486  the  ligatures  tied  around  the  ends  of  the 
tendon  to  prevent  the  sutures  tearing  out.  All  the  above  methods  of  suturing 
are  applicable  where  the  divided  ends  of  tendon  can  be  brought  into  direct 
apposition.  Sometimes  it  is  necessary  to  suture  a  round  to  a  flat  tendon,  in 
which  case  the  flat  maybe  folded  over  the  round  and  there  fixed  by  a  few  stitches 


1 1 94 


TENTJON    SHEATHS   AND   TENORRHAPHY 


(Fig.  1489),  or  the  end  of  one  tendon  may  be  drawn  through  a  split  or  "button 
hole"  in  another  tendon  and  sutured  (Figs.  1490,  1491,  1492). 

Tendons  being  composed  of  parallel  bundles  of  fibres,  it  is  easy  for  sutures  to 
cut  their  way  out  by  separating  the  fibres.  Suter  ("Arch.  f.  klin.  Chir.,"'  Ixxii, 
728)  describes  several  easy  and  efficient  means  of  avoiding  this  accident.  Figures 
1493  to  1497,  show  how  the  sutures  are  introduced;  the  ends  of  the 
sutures  are   tied  together  at  one    side   of   the    tendon    (Fig.    1498).      After 


Fig.  i486. 


Fig.  1487. 


R 


Fig.  14SS 


Fig.  1489. 


the  sutures  are  in  place  tie  the  two  ends  a  a^  to  the  two  ends  B  B*  (Fig, 
1499);  and  thus  obtain  lateral  approximation  of  the  ends  of  the  tendon.  For 
further  security  the  two  ends  of  suture  a  a^  may  be  made  to  surround  both 
segments  of  tendon,  and  the  same  may  be  done  with  the  suture  B  b*  (Fig.  1500). 
After  healing  takes  place  it  becomes  impossible  to  distinguish  between  a  union 
obtained  by  this  method  and  that  by  end-to-end  approximation.  If  end-to-end 
approximation  is  desired,  the  sutures  a  a\b  b\  maybe  used  as  relaxation  sutures. 
Often  it  is  impossible  to  bring  the  ends  into  the  desired  apposition,  owing  to 
shrinkage,  loss  of  substance,  or  the  exigencies  of  transplantation,  and  various 


TENORRHAPHY 


II95 


Fig.  1490. 


Fig.  1493- 


Fig.  1492. 


Fig.  1494. 


Fig.  1495. 


Fig.  1496. 


Fig.  1497. 


Fig.  1498. 


m 


Fig.  1499. 


Fig.  lioo. 


Fig.  X501. 


1 1 96 


TENDON  SHEATHS  AND  TENORRHAPHY 


means  of  tendon  lengthening  must  be  used.  Figures  1502,  1503,  1504  and  1505 
show  the  best-known  methods.  Occasionally  the  above  means  are  inapplicable, 
and  in  order  to  obtain  union  between  the  separated  ends  of  tendon  it  is  nec- 
essary to  fill  the  gap  with  some  suture  material  or  a  graft.  Figures  1482  and 
1483  show  how  such  sutures  may  be  applied. 

Hunkin  devised  the  following  useful  stitch: 

Put  the  two  fore  ends  of  a  double  silk  or  hemp  suture  through  the  eye  of  a 
needle.  Introduce  the  needle  into  the  cut  surface  of  one  tendon  (X)  and  make 
it  follow  the  course  shown  in  Fig.  1506.  \\Tien  the  needle  at  last  emerges  (Y)  tie 
the  ends  of  the  suture  Y  to  the  loop  X  by  means  of  a  half-hitch. 


Fig.  1502. 


Fig.  1503. 


Fig.  1504. 


Fig.  1505. 


A  number  of  strands  of  catgut  or  catgut  and  silk  together  may  be  formed  into 
a  small  cable  the  ends  of  which  may  be  sutured  to  the  divided  end  of  the  tendon. 
Whatever  material  is  used  to  fill  the  gap,  it  merely  acts  as  a  guide  or  scaffold  along 
which  nature  may  deposit  new  tendon  tissue  or  a  substitute  therefor.  Vulpius 
finds  that  even  after  aseptic  healing  silk  sutures  are  ultimately  thrown  off,  with- 
out ill  result,  in  15  to  20  per  cent,  of  all  cases  when  used  as  ordinary  tendon  su- 
tures. When  used  as  grafts,  more  damage  must  follow.  Probably  as  a  graft, 
chromicized  catgut  or  prepared  tjendon  is  preferable  to  silk.  A  combination  of 
silk  and  catgut  is  well  recommended.  If  two  neighboring  tendons  are  in  part 
destroyed  by  the  same  accident,  a  portion  of  the  less  important  one  may  be  used 
to  replace  the  defect  in  the  more  important  (Fig.  1507).  When,  as  a  result  of  an 
incised  wound,  e.g.,  of  the  dorsum  of  the  foot,  a  tendon  is  divided,  the  proximal 
end  is  immediately  retracted  into  its  sheath.  To  find  the  retracted  portion  pass 
forceps  up  the  sheath,  seize  the  tendon,  and  pull  it  down.  Very  commonly, 
this  procedure  is  futile,  and  we  are  compelled  to  split  open  the  sheath  for  a 
greater  or  less  distance  upwards.  The  retracted  tendon  may  be  forced  down- 
wards by  methodically  pressing  the  muscular  belly  downwards  or  by  applying 
an  elastic  bandage  tightly  around  the  limb  from  the  origin  of  the  muscle  at  fault 
downwards.     If  after  thorough  and  extensive  search  the  upper  end  of  the  tendon 


TENORRHAPHY 


II97 


cannot  be  found,  the  distal  end  ought  to  be  united  to  a  neighboring  tendon  by 
the  methods  shown  in  figures  1490,  1491,  and  1492.  The  approximated  surfaces 
of  tendon  must,  of  course,  be  suitably  freshened  before  the  sutures  are  applied. 
Sometimes  the  proximal  end  of  the  tendon  is  accessible  and  the  distal  lost 
or  destroyed.  Several  methods  of  treatment  are  applicable:  (a)  The  end  of 
the  tendon  may  be  united  to  the  side  of  a  neighboring  tendon.  (See  "Trans- 
plantation of  Tendons.")     (b)  The  end  of  the  tendon  may  be  fixed  to  the  peri- 


//        ^ 


Fig.  1506. 


Fig.  150/ 


osteum  or  to  the  bone  itself  at  a  point  as  near  as  possible  to  its  normal  insertion. 
(c)  The  end  of  the  tendon  may  be  united  to  the  bone  at  its  normal  point  of  in- 
sertion by  the  intermediation  of  a  catgut  or  silk  graft. 

Implantation  of  tendon  to  periosteum  or  bone  may  be  affected  as  follows: 
Method  I  (Lange). — With  knife  and  periosteal  elevator  raise  a  flap  of  peri- 
osteum, ^^  to  %  inch  in  length,  at  the  site  chosen  for  the  tendon  insertion. 


-Perimiieum. 


V  Sone 

^  Cutler  in  Bene 

Fig.  1508. 

Suture  the  end  of  the  tendon  to  the  periosteal  flap.  When  the  tendon  is  not 
long  enough  to  reach  the  point  of  insertion,  Lange  makes  use  of  a  double  suture 
of  strong  silk  as  a  graft. 

Method  2  (Wolff). — Divide  the  periosteum  at  the  site  selected.  Reflect  the 
periosteum  laterally.  With  a  chisel,  cut  a  gutter  or  groove  in  the  exposed  bone. 
Place  the  tendon  in  the  bone  gutter.  Replace  the  periosteal  flaps  over  the  im- 
planted tendon  and  suture  them  together  and  to  the  tendon  (Fig.  1508). 

When  tendon  suturing  is  done  as  a  secondary  operation,  the  ends  of  the 
tendon  will  be  found  adherent  to  a  mass  of  scar  tissue  lying  between  them,  and 


iiqS 


TENDON  SHEATHS  AND  TENORRHAPHY 


which  is  firmly  adherent  to  surrounding  structures,  especially  to  the  skin. 
Before  the  vivified  ends  of  the  tendon  are  united,  this  mass  of  firm,  hard  tissue 
must  be  thoroughly  excised,  and  adhesions  which  prevent  approximation  and 
gliding  of  the  tendons  must  be  broken  down. 

Where  it  seemed  impossible  to  obtain  a  satisfactory  result  by  excising  the  scar 
tissue  in  a  case  in  which  the  distal  portion  of  the  flexor  of  the  index  finger  was 
adherent  to  the  cicatrix,  Chassaignac  sought  for,  found,  and  united  the  proximal 
portion  of  the  tendon  to  the  scar  close  to  the  distal  portion  (tendo-cutaneous 
suture). 

After-treatment. — The  wound  having  been  closed,  if  possible  without 
drainage,  abundant  dressings  are  applied,  and  the  parts  fixed  by  splints  or  plaster 
of  Paris  in  such  a  position  that  tension  on  the  sutures  is  relaxed.  No  attempts 
at  motion  should  be  made  before  the  lapse  of  two  weeks,  in  the  case  of  the  smaller 


Fig.  1509. 


Fig.  1510. 


tendons;  for  the  larger  tendons,  or  in  cases  where  grafts  (of  catgut,  silk,  etc.) 
have  been  employed,  a  longer  period  of  rest  is  proper.  After  this  passive  and 
then  active  motion  must  be  begun,  aided  by  massage  and  electrical  stimulation. 
Owing  to  the  occurrence  of  atrophy  from  disuse  the  after-treatment  will  be  more 
prolonged  where  the  tenorrhaphy  was  secondary  than  where  it  was  performed 
at  the  time  of  the  original  injury. 

Approximation  of  Severed  Ends  of  Tendon  by  Means  of  Transplanting 
its  Osseous  Insertion  (Bergmann,  Poncet). — It  may  be  impossible,  by  ordinary 
means,  to  approximate  the  fragments  in  transverse  fracture  of  the  patella 
in  rupture  of  the  ligamentum  patellae  or  quadriceps  tendon,  but  the  following 
operation  may  suffice  to  permit  it: 

Step  I. — Expose  the  parts  by  means  of  a  vertical  or  crucial  incision  (Figs. 
1509,  1510). 

Step  2. — With  a  chisel  separate  the  tibial  tubercle,  and  with  it  the  liga- 
mentum patella,  from  the  tibia. 

Step  3. — Divide  any  adhesions  which  prevent  approximation. 

Step  4. — Unite  the  fragments  of  bone  or  tendon  by  strong  sutures. 

Step  5. — The  fragments  of  bone  or  tendon  ha\dng  been  united,  the  separated 
tibial  tuberosity  attached  to  the  ligamentum  patellae  has  slipped  upwards  and 


TENORRHAPHY 


1 199 


assumed  a  new  position  on  the  surface  of  the  tibia.  Fix  the  tibial  tuberosity 
in  its  new  position  by  means  of  a  buried  ivory  peg  or  by  a  steel  nail,  which  is 
left  protruding  through  the  skin  wound,  to  be  removed  after  union  has  been 
secured. 

Step  6. — Suture  the  fascia  and  skin-wounds.     Apply  dressings.     Immobi- 
lize with  splints  or  plaster  of  Paris  in  extended  position  and  elevate  the  limb. 


Fig.  i;ii. 


^ 


Fig.  1514. 


Fig.  1515. 


A  similar  operation  may  be  used  in  cases  where  there  is  much  loss  of  sub- 
stance in  the  tendo  Achillis  or  in  the  tendon  of  the  triceps  brachialis.  Figures 
1 51 1  and  151 2  are  self-explanatory. 

For  the  correction  of  deformity,  tendons  which  have  never  been  divided 
often  require  to  be  lengthened.     Tenotomy  is  the  most  common  means  of 


I200 


TENDON  SHEATHS  AND  TENORRHAPHY 


securing  the  necessary  elongation.  (See  "Tenotomy.")  Poncet's  method 
of  making  shallow  lateral  incisions  (Fig.)  1505  may  be  of  service  under  such 
circumstances.  Anderson's  method  of  tendon  lengthening  by  splitting,  sliding, 
and  suturing  is  shown  in  figure  1513.  The  Hibbs-Sporon  method  can  be 
readily  grasped  by  glancing  at  figure  1514. 


Fig.  1516. 

Tendon  Shortening. — After  the  correction  of  deformity  certain  tendons 
mav  be  too  long  for  the  proper  transmission  of  power,  or  the  exigencies  of 
transplantation  may  require  that  they  be  shortened.  Figures  1515  and  15 16 
show  a  simple  reduplication  of  the  tendon.  In  figure  151 7  the  tendon  is  spht 
longitudinally  and  the  longitudinal  converted  into  a  transverse  wound.  In 
figure  1 5 18  the  whole  thickness  of  the  tendon  has  been  cut  away  with  the 

r\ 


W 


s 


Fig.  1517. 


Fig.  1518. 


Fig. 


1519- 


exception  of  a  thin  slip  at  the  side,  which  aids  in  the  subsequent  healing. 
In  figure  15 19  a  "draw"  stitch  when  pulled  tight  throws  the  tendon  into  folds 
and  so  shortens  it.  Figures  1541,  1542,  1543,  1544,  show  in  detail  how  much 
a  tendon  as  the  Achilles  may  be  shortened.  Other  methods  of  tendon  short- 
ening will  be  incidentally  described  in  the  paragraphs  devoted  to  transplantation. 


Fig.  1520.  Fig.  is-'i. 

Figs.  1520  and  1521. — Operations  for  displaced  peroneus  longus  tendon. 

Displacement  of  Peroneus  Longus  Tendon. — Make  an  incision  about 
2  inches  in  length,  obliquely  from  above  downwards  and  forwards,  over  the 
outer  surface  of  the  external  malleolus  (Fig.  1520).  Do  not  cut  deeper  than 
the  subcutaneous  tissue.  Expose  the  external  annular  ligament,  which  is 
torn  when  the  peroneus  tendon  is  luxated.  If  the  fragments  of  the  ligament 
can  be  brought  into  apposition  over  the  tendon,  suture  them  in  their  normal 


TENDON    TRANSFERENCE  I20I 

position.  If  this  cannot  be  done,  expose  a  larger  surface  of  the  external 
malleolus  and  from  it  raise  a  flap  of  periosteum  with  its  base  downwards. 
Turn  this  flap  downwards  and  suture  its  free  extremity  to  the  remnants  of  the 
annular  ligament  or  to  the  periosteum  of  the  os  calcis.  Another  method 
consists  in  making  the  periosteal  flap  at  a  slightly  higher  level — turning  it 
back,  over  the  peroneal  tendons  and  there  suturing  it  to  the  deep  fascia  (Fig. 
1521)  (Walsham).  Close  the  skin-wound  without  drainage.  Dress.  Immobi- 
lize for  two  weeks  and  then  begin  passive  motion. 

Instead  of  using  the  periosteum,  Lexer  obtains  a  free  (unattached)  slip  of 
tendon  from  the  tendo  Achillis  or  the  rectus  femoris  (of  the  patient  himself  or 
from  a  recently  amputated  limb)  and  either  sutures  it  to  the  periosteum  as  a 
bridge  over  the  peroneal  tendon  or  he  nails  its  ends  into  a  gutter  cut  in  the 
malleolus  above  and  another  gutter  cut  in  the  os  calcis. 

TENDON  TRANSFERENCE  OR  TRANSPLANTATION 

Objects.- — The  objects  of  tendon  transference  are: 

"  (a)  To  fortify  a  weakened  group  of  muscles. 

"(J)  To  supplant  a  completely  paralyzed   muscle  or  group  of  muscles. 

"(c)  To  obstruct,  balance  or  oppose  an  overacting  spastic  group. 

"  (d)  To  deviate  tendon  action  when  perverted — as  in  transference  of  the 
tendo  Achillis  to  the  outer  side  of  the  os  calcis  in  congenital  club-foot  to  prevent 
inversion  of  the  ankle. 

"(e)  As  a  help  in  partial  arthrodesis"  (Robert  Jones). 

F^rinciples. — H.  0.  Thomas  has  pointed  out  that  a  muscle  may  fail  to 
act  and  may  simulate  paralysis  because  it  has  been  overstretched  while  weak. 
This  is  well  seen  in  wrist  drop.  Here  the  weakened  extensors  may  have  re- 
covered from  the  original  disease,  but  the  stronger  flexors  have  so  stretched 
and  dominated  them  that  they  no  longer  act,  while  the  dominant  flexors  have 
assumed  a  condition  of  contracture  from  long-continued  want  of  opposition. 
If  such  a  hand  is  gradually  brought  into  a  position  of  overextension  and  kept 
in  that  position  for  many  months  continuously,  recovery  may  be  expected. 
The  recovery  is  due  to  shortening  of  the  weakened  tendons  (the  muscles  of 
which  ought  of  course  to  be  treated  by  massage,  etc.)  and  to  elongation  of  the 
contracted  (flexor)  tendons  (Tubby  and  Jones). 

This  recognition  of  simulated  paralysis  is  of  very  great  importance  when 
one  is  deciding  on  operation.  Frequently  brilliant  immediate  results  have 
been  obtained  by  tendon  transference,  but  later  there  has  been  relapse.  This 
is  commonly  due  to  neglect  of  the  Thomas  principle  referred  to  in  the  preceding 
paragraph.  After  being  transferred  or  transplanted,  a  tendon  is  naturally 
weak  and  the  point  where  it  is  united  to  its  new  insertion  consists  of  weak 
scar  tissue.  If  after  the  wound  has  healed  we  permit  undue  strain  (exerted 
by  gravity  or  by  opposing  muscles)  to  be  inflicted  on  the  transferred  tendon 
it  cannot  avoid  being  stretched  and  becoming  useless.  The  transferred  tendon 
ought  to  be  treated  on  the  same  principles  as  recommended  in  wrist  drop, 
and  the  treatment  should  be  kept  up  until  "the  patient  is  able  by  a  voluntary 
effort  to  make  it  forcibly  act  and  it  can  successfully  withstand  the  action  of 

76 


I202  TENDON    SHEATHS    AND   TENORRHAPHY 

gravity"  (Robert  Jones).  Some  of  the  methods  of  carrying  out  these  principles 
will  be  discussed  later. 

Tendon  Transplantation.^ — When  there  is  a  loss  of  muscular  function, 
incapable  of  spontaneous  recovery  or  of  relief  by  simpler  means,  tendon  trans- 
plantation may  be  used.  Loss  of  muscular  function  may  be  due  to  paralysis 
or  paresis  of  a  single  muscle  or  of  a  group  of  muscles,  or  to  an  excess  of  power 
in  one  muscle  or  group  of  muscles,  i.e.,  there  is  a  loss  of  balance  between  the 
muscles  acting  on  a  joint.  Balance  may  be  restored  by  transplanting  power 
from  the  strong  to  the  weak.  In  order  that  transplantation  may  be  of  use 
it  is  essential  that  the  loss  of  function  is  limited  in  extent  and  that  sufficiently 
powerful  muscles  are  within  convenient  distance  of  the  weakened  ones,  e.g., 
no  benefit  could  accrue  from  tendon  transplantation  in  the  case  of  a  so-called 
'  flail-joint;"  the  loss  of  function  is  too  wide-spread  and  there  are  probably 
no  neighboring  muscles  in  proper  position  to  lend  power.  Where  there  has 
been  loss  of  tendon  from  accident  or  disease,  and  union,  whether  direct,  by 
implantation,  or  by  tendon  lengthening,  is  impossible,  then  transplantation 
may  restore  function.  Frequently  paralysis  following  acute  poliomyelitis 
is  circumscribed,  so  that  healthy  muscles  are  found  alongside  paralyzed  ones; 
in  such  cases  transplantation  may  be  valuable.  Before  operating,  however, 
we  must  be  very  sure  that  spontaneous  recovery  is  impossible.  Never  operate 
until  six  or  nine  months  have  elapsed  since  the  paralysis  appeared.  Trans- 
plantation is  of  use  not  only  in  restoring  function,  but  in  obviating  deformity. 

The  most  common  forms  of  partial  paralysis  requiring  operation  are  those 
about  the  ankle  evidenced  by  the  presence  of  talipes  calcaneus,  paralytic 
varus  and  equino-varus,  and  flat-foot.  In  spastic  paralysis  the  want  of  muscu- 
lar balance  may  be  due  to  increased  power  in  one  set  of  muscles,  with  or  with- 
out diminished  power  in  the  opposing  muscles.  Inflammatory  arthritis  may 
cause  contractures  remediable  by  transplantation. 

A  well-defined  plan  of  procedure  must  be  worked  out  in  each  case  before 
operation  is  begun.  We  must  know  exactly  which  muscles  are  paralyzed 
completely  or  partially,  and  what  power  is  available  to  aid  them.  In  the  case 
of  adults  we  study  the  possible  voluntary  movements.  Movements  in  weakened 
parts  may  often  be  demonstrated  only  when  the  corresponding  muscles  in 
the  opposite  limb  are  set  in  motion.  Children  we  watch  at  play  and  stimulate 
certain  muscles  to  act  by  tickling,  etc.  When  contractures  are  present,  they 
may  hinder  certain  motions  and  may  have  caused  atrophy  in  certain  muscles 
from  disuse.  Electrical  tests,  according  to  Vulpius,  are  of  comparatively 
little  value.  Weak  currents  do  not  stimulate  sufficiently;  stronger  ones  excite 
neighboring  or  even  antagonistic  muscles.  The  application  of  the  electricity 
frightens  children  and  does  not  help  in  distinguishing  between  paralysis  and 
the  atrophy  from  disuse. 

When  deformity  exists,  it  ought  to  be  corrected  before  the  required  tendon 
transplantation  is  attempted,  e.g.,  in  paralytic  club-foot  with  paralysis  of  the 
extensor  digitorum;  if  we  transplant  part  of  the  tibialis  anticus  tendon  on  to 
the  tendon  of  the  paralyzed  muscle  and  then  correct  the  deformity,  the  tendon 
is  made  loose  and  cannot  transmit  power  to  the  foot.  If,  however,  we  first 
correct  the  deformitv  and  then  make  the  transplantation,  the  tendon  will  have 


TENDON   TRANSPLANTATION 


1203 


the  proper  tension  for  the  transmission  of  power.  If  the  operation  for  the 
correction  of  deformity  is  severe,  transplantation  should  not  be  attempted 
until  the  parts  have  completely  recovered  from  the  operative  trauma.  If 
contracted  tendons  hinder  complete  correction  of  deformity,  Vulpius  defers 
the  necessary  tenotomy  until  he  is  ready  to  transplant,  when  he  combines  ten- 
otomy and  tendon  splitting. 

Lorenz  ("  Centralblatt  flir  Chir.,"  1905,  No.  49)  considers  that  the  opera- 
tion has  been  overdone,  especially  in  cases  of  paralytic  flexion  of  the  knee. 
In  such  cases  it  is  easy  to  produce  hyperextension  of  the  knee  (genu  recurva- 
tum).  For  him  the  biceps,  semimembranosus  and  semitendinosus  constitute 
a  "noli  me  tangere^  At  most,  the  gracilis,  semitendinosus,  sartorius  and 
tensor  vaginae  may  be  used  to  help  the  quadriceps,  but  this  amount  of  help  is 
insufficient. 

General  Remarks  on  Method  of  Operating. — Incisions  to  expose  the 
tendons  should  be  longitudinal  and  so  placed  that  they  may  be  slid  over  all 
the  parts  it  is  necessary  to  expose.  An  incision  ought  not  to  be  made  directly 
over  a  tendon;  it  should  be  to  one  side  of  it.  Flaps  and  V-shaped  incisions 
lead  to  extensive  skin  dissection  and  favor  the  formation  of  adhesions. 

If  the  donating  tendon  is  remote  from  the  receiving  tendon,  a  second 
incision  will  be  necessary,  and  the  tendon  is  carried  from  the  one  opening  to 


Fig.  1522. 


Fig.  1523. 


the  other  through  a  tunnel  bored  with  a  forceps.  Numerous  incisions  may  be 
made  into  both  the  donating  and  the  receiving  muscle.  These  incisions  let 
us  know  the  actual  condition  of  the  muscles.  Next  to  a  dark-red  healthy 
muscle  we  may  find  a  yellowish-white  muscle  completely  paralyzed  and  scarcely 
distinguishable  from  the  surrounding  fat.  Another  muscle  may  show  varying 
shades  of  rose  color  (atrophy  from  disuse);  such  a  muscle  may  recover.  In 
still  another  muscle  we  may  find  all  three  conditions — -health,  paralysis,  atrophy 
in  streaks. 

In  exposing  the  donating  tendon  a  very  long  incision  may  be  required, 
especially  if  it  seems  necessary  to  form  two  muscles  out  of  one.  Under  such 
circumstances  not  only  is  a  slip  split  oflf  the  donating  tendon,  but  the  tendon 
split  or  incision  is  carried  well  up  into  the  muscle  belly.  In  continuing  the 
"split"  up  into  the  muscle  do  so  by  blunt  dissection,  and  see  that  the  portion 
of  muscle  left  attached  to  each  segment  of  tendon  normally  belongs  to  that 


I204 


TENDON  SHEATHS  AND  TENORRHAPHY 


segment.  This  renders  possible  the  formation  of  two  physiologically  distinct 
muscles  out  of  one  (Figs.  1522  and  1523).  The  donating  tendon  must  be 
conducted  by  as  straight  a  route  as  possible  to  the  receiving  one.  To  succeed 
in  this,  e.g.,  when  a  flexor  of  the  leg  is  to  donate  power  to  an  extensor  or  vice 
versa,  it  may  be  necessary  and  proper  to  conduct  it  through  a  tunnel  bored 
in  the  interosseous  membrane. 


I 


Fig.  1524. 


Fig.  1525. 


Fig.  1526. 


A  tendon  receives  nourishment  from  its  muscle,  its  bone  insertion,  and 
Us  sheath,  hence  R.  Jones,  whenever  possible,  transplants  the  tendon  sheath 
along  with  the  tendon. 

When  exposing  tendons  through  a  long  cutaneous  incision  it  is  not  necessary 
to  divide  the  fascia  throughout  the  whole  length  of  the  wound;  the  fascial 


Fig.  1527. 


Fig.  1528, 


cut  may  be  interrupted  in  places  and  thus  union  is  rendered  easier  and  more 
exact.  The  fascia  should  never  be  divided  near  its  insertion  into  bone,  other- 
wise union  will  be  difl&cult. 

Methods  of  Uniting  Transplanted  Tendons.— ^Most  of   what  has   been 
written  as  to  the  union  of  divided  tendons  is  applicable  here.     Figures  1524 


TENDON    TRANSFERENCE 


I20: 


lo  1536  illustrate  sufficiently  the  usual  methods  of  transplantation.  In  the 
figures  the  non-paralyzed  muscle  and  tendon  (the  donor)  are  uniformly  left 
unshaded;  the  paralyzed  muscle  and  tendon  (the  receiver)  are  shaded.  Before 
applying  sutures  always  vivify  the  surfaces  to  be  united,  and  always  pull  up 
any  "slack"  there  may  be  in  the  receiving  tendon  so  that  sufficient  tendon 


Fig.  1529. 


Fig.  1530. 


Fig.  1 53 1. 


tenseness  is  secured  to  permit  of  transference  or  application  of  muscle  power 
to  the  point  of  tendon  insertion.  A  lax  tendon  between  muscle  and  point  of 
insertion  is  useless. 

In  Fig.  1526  the  tendons  both  of  the  donor  and  of  the  receiver  are  com- 
pletely divided  and  the  peripheral  portion  of  the  donor  is  discarded,  i.e.,  none 


Fig.  1532. 


Fig.  1533. 


Fig.  1534. 


of  the  normal  function  of  the  donor  is  retained.  This  procedure  is  justifiable 
only  when  the  donor  is  an  entirely  unimportant  muscle  or  if,  under  the  cir- 
cumstances for  which  operation  is  undertaken,  its  normal  action  is  objectionable. 
Functionally  negligible  muscles  are  rare,  and  unexpected  evils  are  liable  to  follow 


I2o6 


TENDON   SHEATHS    AND   TENORRHAPHY 


when  even  unimportant  muscles  are  entirely  cut  off  from  their  normal  insertion. 
To  obviate  part  of  this,  many  devices  have  been  suggested,  and  most  of  them 
will  be  easily  understood  after  a  glance  at  the  figures. 

Robert  Jones  believes  that  the  union  between  the  two  tendons  should  be  as 
near  the  insertion  of  the  receiving  (paralyzed)  tendon  as  possible  to  avoid 


Fig.  1535. 


Fig.  1536. 


dangers  from  subsequent  stretching  of  that  structure.  He  prefers,  if  possible, 
to  implant  the  end  of  the  "donor"  into  the  periosteum  in  a  suitable  place  rather 
than  into  the  tendon  of  the  paralyzed  muscle. 

Lange  in  his  transplantations  makes  free  use  of  artificial  tendons  of  silk. 

Indirect  tendon  transplantation  may  be  necessary  when  the  donor  is  not 
long  enough  and  when  the  ordinary  methods  of  implantation  seem  inadvisable. 


Fig.  1537. 


I.  Tendo  Achillis.     2.  Peroneus  longus.     3.  Peroneus  brevis. 

Achillis.     6.  Tendon  of  peroneus  brevis  used  as  a  graft, 


Fig.  1S38. 

4.   Extensor  tendons. 


5.  Slip  from  tendo 


Mainzer  (quoted  by  Vulpius)  used  the  following  plan  in  a  case  of  paralysis 
of  the  extensors  of  the  toe:  Form  a  slip  from  the  tendo  Achillis  (Figs.  1537 
and  1538);  suture  the  end  of  this  slip  to  an  appropriate  point  on  the  peroneus 
brevis  tendon.  Divide  the  tendon  of  the  peroneus  brevis  at  such  a  place  that 
a  sufl&ciency  of  the  tendon  is  left  below  the  point  of  suture  with  the  tendo 


TENDON    TRANSPLANTATION  1207 

Achillis  to  reach  from  that  point  to  the  extensors  which  require  strengthening. 
Pull  this  chosen  portion  of  tendon  centralwards  out  of  its  sheath  and  sew  its  end 
to  the  extensors  (Fig.  1538,  6). 

Closure  of  Wound. — Suture  the  wounded  tendon  sheaths  with  very  fine 
catgut.  Carefully  suture  the  deep  fascia  with  buried  sutures.  Close  the  skin- 
wound.     Apply  abundant  dressings  and  a  stiff  bandage. 

Several  methods  (apart  from  splints  and  apparatus)  are  available  by  means 
of  which  the  transferred  tendon  may  be  protected  from  overstretching  until 
such  time  as  it  gains  strength.  HofTa  exposed  the  completely  paralyzed  tendons 
which  were  supplanted  by  the  operation  and  shortened  them  so  that  they  could 
act  as  cords,  keeping  the  limb  in  a  position  of  overcorrection.  Division  or 
lengthening  of  the  active  opposing  tendons  which  stretch  the  transferred  tendon 
is  harmless  and  useful.  Robert  Jones,  in  addition  to  the  above  methods, 
makes  use  of  his  "skin-flap  removal"  to  secure  uninterrupted  continuity  of  the 
overcorrection. 

After-treatment." — Keep  immobilized  for  six  weeks  in  simple  cases,  for 
eight  weeks  in  cases  where  there  has  been  much  deformity,  especially  bony 
deformity,  corrected.  The  period  of  rest  is  shortened  if  there  is  cause  to  fear 
adhesions,  e.g.,  if  the  tendon  has  been  left  outside  the  fascia  or  traverses  an 
interosseous  space.  For  a  period  of  four  weeks  the  patient  ought  to  remain 
in  bed  to  avoid  any  chance  of  injury  to  the  lines  of  suture.  After  union  is 
complete  applications  of  moist  and  dry  heat  stimulate  the  circulation.  Elec- 
trical stimulation  is  advantageous.  Passive  motion  and,  as  soon  as  possible, 
gymnastic  exercises  are  necessary.  When  the  patient  begins  walking  some 
simple  form  of  supporting  apparatus  or  boot  will  be  necessary  for  a  longer  or 
shorter  time. 

Examples  of  Tendon  Transplantation. 

I.  Talipes  equinus^ — ^due  to  infantile  palsy.  The  tibialis  anticus  and  the 
extensor  communis  digitorum  are  alone  affected.  Power  from  the  extensor 
proprius  hallucis  and  from  the  peronei  muscles  may  be  transferred  to  the 
tendon  of  the  paralyzed  muscles.  In  all  the  operations  for  equinus  it  is  pre- 
sumed that  any  shortening  of  the  tendo  Achillis  which  obstructs  overcorrection 
has  been  overcome  by  tenotomy  or  by  tendon  lengthening. 

(A)  Transplantation  of  a  "slip"  from  the  tendon  of  the  peroneus  brevis 
to  the  extensor  digitorum. 

Step  I. — From  a  point  at  least  five  fingers'  breadth  above  the  intermalleolar 
space  make  a  median  incision  downwards.  Curve  the  lower  end  of  the  cut 
slightly  inwards.  Divide  the  skin  alone.  In  the  subcutaneous  tissue  of  the 
lower  part  of  the  wound  lie  the  terminal  filaments  of  the  musculo-cutaneous 
nerve.     Preserve  these  if  possible. 

Step  2. — Split  the  deep  fascia  throughout  the  whole  length  of  the  wound 
close  to  the  tendons  of  the  extensor  digitorum  and  peroneus  brevis  which  can 
be  seen  through  the  fascia.  Separate  the  extensor  digitorum  from  its  surround- 
ings for  a  short  distance  (Fig.  1539). 

Step  3. — From  a  point  slightly  below  the  external  malleolus  make  an  incision 
upwards  parallel  to  and  about  3^^  inch  behind  the  fibula  for  a  distance  of  5 
inches.     Incise  the  sheath  of  the  peronei.     Isolate  the  tendon  of  the  peroneus 


I208 


TENDON   SHEATHS    AND   TENORRHAPHY 


brevis.  Split  this  tendon,  carrying  the  split  as  high  up  as  possible,  in  such  a 
manner  as  to  divide  it  into  an  anterior  and  posterior  segment.  Divide  the 
anterior  segment  at  the  level  of  the  malleolus.  This  forms  a  flap  of  tendon 
having  its  base  above. 

Step  4. — With  forceps  and  knife  make  a  tunnel  from  the  wound  made 
in  Steps  i  and  2.  This  tunnel  must  hug  the  outer  side  of  the  fibula,  which  is 
bared  for  a  distance  of  about  2  to  3  inches.  Pull  the  flap  of  peroneus  brevis 
tendon  through  this  tunnel  so  that  it  now  lies  in  the  front  of  the  leg. 


Fig.  1539.  I'lo.  1540. 

Figs.  1539  .^nu  1540. — Tendon  transplantation.     {Bcrgcr  and  Banzel.) 


Step  5. — Hold  the  foot  in  a  position  of  exaggerated  dorsal  flexion.  Pull 
the  extensor  communis  tendon  upwards  until  it  is  tense  and  then  make  a  longi- 
tudinal button-hole  in  it.  Through  the  button-hole  pull  the  flap  of  the  brevis 
from  behind  forwards  and  suture  as  great  a  surface  as  possible  of  one  to  the  other 

(Fig-  1539)- 

Step  6. — Close  all  the  wound  after  painstaking  hemostasis;  dorsal  flexion.* 

(B)  Transplantation  of  a  Slip  from  the  Extensor  Proprius  Hallucis  to  the 
TibiaUs  Anticus. 

This  operation  may  be  performed  either  as  an  independent  procedure  or 
to  supplement  the  flexing  power  given  by  the  peroneus  brevis  to  the  extensor 
digitorum  as  described  in  the  previous  paragraphs.  Steps  i  and  2  as  in  the 
preceding  operation. 

*  This  description  and  others  closely  follow  Berger  and  Banzet. 


TF.XnOX    TRAXSPI.AXTATKIN 


1209 


Step  3. — Retract  the  edge  of  the  wound  inwards.  Expose  the  extensor 
proprius  hallucis  and  its  tendon.  Split  the  tendon  into  an  outer  and  an  inner 
segment.  Divide  the  outer  segment  transversely  at  the  level  of  the  annular 
ligament,  so  as  to  provide  a  tendon  flap  united  to  the  muscle  above  and  free 
below. 

Step  4. — Isolate  the  tendon  of  the  tibialis  anticus  and  pull  it  upwards,  flex- 
ing the  foot  dorsally.  Make  a  longitudinal  button-hole  in  the  tendon.  Pull 
the  free  end  of  the  tendon  flap  (from  the  ext.  proprius  hallucis)  through  the 
button-hole  and  unite  it  there  as  in  Fig.  1540. 

II.  Talipes  Equinus  Due  to  Infantile  Palsy. 

The  tibialis  anticus  and  extensor  communis  digitorum  are  paralyzed. 
The  peroneus  brevis  is  not  available  as  a  donor  of  power.  The  extensor  proprius 
hallucis  is  hcalthv. 


Fig.  1541.  Fig.  1542. 

Figs.  1541  and  1542. — Tendon  shortening.     (Labey.) 


Transplantation  of  a  Slip  from  the  Ext.  Proprius  Hallucis  to  the  Extensor 
Communis  Digitonmi.     Shortening  of  the  Tibialis  Anticus. 

Step  I. — From  a  point  at  least  five  fingers'  breadth  above  the  intermalleolar 
space  make  a  median  incision  downwards.  Curve  the  lower  end  of  the  cut 
slightly  upwards.  Divide  the  skin  alone.  Preserve,  if  possible,  the  terminal 
filaments  of  the  musculo-cutaneous  nerve  in  the  subcutaneous  tissue. 

Step  2: — Split  the  deep  fascia.  To  the  inner  side  of  the  tendon  of  the 
ext.  communis,  recognize  and  isolate  the  tendon  of  the  ext.  proprius  hallucis. 

Step  3.- — Split  longitudinally  the  tendon  of  the  ext.  proprius  into  an  outer 
and  inner  segment.  Divide  the  outer  segment  transversely  at  the  level  of  the 
annular  ligament  (Fig.  1540). 

Step  4. — Pull  the  ext.  com.  digitorum  upwards,  strongly  flexing  the  foot. 
Make  a  longitudinal  button-hole  in  this  tendon  and  pull  through  the  button- 


I2IO 


TENDON  SHEATHS  AND  TENORRHAPHY 


hole  the  mobUized  flap  provided  at  the  expense  of  the  ext.  proprius.  Suture 
securely. 

Step  5. — Retract  the  inner  edge  of  the  wound  and  expose  the  tendon  of  the 
tibialis  anticus  and  shorten  it  in  the  same  manner  as  the  tendo  Achillis  is 
depicted  as  being  shortened  in  Figs.  1541,  1542,  1543,  1544. 

After  any  of  the  operations  such  as  have  been  now  described,  Robert 
Jones  endeavors  to  keep  the  united  tendons  free  from  tension  by  means  of  the 
removal  of  skin  flaps.  He  writes:  "Personally  I  see  that  the  deformity  of  the 
foot  is  overcorrected  before  any  operation  is  performed;  and  as  soon  as  the 


Fig.  1543. 
Figs.  1543  and  1544-- 


FlG.  1544. 
-Tendon  shortening.     {Labey.) 


tendon  is  transplanted,  as  in  arthrodesis,  I  remove  an  oval  skin  flap  from  the 
paralyzed  side  so  large  that  when  the  edges  are  sewn  together  the  foot  remains 
fixed  in  an  overcorrected  position.  The  removal  of  the  skin  flap,  I  venture 
to  suggest,  gives  us  considerable  help  in  removing  strain  from  the  transplanted 
tendon.  The  foot  by  this  means,  as  I  have  before  said,  remains  in  the  desired 
position  in  spite  of  any  outside  influences."  The  reader  wiU  easily  see  how 
Jones's  method  may  be  applied  to  the  operation  here  described  and  how  valuable 
it  is  calculated  to  prove. 

Regarding  tendon  transplantation  in  paralytic  club-foot.  Royal  Whitman 
writes:  "Tendon  transplantation  is  most  effective  from  the  curative  stand- 
point when  but  one  muscle  of  the  anterior  leg  group,  for  example  an  adductor 
or  abductor,  is  paralyzed.  The  most  common  form  of  this  mflder  type  is 
paralysis  of  the  tibialis  anticus.  As  this  muscle  is  the  most  powerful  dorsal 
flexor  and  adductor  of  the  foot  its  loss  is  followed  by  secondary  equino-valgus. 
In  Parish's  operation  the  tendon  of  the  adjoining  extensor  proprius  poUicis  was 
simply  attached  to  that  of  the  tibialis  anticus,  but  as  the  extensor  of  the  great 
toe  is  a  very  weak  muscle,  its  power  is  hardly  sufficient  for  the  double  task.  A 
more  efficient  procedure  is  to  split  the  tendon  of  the  paralyzed  muscle.  The 
outer  half  is  then  separated  from  its  muscular  attachment,  and  the  distal  ex- 


TENDON    TRANSPLANTATION  121 1 

tremity  is  carried  across  the  foot  and  is  sutured  to  all  the  other  tendons.  The 
proprius  pollicis  is  then  attached  to  the  inner  half.  In  cases  of  longer  standing 
and  more  marked  deformity  it  is  well  to  reduce  the  power  of  the  abductors  by 
cutting  the  tendon  of  the  peroneus  tcrtius  from  its  insertion.  This  is  then 
drawn  beneath  the  other  tendons  and  is  attached  to  that  of  the  tibialis  anticus. 
All  of  the  tendons  on  the  front  of  the  ankle  may  then  be  sutured  to  one  another, 
so  that  all  may  act  as  direct  dorsal  flexors." 

"The  relative  strength  of  the  muscles,  as  well  as  their  function,  should  be 
considered  in  selecting  grafts,  and  in  prognosis  also.  According  to  Fick,  it  is 
as  follows,  in  kilogrammeters: 

Back  of  the  Leg 

The  calf  muscle — gastrocnemius  and  soleus 8.21 

Tibialis    posticus 0.40 

Peroneus  longus o .  44 

Flexor  com.  digitorum 0.37 

Flexor  longus  pollicis 0.82 

10.  24 
Front  of  the  Leg 

Tibialis  anticus 1.61 

Extensor  proprius  pollicis o  -39 

Extensor  longus  digitorum 0.72 

Peroneus  brevis 0.31 

Peroneus  tertius 0.20 

3-23 

"The  importance  of  the  calf  muscle  on  the  back,  and  tibialis  anticus  on 
the  front  of  the  leg,  is  apparent.  The  former  is  nearly  four  times  as  strong  as 
the  combined  posterior  group,  the  latter  equal  to  all  the  others  on  the  front 
of  the  leg.  It  has  been  claimed  that  the  transplanted  muscle  may  become 
hypertrophied,  and  that  its  strength  may  increase  sufficiently  to  carry  out  its 
new  function,  but  this  is  somewhat  doubtful." 

III.  The  muscles  of  the  calf  are  paralyzed.  Talipes  calcaneus  has  resulted. 
If  the  muscles  are  not  hopelessly  paralyzed,  an  application  of  Thomas'  principles 
and  prolonged  immobilization  of  the  leg  with  the  foot  in  a  position  of  plantar 
flexion  may  lead  to  regeneration.  It  is  most  important  to  rememeber  this  and 
to  avoid  immediate  recourse  to  what  may  be  a  needless  operation. 

(A)  Shortening  of  the  tendo  Achillis  has  been  frequently  employed  (Willett, 
Gibney,  and  others).  The  methods  of  tendon  shortening  are  sufficiently  de- 
scribed (p.  1200).  It  is  more  logical,  however,  to  supply  new  power  to  the 
tendon  rather  than  merely  to  shorten  it  until  it  acts  as  a  sort  of  passive  support 
to  the  heel. 

(B)  Transference  of  a  Tendon  Flap  from  the  Flexor  Longus  Digitorum  to 
the  Tendo  Achillis. 

Step  I. — From  a  point  about  i  inch  beow  the  tip  of  the  internal  malleolus 
make  a  4-inch  incision  upwards  midway  between  the  tendo  Achillis  and  the 
posterior  border  of  the  tibia.     Expose  the  inner  border  of  the  tendo  Achillis. 


I2I2 


TENDON  SHEATHS  AND  TENORRHAPHY 


Step  2. — Split  the  tendo  Achillis  in  such  a  fashion  as  to  provide  a  tendinous 
flap,  2}^:  inches  long,  free  above  and  attached  to  the  os  calcis  below. 

Step  3. — Incise  the  deep  fascia  parallel  and  close  to  the  posterior  border 
of  the  tibia.  Avoid  injury  to  the  sheath  of  the  tibialis  posticus  and  to  the 
vessels  which  lie  posterior  to  the  flexor  digitorum  and  between  it  and  the 
flexor  proprius  hallucis.  Expose  and  isolate  the  tendon  of  the  flexor  longus 
digitorum  opposite  the  internal  malleolus. 

Step  4. — Divide  the  tendon  (flex,  digit.)  longitudinally  into  an  anterior  and 
posterior  segment.  Leave  the  anterior  segment  intact.  Divide  the  posterior 
segment  transversely  low  down  so  as  to  make  it  into  a  flap  with  pedicle  above. 


Fig.  1545. — Tendon  transplantation.     {Beiger  atid  Banzet.) 

V.   Vessels      l.fl..   Flexor    longus.     t.a..   Tendon   Achillis.      i.  Intact  portion  tendon  of  flexor  longus. 

3.   Flap  from  tendo  Achillis.     3.   Flap  from  long  flexor. 


Step  s.^Put  the  ankle  in  a  position  of  great  plantar  flexion.  Lay  the  two 
flaps  obtained  from  the  tendo  AchiDis  and  the  long  flexor  alongside  each  other 
and  unite  them  by  sutures  (Fig.  1545). 

Step  6. — Shorten  the  intact  portion  of  the  tendo  Achillis. 

Step  7. — Close  the  wound.  Dress.  Immobilize  in  a  position  of  plantar 
flexion. 

(C)  Transference  of  a  Tendon  Flap  from  the  Peroneus  Longus  to  the 
Tendo  Achillis. 

Step  I. — From  a  point  about  i  inch  below  the  external  malleolus  make  a 
4-inch  incision  upwards  between  the  fibula  and  the  tendo  Achillis. 

Step  2.— Expose  the  outer  border  of  the  tendo  Achillis  and  from  it  fashion 
a  substantial  flap— about  2}i  inches  long — free  above,  united  to  the  os  calcis 
below. 


TENDON    TRAXSI'LANTATIUN 


I213 


Step  3. — Incise  the  deep  fascia  parallel  and  close  to  the  posterior  border 
of  the  fibula.  Expose  and  open  the  sheath  of  the  peronei  muscles.  The 
tendon  of  the  p.  longus  lies  posterior  to  that  of  the  brevis.     Fig.  1546. 


Fig.  1546. — Tendon  transplantation.     {Berger  aftd  Banzet.) 

L.P.,  Peroneus  longus.     t.a..  Tendon  AchiUis.     C.P..  Peroneus  brevis.      i.   Intact  portion  tendon  peroneus 
longus.     2.  Flap  from  peroneus  longus.     3.  Flap  from  tendo  AchiUis. 

Step  4. — Split  the  tendon  into  an  outer  and  inner  segment.  Leave  the 
outer  segment  intact.  Divide  the  inner  segment  transversely,  low  down 
below  the  malleolus,  so  as  to  form  a  flap  with  its  pedicle 
above. 

Step  5. — Put  the  foot  in  a  position  of  equinus  and 
hold  it  there.  Lay  the  two  flaps  of  tendon  (from  the 
peroneus  longus  and  from  the  tendo  AchiUis)  alongside 
each  other  and  unite  them  with  sutures. 

Step  6. — Shorten  the  intact  portion  of  the  tendo 
Achfllis. 

Step  7. — Close  the  wound.  Dress.  Immobflize  in 
a  position  of  equinus. 

(D)  A  combination  of  operations  B  and  C  may  be 
employed. 

(E)  Transference  of  slips  from  the  tibialis  posticus 
and  peroneus  longus  to  the  paralyzed  tendo  AchiUis. 

Step  I. — Make  the  forked  incision  A  B   C  D   (Fig. 


1547).     Reflect  the  flaps  A  B  C,  A  B  D,  C  B  D.     In 


Fig.  1547. — Tendon 
transplantation. 
(Labey.) 


doing  this  preserve  and  retract  the  external  saphenous 

vein  and  nerve  which  lie  at  the  outer  side  of  the  tendo  AchiUis. 

Step  2. — SpUt  the  fascia  so  as  to   expose  the  outer   edge  of  the  tendo 
AchiUis.     Freely  split  open  the  sheath  of  the  peronei. 


I2I4 


TENDON  SHEATHS  AND  TENORRHAPHY 


Step  3. — Divide  the  tendon  of  the  peroneus  longus  into  an  anterior  and 
posterior  segment.  The  muscle  fibres  are  inserted  into  the  tendon  in  the 
pennate  fashion,  therefore  it  is  easy  to  continue  the  cut  in  the  tendon  up- 
wards so  as  to  form  two  muscular  bellies  each  attached  to  a  slip  consisting  of 
half  of  the  tendon  (Fig.  1548).  Carefully  avoid  injury  to  any  nerves  entering 
the  muscle.  Transversely  divide  the  posterior  slip  of  tendon  as  low  down 
as  possible. 

Step  4. — Make  a  longitudinal  cut  into  the  outer  side  of  the  tendo  Achillis. 
Retract  the  edges  of  the  cut  so  as  to  form  a  gutter  (Fig.  1548).  Implant  the 
mobilized  posterior  segment  or  slip  of  peroneus  tendon  into  the  gutter  in  the 
tendo  Achillis  and  fix  it  there  by  sutures  (Fig.  1549). 


Fig.  1548.  Fig.  1549. 

Figs.  1548  and  1549. — Tendon  transplantation.     (Labey.) 


Step  5. — Split  the  fascia  on  the  inner  side  of  the  tendo  Achillis.  Retract 
the  tendon  outwards  to  expose  the  deep  fascia  under  which  can  be  seen  posterior 
tibial  vessels  and  nerves.  Split  the  deep  fascia  longitudinally  internal  to  the 
vessels  and  nerves;  retract  these  structures.  This  exposes  the  tibialis  posticus 
in  the  depth  of  the  wound  (Fig.  1550). 

Step  6. — Isolate  and  split  the  tendon  of  the  tibialis  posticus;  imbed  one 
of  the  segments  into  the  tendo  Achillis  exactly  as  was  done  with  the  peroneus 
longus.  During  all  these  procedures  the  foot  must  be  held  in  a  position  of  over- 
correction. 


TENDON   TRANSPLANTATION 


1215 


Step  7. — Close  the  wound.  Dress.  Immobilize  in  a  position  of  over 
correction. 

(F)  The  flexor  proprius  hallucis  may  be  implanted  into  the  tendo  Achillis 
by  an  operation  almost  identical  with  that  for  the  tibialis  posticus,  and  im- 
plantation of  the  peroneus  brevis  is  almost  identical  with  that  of  the  longus. 

IV.  The  abductors  of  the  foot  (extensor  communis  digitorum,  peroneus 
longus  and  brevis)  are  paralyzed.     The  foot  assumes  the  position  of  varus. 

(A)  Transference  of  power  to  the  peronei  by  means  of  a  slip  of  tendon 
derived  from  the  tendo  Achillis.  (The  following  description  closely  follows 
that  of  Labey,  "Chir.  du  Membre  inferieur.) 


Fig.  1550. 
Figs.  1550  and  1551. 


Fig.  1551. 
-Tendon  transplantation.     {Labey.) 


Place  the  patient  on  his  sound  side  in  the  latero-ventral  posture.  Flex 
the  leg  on  the  thigh.     Have  an  assistant  hold  the  foot. 

Step  i.-r-From  a  point  ^^  inch  below  the  level  of  the  point  of  the  malleolus, 
cut  upwards  midway  between  the  posterior  border  of  the  external  malleolus 
and  the  external  border  tendo  Achillis,  to  the  level  of  the  middle  of  the  calf. 
Expose  and  retract,  uninjured,  the  external  saphenous  vein  and  nerve. 

Step  2. — Expose  and  free  the  outer  border  of  the  tendo  Achillis.  In  the 
upper  part  of  the  wound  expose  the  muscular  belly  of  the  outer  head  of  the 
gastrocnemius,  and  working  from  above  downwards  separate  it  from  the  soleus 
until  a  point  is  reached  where  their  fusion  is  complete  and  further  separation 
is  impossible.     Relax  the  tendon  by  plantar  flexon  of  foot. 


I2l6 


TENDON    SHEATHS    AND    TENORRHAPHY 


Step  3. — With  a  knife  split  the  tendo  Achillis  as  in  Fig.  1551.  The  slip 
of  tendon  is  continuous  above  with  the  gastrocnemius,  but  is  free  from  the 
soleus.  Divide  the  slip  of  tendon  transversely  low  down  so  as  to  convert  it 
into  a  flap. 

Step  4. — Divade  the  fascia  covering  the  peronei  muscles  in  the  lower  three- 
fourths  of  the  wound.  Isolate  the  peroneus  longus  (superficial)  and  the  brevis 
(more  deeply  situated).  Retract  the  tendon  of  the  longus.  The  muscular 
fibres  of  the  brevis  are  inserted  into  a  flat  tendon  which  is  superficial  to  these 
fibres.  Make  a  longitudinal  split  penetrating  to  half  the  thickness  of  the 
muscle  and  retract  the  edges  of  this  split  so  that  the  peroneus  brevis  now  forms 
a  sort  of  gutter  into  which  the  tendon  of  the  longus  is  permitted  to  fall  (Fig. 

1550)- 


Fig.  1552.  Fig.  1553. 

Figs.  1552  .\kd  1553. — Tendon  transplantation.     {Labey.) 


Step  5. — Pull  the  mobilized  flap  of  tendon  Achillis  through  between  the 
peroneus  longus  and  brevis  (Fig.  1552),  and  fix  it  there  by  sutures  as  in  Fig. 
1553.  When  bringing  the  tendon  flap  into  position  twist  it  carefully  in  such  a 
fashion  that  its  posterior  surface  (which  has  not  been  vivified  or  cut)  lies  against 
the  cut  surface  of  the  soleus  so  as  to  avoid  the  formation  of  adhesions. 

Step  6. — Close  the  wound.  Dress.  Immobilize  in  a  posture  of  plantar 
fle.xion  and  outward  rotation. 

V.  A  finger  flexor  tendon  is  lost.     Repair  by  transplantation. 

V.  Hacker  ("Beitrage  zur  klin,  Chir.,"  Ixvi,  Hft.  2,  p.  279.  Ref.  ''Journ. 
de  Chir.,"  May  10,  1910)  reports  the  case  of  a  young  girl  who  lost  the  flexor 
tendons  of  the  middle  finger  as  a  result  of  a  deep  whitlow,  v.  Hacker  operated 
as  follows:  He  made  a  skin  flap  (Fig.  1554)  which  exposed  the  whole  palmar 
aspect  of  the  middle  finger  and  showed  the  complete  absence  of  the  flexor 
tendons.  Next  he  made  two  incisions  (Fig.  1555)  along  the  line  of  the  extensor 
communis  digitorum  over  the  second  metacarpal  bone.     Through  these  incisions 


TENDON    TRANSPLANTATION 


1217 


he  split  the  tendon,  forminfj  a  long  flap  of  tendon  having  its  pedicle  near  the 
base  of  the  index  linger.  This  flap  he  passed  through  a  subcutaneous  tunnel 
to  the  palmar  aspect  of  the  middle  finger  and  sutured  its  end  to  the  periosteum 
of  the  ungual  phalanx.  To  avoid  peritendinous  adhesions  he  surrounded  the 
transplanted  tendon  with  a  piece  of  freshly  removed  hernial  sac  and  in  the 
middle  of  the  finger  sutured  across  the  tendon  a  band  of  fibrous  tissue  obtained 
from  the  debris  of  the  tendon  sheath  destroyed  by  the  whitlow.  The  wounds 
were  sutured  and  healing  took  place  by  first  intention.     Sixteen  days  later 


Fig.  1554.  Fig.  1555. 

Figs.  1554  and  1555. — Tendon  transplantation,     (von  Hacker.) 


the  stump  of  the  pld  flexor  tendon  was  exposed  in  the  palm  and  sutured  to  the 
proximal  end  of  the  transplanted  flap  of  tendon,  which  was  of  course,  divided 
from  its  old  connections  on  the  dorsum  of  the  hand.  Closure  of  the  wound 
and  immobilization  in  a  position  of  flexion  was  followed  by  healing.  Eighteen 
months  later  the  patient  could  close  her  fist  completely. 

VL  There  is  drop  wrist  due  to  musculo-spiral  paralysis. 

Tendon   Transplantation   in   Musculo-spiral    (Radial)   paralysis.     (Wrist 
drop.) — J.  B.  ]\Iurphy's  operation  has  been  described  on  page  806. 

Robert  Jones'  Operation.— While  most  of  the  operations  for  wrist  drop 
merely  endeavor  to  apply  power  to  the  tendons  of  the  extensors  of  the  fingers 
(Murphy's  method  permits  independent  use  of  the  thumb  and  index  finger.) 
Jones'  operation  makes  use  of  the  pronator  radii  teres  as  a  motor  for  the  radial 
extensors  and  of  the  palmaris  longus  and  flexor  carpi-ulnaris  for  the  extensors  of 
the  fingers,  thus  dissociating  the  movement  of  dorsal  flexion  of  the  wrist  and 
dorsal  flexion  of  the  fingers. 
77 


I2l8 


TENDON   SHEATHS    AND   TENORRHAPHY 


Step  I. — Make  a  three  inch  incision  in  the  middle  of  the  radial  side  of  the 
forearm  along  a  line  joining  the  styloid  process  of  the  radius  and  the  external 
condyle  of  the  humerus.  Through  this  cut  expose  the  posterior  border  of  the 
supinator  longus  and  retract  this  muscle  forwards  {i.e.  ventrally).  Recognize 
and  retract  dorsally  the  tendons  of  the  extensor  carpi-radialis  longior  and  brev- 
ior,  thus  exposing  the  broad  tendon  of  the  pronator  radii  teres  the  sharp  dis- 
tinct upper  edge  of  which  is  easily  palpated.  If  the  assistant  pronates  and 
supinates  the  forearm,  recognition  of  the  muscle  is  facilitated. 

Step  2. — From  the  upper  half  of  the  tendon  of  the  pronator  make  a  flap 
with  pedicle  above  (Figs.  1556  and  1557).  Pass  the  flap  through  splits  made 
in  the  tendons  of  the  two  radial  extensors  and  fix  it  to  these  tendons  by  a 
few  fine  sutures.     Close  the  wound. 


Fig.  1556. 


Fig.  1557. 


Fig.  1558. 


Step  3. — Make  a  four-inch  incision  parallel  and  internal  (medial)  to  the 
radial  artery  beginning  near  the  anterior  surface  of  the  styloid  process  of  the 
radius  and  passing  obliquely  upwards  and  medially  (Fig.  1558).  Expose  and 
free  the  tendon  of  the  palmaris  longus  and  divide  it  as  low  as  possible. 

Step  4. — Make  an  incision  from  the  pisiform  bone  upwards  for  2  3-^  inches 
(Fig.  1558)  and  expose  the  tendon  of  the  flexor  carpi-ulnaris.  Free  the  tendon 
and  divide  it  at  its  carpal  insertion.  This  step  is  diflScult  as  the  tendon  is 
short  and  receives  muscle  fibres  almost  to  its  insertion.  Protect  the  wounds 
and  mobilized  tendons. 

Step  5. — Expose  the  extensor  tendons  of  the  fingers  by  a  dorsal  median 
longitudinal  incision  just  above  the  wrist.  Some  surgeons  use  a  horse-shoe 
incision  and  flap  but  this  is  unnecessary.  With  forceps  make  a  subcutaneous 
tunnel  from  the  dorsal  wound  around  the  radial  side  of  the  arm  to  the  wound 
exposing  the  palmaris  longus  and  pull  the  palmaris  tendon  through  the  tunnel. 
Make  a  similar  tunnel  round  the  ulnar  side  of  the  arm  and  through  it  pull  the 
tendon  of  the  flexor  carpi-ulnaris. 


CLAW   FINGERS 


I219 


Step  6. — Pass  the  tendon  of  the  palmaris  longus  successively  through 
button  holes  made  in  the  extensor  tendons  of  thumb  and  fingers  and  when  it 
has  gone  through  that  of  the  little  finger,  suture  its  free  end  to  the  mobilized 
tendon  of  the  flexor  carpi  ulnaris.  With  fine  sutures  unite  the  palmaris  tendon 
to  each  of  the  flexor  tendons  where  it  passes  through  these.  Of  course  the  wrist 
ought  to  be  dorsally  flexed  and  the  distal  end  of  the  extensor  tendons  ought  to 
be  on  some  tension  when  sutured.  Mauclaire  and  Massart  (La  Pr.  Med., 
May  I,  1919)  recommend  shortening  of  the  extensor  tendons  by  plication  in 
many  cases. 

Step  7. — Close  all  the  wounds  without  drainage.  Dress.  Immobilize  in  a 
position  of  dorsal  flexion  by  means  of  Jones'  "cock-up"  splint.  Figs. 
1559,  1560. 


Fig.  1559. — Dorsiflexed  wrist  splint 
to  secure  good  grasp.  {Robert  Jones, 
British  Med.  Journ.) 


Fig.     1560. — Dorsiflexed    wrist    splint    applied. 
{Robert  Jones,  British  Med.  Journ.) 


After  Treatment. — Keep  up  hyper-extension  (dorsal  flexion)  of  the  wrist  and 
proximal  phalanges  for  three  weeks,  but  permit  motion  of  the  second  and  third 
phalanges.  After  about  three  weeks  the  splint  may  be  removed  and  muscular 
education  begun.  It  is  well  to  remember  Jones'  warning  against  too  early 
motion. 

VII.  Claw  Fingers  "Griffe  Cubital."  Ulnar  Paralysis. — When  the  conduc- 
tivity of  the  ulnar  nerve  is  destroyed  in  the  lower  part  of  the  forearm  there 
results  paralysis  of  the  short  muscles  of  the  little  finger  with  the  palmaris  brevis, 
the  interosseous  muscles  of  the  hand,  the  two  inner  (ulnar)  lumbricales,  the  ad- 
ductor pollicis  and  the  inner  part  of  the  flexor  brevis  pollicis.  This  paralysis 
of  the  extensors  of  the  fingers,  permits  the  flexors  unopposed  play  so  that  the 
proximal  phalanx  assumes  a  position  of  hyper-extension  while  the  two  distal 
phalanges  become  flexed.  The  deformity  is  of  course  most  marked  in  the  ring 
and  middle  finger.  If  the  lesion  to  the  ulnar  nerve  is  high  up,  then  the  inner 
half  of  the  flexor  profundus  digitorum  is  also  involved  and  no  clawing  of  the 
fingers  is  produced. 

The  extensor  tendons  of  the  fingers  pass  from  the  wrist  over  the  heads  of 
the  metacarpal  bones,  and  each  sends  a  slip  of  insertion  to  the  bases  of  the 
first,  second  and  third  phalanges  respectively.  At  the  level  of  the  metacarpo- 
phalangeal joint,  a  fibrous  expansion  passes  from  each  side  of  tendon  and  joins 
perforating  fibres  of  the  palmar  fascia.     Fig.  1561. 

These  connections  with  the  palmar  fascia  and  the  slip  of  insertion  into  the 
first  phalanx  limit  greatly  any  action  of  the  extensors,  or  the  two  distal  pha- 
langes. Extension  of  the  two  last  phalanges  is  produced  by  the  interossei  and 
the  lumbricales  which  are  inserted  into  the  extensor  tendon  below  the  articula- 


I220 


TENDON    SHEATHS    AND    TENORRHAPHY 


tion.  Thus  the  tendon  of  the  extensor  beyond  its  insertion  into  the  proximal 
phalanx  is  activated  by  these  small  muscles,  the  action  of  its  own  proper  muscle 
being  checked  by  its  insertion  into  the  proximal  phalanx  and  its  connection 

with  the  j)almar  fascia. 

From  the  above  anatomical  facts  Rene 
Le  Fort  (La  Pr.  Med.,  July  21,  1919)  concluded 
that  claw  fingers  due  to  permanent  interrup- 
tion of  ulnar  conductivity  might  be  relieved 
by  a  simple  operation  provided  always  that  the 
joints  of  the  fingers  remained  supple.  The 
whole  operation  consists  in  freeing  the  extensor 
tendons  from  their  insertion  into  the  proximal 
phalanges,  from  their  connections  with  the 
palmar  fascia  and  in  dividing  the  insertions  of 
the  interossei  and  lumbricales  muscles.  If  these 
obstructions  are  removed  then  the  extensor 
muscle  is  free  to  activate  its  whole  tendon 
and   the  deformity  disappears. 

Le  Fort's  Operation. — (There  is  marked 
"claw"  of  the  little  and  ring  finger.) 

Step  I. — Make  a  dorsal  incision  along  the 
extensor  tendon  of  the  little  finger  and  a  similar 
incision  along    that   of    the    ring    finger.     The 
middle  of  each  of    these    incisions   is   opposite 
the  corresponding  metacarpo-phalangeal  joint. 
Step  2. — Divide  the  interossei  and  lumbri- 
cales muscles  at  their  insertions  into  the   sides 
of  the  extensor   tendons,    Fig.    1561.      Divide 
the  anastomoses  between  the  extensor  tendons 
and  the  palmar  fascia.     Divide  the  band  by  which  the  extensor   tendon  is 
inserted  into  the  base  of  the  proximal  phalanx. 

Step  2,. — Cover  the  deep  surface  of  each  tendon  with  a  slip  of  rubber  (from 
an  old  glove)   to  prevent  reunion  of  the  divided 
tendon  and  fascia.  ,.--  , 

Subsequent    treatment     consists     in    massage 
and  methodical  mobilization. 

The  operation  seems  both  logical  and  easy. 
VIII.  There  is  paralytic  e\ersion  of  the  leg 
necessitating  the  use  of  apparatus  which  must  be 
fastened  to  a  pelvic  band.  To  obviate  the 
necessity  of  apparatus  G.  G.  Davis  proceeds  as 
follows: 

(a)  The  Tensor  Fasciae  Femoris  muscle  is  not  paralyzed.  Make  a  \ertical 
incision  about  2}  2  inches  in  length  down  to  the  great  trochanter  near  its  anterior 
edge.  From  this  cut  elevate  the  periosteum  backwards  for  a  short  distance. 
Undermine  the  skin  anteriorly  to  the  wound  and  expose  the  tensor  fasciae  fem- 
oris at  its  insertion  between  the  layers  of  the  fascia  lata.     Make  a  flap  of  the 


i-"lG.   1561. — A,  B,    C,    Phalanges; 
D,  metacarpus.     (After  Le  Fori.) 

I.  Extensor  tendon. 
2    and   3.    Insertion    of   tendon    into 
distal  and  middle  phalanges. 

4.  Divided  insertion  of  tendon  into 
proximal  phalanx. 

5.  Divided  lateral  expansion  which 
united  the  extensor  tendon  to  the  pal- 
mar fascia. 

6.  Tendons  of  the  interossei  and  lum- 
bricales divided  near  their  insertion 
into  the  extensor  tendon. 


Fig.  1562. — Davis'  operation. 


TENOTOMY 


I22I 


muscle  with  its  pedicle  above.     Unite  the  free  end  of  the  muscle  flap  to  the 
posterior  (elevated)  edge  of  the  periosteal  wound. 

(b)  The  tensor  fasciae  femoris  is  paralyzed  Expose  the  trochanter  major 
as  already  described.  Undermine  the  skin  forwards  from  the  original  incision, 
exposing  the  fascia  lata.  At  an  appropriate  distance  in  front  of  the  trochanter 
major  incise  (A  B,  Fig.  1562)  the  fascia  parallel  to  the  incision  in  the  periosteum 
(C  D),  unite  the  posterior  edge  of  the  periosteal  wound  C  D  to  the  anterior  edge 
of  the  fascial  wound  A  B  by  the  sutures  xx'-yy'-zz'. 


CHAPTER   CVIII 
TENOTOMY 

There  are  two  methods  of  performing  tenotomy:  (A)  The  open  operation; 
(B)  the  subcutaneous  operation. 

(A)  Open  Operation. — Make  an  incision  of  sufficient  length  to  expose 
the  parts  to  be  divided.  Usually  this  cut  is  made  parallel  to  the  tendon. 
Isolate,  by  blunt  and  sharp  dissection,  the  segment  to  be  divided.  Retract 
surrounding  structures.  Sever  the  tendon.  Close  the  wound.  If  it  is  im- 
possible or  improper  to  isolate  the  oflfending  structure,  expose  it  by  retracting 


Fig.  1503. — Jones's  tenotome. 

the  edges  of  the  superficial  wound,  and  then  make  the  section,  cautiously  and 
with  small  cuts,  under  guidance  of  the  eye. 

(B)  Subcutaneous  Operation.^ — For  this  operation  small,  narrow-bladed 
knives  (tenotomes)  are  necessary.  Usually  a  sharp-pointed  straight  tenotome 
suflices,  but  a  probe-pointed  instrument  is  occasionally  useful.  The  shorter 
and  narrower  the  blade,  the  better  it  is,  so  long  as  it  is  sufficiently  strong  (Figs. 
1563,  1564).  The  advantages  of  subcutaneous  tenotomy  are 
(a)  diminished  danger  of  infection;  {b)  absence  of  scar.  The 
dangers  of  injury  to  neighboring  important  structures  are 
shght,  and  in  most  localities  easily  avoided. 

Tenotomy  of  Tendo  AchiUis  (Achillo-tenotomy). —  i. 
Cleanse  the  foot  and  leg,  and  turn  them  over  on  to  the  outer 
side.  By  palpation  locate  the  most  accessible  part  of  the 
tendon.  (The  position  of  choice  for  section  is  }i  inch  above 
the  insertion  in  infants  and  1^2  inches  in  adults.) 

2.  Introduce  a  sharp-pointed  tenotome  through  the  skin 
under,  i.e.,  anterior  to,  the  tendon.  Keep  the  flat  surface  of 
the  tenotome  parallel  to  the  tendon. 

3.  Turn  the  cutting-edge  of  the  tenotome  against  the  tendon. 

4.  Have  the  assistant  flex  the  foot  until  the  tendon  is  tense. 

5.  Press  the  tenotome  against  the  tendon  and  by  a  slight  levering  motion 
divide  it.     Take  care  not  to  injure  the  skin. 


Fig.  1564. 
Tenotomes. 


1222 


TENOTOMY 


6.  Withdraw  the  knife  after  turning  its  blade  once  more  parallel  to  the 
tendon.     Apply  dressings. 

N.  B. — Beginners  frequently  perforate  the  tendon  with  the  tenotome  and  do  not  get 
complete  division.  Many  surgeons  in  Step  2  pass  the  tenotome  behind  the  tendon  and  cut 
forward;  others,  having  made  a  passage  along-side  the  tendon  with  the  sharp-pointed  teno- 
tome, substitute  a  probe-pointed  one  for  the  division  of  the  tendon. 

When  the  tendo-Achillis  has  been  divided  in  adults,  the  result  is  often  medi- 
ocre or  poor.  Tendon  lengthening  is  therefore  preferable  to  simple  tenotomy 
in  adults.     Toupet's  method  of  operating  is  probably  the  best.     Figs.  1566  and 


Fig.  1566.— (To  u  pet.) 


Fig.  1567. — (Toupet.) 


1567  (La  Pr.  Med.,  Feb.  21,  1910)  show  clearly  how  the  operation  is  per- 
formed. The  after-treatment  consists  in  immobilization  for  eight  days.  After 
12  days  walking  with  two  canes  is  permissible.  During  the  night  some  appara- 
tus ought  to  be  worn  to  prevent  the  weight  of  the  bedclothes  from  causing 
recurrence  of  the  equinus.  Fig.  1568  shows  Toupet's  apparatus  which  consists 
of  (a)  a  plaster  of  Paris  belt  applied  above  the  knee  and  provided  with  two 


—(Toupet.) 


rings;  (b)  a  strip  of  adhesive  plaster  round  the  foot  and  (c)  rubber  tubing  to 
unite  these  two  and  so  keep  up  dorsal  flexion. 

Tenotomy  of  Tibialis  Anticus. — This  tendon  is  usually  divided  near  its  inser- 
tion into  the  internal  cuneiform.  The  surgeon  stands  on  the  opposite  side  of 
the  leg  to  that  of  the  tendon.  The  assistant  grasps  the  leg  and  the  foot  in  his 
hands.     Abduction  and  plantar  flexion  demonstrate  the  position  of  the  tendon. 

Step  I. — Place  tips  of  fingers  on  the  opposite  edge  of  tendon. 


little's  disease  1223 

Step  2. — Introduce  the  tenotome  through  the  skin  a  short  distance  from  the 
proximal  edge  of  the  tendon. 

Step  3 — Change  the  direction  of  the  knife  and  pass  it  horizontally  over  the 
tendon  until  its  point  is  felt  by  the  finger  guarding  the  opposite  side. 

Step  4. — Have  the  assistant  make  the  tendon  tense  (abduction  and  plantar 
flexion  of  foot). 

Step  5. — Turn  the  edge  of  tenotome  against  the  tendon  and  divide  it. 

Step  6. — Withdraw  tenotome.     Dress  in  a  position  of  eversion. 

Tenotomy  of  Tibialis  Posticus. — Point  of  division  should  be  about  i3^ 
inches  above  the  internal  malleolus.  The  surgeon  stands  in  same  position  as 
in  tenotomy  of  the  tibialis  anticus.  Demonstrate  the  tendon  by  abduction 
and  plantar  flexion  of  the  foot. 

Jacobson  writes:  "In  fat  infants  it  is  often  quite  impossible  to  feel  the 
tendon,  and  in  these  cases  a  spot  midway  between  the  anterior  and  internal 
borders  of  the  leg  will  be  the  best  guide,  as  denoting  the  inner  margin  of  the 
tibia.  The  surgeon  then  introduces  a  sharp  tenotome  so  as  just  to  touch, 
if  possible,  the  inner  margin  of  the  tibia,  taking  care  to  sink  the  blade  sufl&ciently 
to  open  the  sheath  freely.  This  being  done,  a  blunt  tenotome  is  introduced 
through  the  same  opening,  and  pushed  under  the  tendon;  the  edge  being  then 
turned  towards  it,  and  the  tibia  used  as  a  fulcrum,  the  tendon  is  severed,  to- 
gether with  that  of  the  flexor  longus  digitorum." 

Division  of  Plantar  Fascia. — The  plantar  fascia  may  be  divided  in  several 
places:  immediately  in  front  of  its  origin  from  the  os  calcis;  beside  the  transverse 
crease  which  is  present  in  all  marked  cases  of  plantar  contracture,  or  in  any 
line  which  may  seem  suitable.  Division  in  more  than  one  place  may  be  neces- 
sary before  satisfactory  results  are  obtained. 

Step  I. — The  assistant  makes  the  fascia  tense,  and  the  surgeon,  by  palpa- 
tion, satisfies  himself  as  to  its  "geography." 

Step  2. — A  tenotome  is  introduced  through  the  skin,  at  the  inner  side  of 
the  fascia  (the  fascia  is  not  kept  tense  at  this  stage)  and  passed,  with  its  flat 
surface  parallel  to  the  skin,  between  the  skin  and  fascia  across  the  sole  until 
its  point  is  beyond  the  outer  edge  of  the  fascia. 

Step  3. — The  cutting-edge  of  the  tenotome  is  turned  against  the  fascia, 
now  made  tense  by  the  assistant,  and  this  structure  is  divided. 

Step  4. — The  tenotome  is  withdrawn,  suitable  dressings  applied,  and  the 
foot  immobilized  in  a  position  of  overcorrection. 

Little's  disease,  spastic  paraplegia. — A  large  proportion  of  children  suffer- 
ing from  severe  paralysis  may  be  transformed  into  useful  beings  and  enabled  to 
walk  with  comparatively  Httle  deformity.  Robert  Jones  writes  regarding  tenot- 
omy of  spastic  muscle,  "Empiricism  has  taught  us  that  for  some  reason  or 
another  tenotomy  lessens,  both  in  frequency  and  intensity,  the  spasmodic  ele- 
ment in  paraplegia.  I  do  not  merely  mean  to  say  that  division  of  the  tendo 
AchiUis  controls  spasm  in  the  calf  muscles,  although  of  course  it  does,  but  rather 
that  spasm  in  which  those  muscles  are  not  directly  concerned  is  also  influenced." 
*  *  *  "The  practical  deduction  from  these  observations  is,  that  no  oppor- 
tunity should  be  lost  of  performing  a  tenotomy.  Even  in  mild  cases,  where  a 
spastic  tendon  is  to  be  felt,  we  need  have  no  hesitation  in  dividing  it. 


12  24  TENOTOMY 

"If  the  surgeon  has  decided  that  a  case  of  spastic  paralysis  is  suitable  for 
treatment,  a  splint  should  be  prepared  so  designed  as  to  keep  the  limbs  in  pro- 
nounced abduction.  The  area  over  the  hamstrings,  the  adductors  at  the  groin, 
and  the  tendo  AchiUis  should  be  suitably  prepared  for  operation.  The  adduc- 
tors should  be  first  attacked.  An  incision  an  inch  or  two  long  should  be  made  to 
the  inside  of  the  adductor  longus.  This  muscle  should  be  seized  by  a  forceps 
and  about  ^  inch  of  it  removed.  The  limb  is  then  abducted  and  portions  of 
the  adductor  brevis  and  gracilis  are  exsected  in  similar  fashion.  The  horizontal 
portion  of  the  adductor  magnus,  and,  if  necessary,  the  pectineus,  is  divided, 
and  also  any  tissue,  muscular  or  fibrous,  obstructive  to  an  absolutely  free  abduc- 
tion of  the  femur.  Experience  has  shown  me  that  although  the  chief  offenders 
are  the  adductors  longus  and  brevis,  nevertheless  the  deeper  muscles  often 
require  division.  To  anyone  who  has  practised  the  operation,  the  futility  of 
attempts  to  divide  the  muscles  effectively  subcutaneously,  will  be  apparent. 
Division  is  followed  with  but  little  hemorrhage  and  the  wounds  are  closed  with- 
out drainage.  Having  exsected  the  pieces  of  the  adductors  each  tendo  AchiUis 
is  divided,  or,  better  still,  elongated,  for  we  often  note  that  after  division  of  the 
tendon  outright,  there  is  a  tendency  to  walk  too  much  on  the  heel.  Rectangular 
splints  are  then  applied  to  the  foot.  The  limbs  are  then  well  abducted  and  the 
surgeon  notes  whether  there  is  any  obstacle  to  easy  extension  of  the  knees.  If 
there  should  be  (it  is  not  often  the  case),  an  open  incision  must  be  made  on  each 
side  of  the  popliteal  space  and  the  tense  hamstrings  are  in  turn  divided.  If  these 
incisions  are  long  enough  the  fascial  contraction  can  be  attacked  on  either  side, 
for  it  is  here  that  opposition  is  found.  I  would  discourage  the  use  of  a  transverse 
incision,  as  when  adopted  it  often  seriously  hampers  the  surgeon's  efforts  to 
fully  extend  the  knee  by  reason  of  the  strain  cast  upon  the  sutures.  Simple 
division,  however,  with  fasciotomy,  usually  suffices  to  allow  of  easy  extension, 
and  excision  of  tendons  could  do  no  more.  In  1885,  when  I  was  at  the  Stanley 
Hospital,  there  used  to  be  an  adult  diplegic  always  at  the  gates  in  a  perambula- 
tor, and  on  two  or  three  occasions  I  took  him  in  to  try  and  straighten  his  con- 
tracted limbs.  On  one  occasion  I  removed  about  an  inch  from  each  of  the  ham- 
strings, but  he  was  mentally  so  deranged  that  we  did  not  do  each  other  any 
credit.  I  mention  the  fact,  however,  because  Lorenz  of  Vienna  has  quite 
recently  written  on  the  advantage  of  exsecting  portions  of  the  hamstrings. 

''  We  have  now  presumably  got  our  patient  stretched  comfortably  upon  an 
abduction  frame,  and  we  must  keep  him  there  for  three  months.  The  wounds 
heal  very  rapidly  and  suppuration  has  occurred  in  the  adductor  cavity  on  three 
occasions  only,  despite  the  insanitary  position  of  the  wounds  and  the  number  of 
operations  performed;  for  instance,  in  1890  I  operated  on  27  patients,  and  this 
may  be  taken  as  a  fair  index  of  my  yearly  return.  At  the  end  of  three  months 
the  sphnt  is  taken  off  during  the  day  and  movements  are  sedulously  practised. 
For  some  weeks  stiffness  exists  and  often  the  movements  are  at  first  painful,  but 
after  a  time  (always  shortened  by  vigorous  exercise)  the  pain  disappears  and  the 
effort  must  be  made  to  walk. 

"The  splints  are  of  a  simple  kind,  designed  to  keep  the  knee  from  bending. 
The  boots  should  be  made  of  felt  with  substantial  soles.  The  nurse  should  be 
instructed  to  keep  both  boots  and  splints  upon  the  patient  day  and  night,  and, 


JONES    ON    SPASTICITY  1 225 

for  the  first  two  weeks,  frequently  during  the  day,  abduction,  adduction,  flexion 
and  extension  of  the  hips  should  be  practised  This  should  be  done  with  and 
without  resistance.  At  night  time  the  feet  should  be  attached  to  the  side  of  the 
bed,  in  order  to  obtain  abduction.  After  the  first  few  days  of  this  later  stage  of 
treatment  the  splints  should  be  removed  twice  a  day  and  the  muscles  well  mas- 
saged, and  both  active  and  passive  movements  of  ankles,  toes,  knees  and  hips, 
encouraged.  Any  movement  executed  in  a  jerky  style  should  be  practised 
until  perfected. 

"The  little  patient  may  now  try  to  walk.  It  will  be  noted  that  one  of  the 
difficulties  of  an  untreated  spastic  when  he  tries  to  walk,  is  the  narrowing  of  the 
pedestal  upon  which  the  trunk  rests  by  reason  of  adducted  limbs.  Operation 
has  now  overcome  this,  and  with  abducted  limbs  the  body  is  poised  upon  a 
pedestal  that  is  widened.  During  early  straining  the  nurse  must  see  that  while 
walking  the  limbs  are  not  approximated,  and  that  from  the  first  swinging,  aided 
by  crutches,  must  be  prevented.  Crutches  should  not  be  allowed  until  the 
patient  has  been  taught  to  stand  unsupported.  I  need  not  enter  into  any  more 
details  regarding  this  most  important  stage  of  treatment,  but  would  add  that  it 
affords  an  inexhaustible  field  of  ingenuity,  and  that  upon  the  intelligence  and 
industry  of  the  nurse  very  much  depends. 

"I  cannot  now  deal  with  individual  cases,  but  I  may  say  that  I  have  operated 
upon  cases  from  1 2  months  to  20  years  of  age.  A  large  number  of  these  were 
so  bad  that  they  had  never  attempted  to  place  one  foot  before  the  other.  Some 
were  structurally  flexed  (contracted)  at  ankle,  knee  and  hip.  A  most  helpless 
youth  of  20,  one  limb  across  the  other,  was  able  in  six  months  to  stand  erect 
and  walk  with  sticks,  and  twelve  months  later  was  able  to  move  his  limbs  north, 
south,  east  and  west  with  hardly  an  appreciable  jerk.  Success  in  an  ancient 
case  where  so  much  has  to  be  unlearnt,  and  where  the  mechanical  stage  offers 
so  much  difficulty,  proves  the  soundness  of  the  principles  I  have  endeavored  to 
expound.  It  is  logical  to  infer  that  if  old  neglected  cases  are  amenable  to 
surgical  education,  our  prognosis  should  be  very  hopeful  in  the  young. 

"With  regard  to  the  degree  of  benefit  to  be  derived  from  treatment,  the 
parents  should  be  given  to  understand  that,  under  favorable  conditions  of 
nursing  and  tuition,  the  child,  aided  by  the  hand  or  sticks,  will  be  able  to  walk 
distances  in  from  twelve  months  to  two  years,  and  that  with  perfectly  straight 
limbs  and  heels  on  terra  firma.  A  large  proportion  of  cases  will,  later  on,  man- 
age aided  by  one  stick.  Even  in  the  least  successful  cases  parents,  mostly  hav-- 
,  ing  despaired,  are  full  of  gratitude.  The  mental  condition  of  the  children  obvi- 
ously improves  when  their  physical  defects  are  remedied,  and  they  are  enabled  to 
mix  with  their  little  friends.  Complete  recovery  in  spastic  paraplegia  is,  of 
course,  impossible. 

"It  will  be  gathered  from  my  remarks  that  the  treatment  of  spastic  paralysis 
should  resolve  itself  into  a  system.  That  system  involves  operative,  mechanical 
and  educational  stages.  The  treatment  cannot  be  separated  into  parts.  If  the 
surgeon  is  not  satisfied  that  the  case  is  to  be  under  his  control  for  twelve  months 
he  will  consult  his  reputation  best  by  leaving  it  alone.  Operations,  not  fol- 
lowed up  by  careful  and  prolonged  after-care,  give  rise  to  disappointment  and 


1226 


TENOTOMY 


discredit.     Merely  dividing  tendons  and  trusting  to  massage  and  electricity  is 
futile  and  dispiriting." 

Foerster's  operation  for  spasticity  and  the  principles  enunciated  by  Stoffel 
are  referred  to  on  page  771. 

CLUB-FOOT 

A  clear  distinction  must  be  drawn  between  congenital  club-foot  and  that 
form  which  results  from  paralysis  acquired  before  or  after  birth.  In  the  former, 
when  correction  or  rather  overcorrection  of  the  deformity  has  been  completed 


Fig.  1569.  Fig.  1570. 

Figs.  1569  and  1570. — Manual  correction.     {Berger  and  Banzet.) 

and  established,  all  has  been  done;  in  the  paralytic  form  after  deformity  has  been 
corrected  it  may  be  necessary  to  resort  to  tendon  transplantation,  etc.,  before  a 
satisfactory  result  is  obtained. 

Congenital  Club-foot. — Talipes  Equino-varus. — Many  cases  of  equino-varus 
may  be  successfully  treated  vsithout  operation  if  taken  early  enough.  If  an 
intelUgent  mother  or  nurse  by  manipulation  endeavors  to  mold  the  deformed 


Fig.  1571.  Fig.   1572. 

Figs.  1571  .axd  1572. — Manual  correction.     (Berger  and  Banzet.) 

foot  into  good  shape  (unwind  the  deformity),  and  does  this  patiently  3  or  4  times 
daily,  a  cure  will  often  be  obtained.  Figures  1569,  1570,  1571,  1572,  show  how 
the  modeling,  molding,  or  unwinding  ought  to  be  done.  In  other  cases  the 
surgeon  may  attain  the  same  result  more  rapidly  by  forcible  rectification  (in 
one  or  more  sittings),  and  by  keeping  the  foot  in  the  corrected  or  overcorrected 
position  by  means  of  a  plaster-of-Paris  dressing  until  the  new  position  is  well 
estabHshed. 


CLUB-FOOT 


1227 


A  cardinal  rule  is  that  overcorrection  must  be  obtained,  otherwise  relapse 
is  the  rule;  but  overcorrection  is  not  all.  ''No  case  of  club-foot  is  cured  until 
the  patient  can  voluntarily  raise  his  own  foot  from  the  deformed  into  the  over- 
corrected  position.  There  are  three  causes  of  so-called  relapse  in  club-foot: 
(i)  Insufficient  correction  of  deformity.  (2)  Erroneous  deflection  of  body  weight 
on  tarsus  when  walking.  (3)  A  slack  and  lengthened  condition  of  muscles  due  to 
overstretching"     (Robert  Jones). 

Forcible  Rectification. — The  necessary  force  may  be  applied  either  by  the 
hands  or  by  a  wrench.  Tenotomy  of  the  tendo  Achillis  is  usually,  and  of  the 
plantar  fascia  frequently,  a  necessity  immediately  before  the  forcible  rec- 
tification. 

Manual  Rectification. — Step  i. — Grasp  firmly  in  one  hand  the  heel  and 
ankle,  in  the  other  the  distal  end  of  the  foot,  leaving  the  region  of  the  calcaneo- 


FiG.  1573. — Manual  correction  over  wedge.     {Ho fa.) 


cuboid  articulation  unsupported  by  the  hands.  Lay  the  convex  surface  of 
this  portion  of  the  foot  against  the  edge  of  a  wedge  of  wood  covered  by  a  towel. 
The  wedge  acts  as  a  fulcrum  (Fig.  1573). 

Step  2. — Apply  force,  even  the  whole  weight  of  the  body,  to  straighten  or 
unfold  the  foot  by  compressing  its  convex  side  against  the  fulcrum  and  stretching 
or  tearing  the  structures  on  the  concave  side.  In  young  children  overcorrection 
is  often  possible  in  one  sitting.  Care  must  be  taken  not  to  tear  the  skin.  If 
the  skin  seems  about  to  tear,  put  off  further  correction  until  another  time, 
when  it  will  be  found  to  have  accommodated  itself  to  the  changed  circumstances. 
If  the  desired  result  is  not  obtained  in  one  sitting,  a  second,  third,  or  fourth 
operation  should  be  done  at  intervals  of  about  a  week. 

Before  the  anesthetic  is  discontinued,  envelop  the  foot  in  a  plaster-of-Paris 
dressing.  To  avoid  trouble  from  swelling  of  the  foot  owdng  to  the  trauma  it  is 
well  to  keep  the  limb  elevated  for  twenty-four  hours. 

Remember  that  Overcorrection  is  the  Aim. — Ridlon  always  uses  forcible 
rectification  with  tenotomies,  and  division  of  fascia  and  ligaments  as  may  be 
required.  He  says,  "  Put  on  thick  layers  of  cotton  batting  with  bandage  over — 
this  must  be  smooth,  so  as  to  prevent  ridges  being  formed  on  inside  of  the  plaster 


1221 


TENOTOMY 


which  is  now  applied  thick— so  thick  that  patient  may  walk  on  it  for  four  or  five 
months.  Don't  change  the  dressings.  Don't  operate  before  the  walking  age. 
Sometimes  the  thick  bandages  will  come  off,  i.e.,  slide  off.  If  this  is  the  case, 
smoothly  pad  the  lid  of  a  cigar  box  fashioned  to  shape  of  sole  and  fix  it  to  the  foot 
by  adhesive  straps,  then  apply  the  plaster.  The  whole  foot  and  leg  is  wrapped 
with  the  cotton  before  the  wood  foot-piece  is  applied.     The  plaster  goes  to 


liG.   1574. — Thomas's  wrench. 

about  the  knee  and  must  be  thick.  The  test  of  cure  is  that  when  the  plaster 
cast  is  removed  the  foot  remains  in  overcorrected  position  and  cannot  without 
force  be  put  into  malposition.     Operate  at  any  age." 

Instrumental  Rectification. — The  best  instrument  for  applying  force  in  the 
rectification  of  clu])-foot  is  Thomas'  wrench  (Fig.  1574)  employed  as  Thomas 
used  it.  The  wrench  is  applied  to  the  foot  and  the  foot  is  twisted  and  bent  in 
the   normal   directions.     The  correction  must  be  accomplished   forcibly  and 


P"IG.    1575.  I"IG.    1570. 

Figs.  1575  and  1576. — Jones'  club-foot  splints. — {Jones.) 

quickly  and  the  foot  immediately  released.  Holding  the  foot  too  long  in  the  bite 
of  the  wrench  may  result  in  a  pressure  sore  (Ridlon  and  Jones).  Apply  force 
sufficiently  to  temporarily  destroy  the  resiliency  of  the  soft  parts  so  that  the  foot 
lies  lax  in  the  hand  of  the  operator.  Place  in  good  position  in  a  retention  brace. 
After  a  few  days  the  resiliency  of  the  soft  parts  begins  to  return  and  the  operation 
is  repeated  if  this  is  necessary  to  obtain  overcorrection," until  there  is  no  ten- 
dency towards  recurrence.     After  this  keep  the  foot  immobilized  until  all  the 


CLUB-FOOT  1229 

parts  have  adapted  themselves  to  their  new  relations;  or,  as  Thomas  said,  "until 
slack  has  been  taken  up  and  the  flexors  and  evertors  of  the  ankle  voluntarily 
act."  Ridlon  writes:  "If  the  patient  cannot  voluntarily  flex  and  evert,  it  is 
because  the  tendons  concerned  are  still  suffering  from  stretch  palsy,  and  relapse 


Fig.  1577. — Application  of  Jones' splints.     {Jones.) 

will  occur  exactly  as  deformity  arises  in  poliomyelitis.     (Figures  1575,  1576, 
1577,  show  the  application  of  R.  Jones'  iron  club-foot  splints.) 

In  some  obstinate  cases  of  club-foot  the  tendo  Achillis  pulls  upwards  on  the 
inner  side  of  the  tuberosity  of  the  calcaneum  to  an  unusual  extent  and  thus 
hinders  or  prevents  correction  of  varus.     Under  these  circumstances  R.  Jones 


Fig.  1578.  Fig.  1579. 

Figs.  1578  and  1579. — Jones'  transplantation  of  insertion  tendo  .\chillis. 

by  transplantation  moves  the  insertion  of  the  tendo  Achillis  outwards  in  the 
following  manner:  Expose  the  tendo  Achillis  by  a  T-shaped  incision  (Fig.  1578). 
Split  the  tendon  longitudinally.  Separate  the  inner  half  of  the  tendon  from  its 
insertion.  Pass  the  inner  segment  of  tendon  (now  a  flap  with  pedicle  above) 
under  the  outer  (Fig.  1579)  segment  and  suture  its  free  end  to  the  periosteum  of 


I230 


TENOTOMY 


the  OS  calcis  outside  and  in  immediate  juxtaposition  to  the  still  attached  half. 
The  opposing  surfaces  of  tendon  should  be  vivified  and  sutured  together. 

Phelps'  Operation.— Preliminary  Treatment. — If  the  patient  has  walked, 
large  callosities  will  be  present  on  the  foot;  to  soften  and  clean  these  soap  poul- 
tices should  be  applied  for  twenty-four  hours;  twelve  hours  before  the  operation 
the  foot  must  be  thoroughly  scrubbed  and  an  antiseptic  fomentation  applied. 

Step  I. — Render  limb  avascular  by  elevation  and  apply  tourniquet.  Place 
the  foot,  with  outer  side  downwards,  on  a  sand-bag.  Have  the  assistant  hold 
the  heel  firmly.  Grasp  the  distal  portion  of  the  foot  and  make  the  plantar 
tissues  tense. 

Step  2. — On  the  inner  side  of  the  foot  make  an  incision  beginning  directly 
in  front  of  the  malleolus  and  ending  one-fourth  of  the  distance  across  the  sole 
of  the  foot.  Divide  all  resisting  structures,  penetrating  to  the  bone  if  necessary. 
(See  Fig.  1580;  here  the  cut  is  being  made  from  the  sole  to  the  malleolus.) 


Fig.  1580. — Phelps'  operation. 

Step  3. — By  manipulation  complete  the  overcorrection  of  the  varus. 

Step  4. — Correct  the  equinus  by  a  tenotomy  of  tendo  Achillis. 

Step  5. — Pack  the  wound  with  sterile  iodoform  gauze.  Dress.  Immobilize 
in  a  position  of  overcorrection  by  a  plaster-of-Paris  bandage,  which  reaches 
well  up  the  calf.  While  the  plaster  is  hardening,  hold  the  foot  in  its  new  position 
by  means  of  a  flat  board  laid  against  the  sole. 

Step  6. — Remove  the  tourniquet.  Elevate  the  limb  for  twenty-four  hours. 
If  cleanliness  has  been  attained,  the  dressings  may  be  left  untouched  for  from 
two  or  three  weeks,  when  the  wound  will  generally  be  found  practically  healed. 

Tarsectomy.^ — Occasionally  the  above  operation  may  be  found  insufficient 
to  produce  overcorrection.  Having  divided  the  soft  parts  as  described,  cut 
through  the  neck  of  the  astragalus  with  a  chisel.  In  packing  the  wound  do 
not  introduce  the  gauze  into  the  cleft  in  the  bone. 

After-treatment.^ — ^Plaster  of  Paris,  renewed  when  necessary,  should  be 
worn  for  from  six  to  eight  weeks,  after  which  massage  and  exercises  should  be 
used  and  a  good  strong  shoe  worn.  As  a  rule,  no  special  club-foot  shoe  is 
necessary  after  the  Phelps  operation. 


CLUB-FOOT 


I23I 


Jonas's  Operation.- — A.  F.  Jonas  ("Annals  of  Surg.,"  April,  1899)  thus 
describes  his  method:  "An  incision  is  made,  beginning  slightly  below  the  margin 
of  the  plantar  fascia  on  the  inner  side  of  the  foot,  at  a  point  on  a  line  directly 
below  and  anterior  to  the  internal  malleolus,  extending  forwards  and  upwards  to 
a  point  on  the  first  metatarsal  bone  and  nearly  to  the  metatarso-phalangeal  ar- 
ticulation. A  second  incision  is  made,  beginning  at  a  point  over  the  astragalo- 
scaphoid  articulation,  extending  forwards  and  slightly  downwards,  joining  the 
first  incision  near  the  metatarso-phalangeal  joint,  forming  a  V  (Fig.  1581).  The 
incisions  are  made  deep,  so  as  to  include  the  subcutaneous  tissues  and  fat." 
Dissect  back  the  flap  thus  outlined.  Sever  diagonally  the  inner  fasciculus  of 
the  plantar  fascia.  Divide  the  remaining  structures  successively,  as  directed 
by  Phelps.  Do  not  injure  the  astragalo-scaphoid  capsule.  Make  another 
incision  on  the  outer  side  of  the  foot  over  the  head  of  the  astragalus,  and  with 


/ 


Fig.  1581.  Fig.  1582. 

Figs.  1581  and  1582. — Jonas's^operation.     (Jonas.) 

a  chisel  divide  the  neck  of  the  bone,  if  necessary,  removing  the  head.  Over- 
correction is  now  easy.  Ligate  the  bleeding  points.  Replace  the  triangular 
flap  (Fig.  1582).  Do  not  suture.  Cover  the  wound  with  perforated  oiled  silk. 
Dress.  Immobilize  in  a  plaster-of-Paris  bandage  which  reaches  one-third  up  the 
thigh.  Leave  dressings  undisturbed  for  five  or  six  weeks.  This  method  is 
only  suitable  in  "old,  inveterate,  and  relapsing  cases." 

Lorenz  (Konig,  Lehrbuch  der  speciellen  Chir.,"  iii,  809)  gives  the  following 
list  of  operations  for  club-foot,  in  which  the  bones  are  attacked: 

(A)  Osteotomies. 

(i)  Linear  division,  navicular  bone  from  the  sole  (Hahn). 

(2)  Linear  division,  tibia  and  fibula  above  the  ankle. 

(B)  Enucleation, 
(a)  Of  one  bone: 

(3)  Of  the  cuboid  (Solly). 

(4)  Of  the  astragalus  (Lund,  Mason). 

(5)  Of  the  astragalus  with  resection  of  the  point  of  the  external 

malleolus  (Mason,  Ried). 

(6)  Curettement  of  the  spongy  part  of  the  astragalus,  leaving  the 

articular  surfaces  intact  (Verebely). 


12,32  TENOTOMY 

(7)  Of  the  astragalus  plus  removal  of  a  wedge  with  base  external 
from  the  anterior  process  of  the  calcaneum  (Hahn). 

Meiissel's  operation  of  extirpation  of  ossifying  centres  of  the  astragalus  in 
young  children. 

(b)  Of  several  bones. 

C8)  Enucleation  of  astragalus  and  cuboid  (Hahn,  Albert)  and  of  the 
navicular  bone  (West). 

(9)  Enucleation  of  the  navicular  and  cuboid  (Bennet). 
(C)  Resections. 

(10)  Of  the  head  of  the  astragalus  (Lucke,  Albert). 

(11)  Of  a  portion  of  bone  from  the  external  half  of  the  neck  of  the 

astragalus  (Hueter). 

(12)  Resection  of  a  wedge  from  the  outer  and  upper  sides  of  the 

tarsus  (O.  Weber,  Davis,  Colley,  R.  Davy,  Schede,  Meussel, 
etc.). 
(1.3)  Resection  of  two  wedges  perpendicular  to  each  other  with  their 
bases    directed  outwards  from  the  astragalo-calcaneal  and 
Chopart's  joints  (Rydygier). 

Occasionally  the  fibula  occupies  a  position  too  far  back  near  the  tendo  Achil- 
lis,  the  space  between  the  internal  and  external  malleoli  is  too  narrow,  and  the 
anterior  portion  of  the  astragalus  is  too  wide.  This  state  of  affairs  is  an  indica- 
tion for  excision  of  the  astragalus  (Konig). 

Astragalectomy.- — i.  Apply  an  Esmarch  bandage. 

2.  Make  a  longitudinal,  slightly  curved  incision  2  inches  long  over  the  most 
prominent  part  of  the  head  of  the  astragalus  from  the  external  malleolus  down- 
wards and  inwards  between  the  outermost  tendon  of  the  extensor  longus  dig- 
itorum  and  the  peroneus  tertius.  Reflect  the  soft  parts  with  a  periosteal 
elevator. 

3.  Open  the  ankle  and  astragalo-scaphoid  joints.  Seize  the  bone  with  a 
lion-jawed  forceps,  loosen  it  with  an  elevator,  and  divide  its  ligaments  with 
strong,  blunt-pointed  scissors  or  the  scalpel. 

4.  Place  the  foot  in  good  position.  If  correction  cannot  yet  be  obtained,  one 
may  follow  Walsham's  advice  (Jacobson's  "Operations  of  Surg.,"  ii,  711) :" When 
once  a  bone  operation  has  been  embarked  on,  it  is  no  use  stopping  short  till 
suf&cient  bone  has  been  cleared  away  to  permit  of  the  rectification  of  the  foot. 
No  more  should,  of  course,  be  removed  than  is  necessary,  but  to  take  away  too 
little  is  to  my  mind  the  graver  fault." 

Cuneiform  Tarsectomy. — The  operation  of  cuneiform  tarsectomy  consists 
in  making  a  longitudinal  incision  over  the  most  prominent  portion  of  the  tarsus, 
without  injury  to  the  tendons,  in  reflecting  the  soft  parts  to  lay  bare  the  bone, 
and  in  excising  a  wedge  of  bone.  The  steps  of  the  operation  do  not  require 
description;  the  surgeon  must  apply  Walsham's  rule,  quoted  in  the  previous 
paragraph,  and  also  make  use  of  common  sense. 

Ogston's  Operation  ("Brit.  Med.  Jour.,"  June  21,  1902). — This  operation 
is  similar  to  that  of  Meussel,  and  is  suitable  in  bad  cases  of  club-foot  in  children 
up  to  the  sixth  or  possibly  the  eighth  year.     A  skiagraph  will  tell  if  ossification 


REMARKS    ON    CLUB-FOOT  1 233 

has  proceeded  too  far.  The  principle  of  the  operation  is  to  remove  the  osseous 
centres  from  those  bones  which  impede  rectification.  After  correction,  the 
remaining  envelope  of  cartilage  will  become  ossified.  "An  incision  through  the 
skin  is  made  in  a  gentle  curve,  beginning  in  front  of  the  external  malleolus  and 
extending  forwards  with  its  convexity  towards  the  sole,  until  it  terminates  over 
the  calcanco-cuboid  joint  on  its  dorsal  aspect.  When  its  edges  are  retracted, 
the  outline  of  the  astragalus  is  visible.  The  soft  parts  covering  it  and  the  car- 
tilaginous shell  surrounding  its  osseous  centre  are  then  divided  by  a  shorter 
incision  in  the  same  line  as  the  cutaneous  one,  the  knife  being  made  to  sever  every 
thing  down  to  the  bony  kernel.  A  Volkmann's  spoon,  slightly  curved  forwards 
at  its  neck  is  passed  into  the  wound  of  the  cartilage,  and  its  whole  bony  centre, 
save  the  upper  part  constituting  the  pulley  between  the  two  malleoli,  is  cauti- 
ously scraped  out."  If  necessary,  the  same  treatment  may  be  applied,  through 
the  same  external  wound,  to  the  cuboid  and  anterior  end  of  the  os  calcis.  After 
removing  the  Esmarch  constrictor  and  attending  to  hemostasis,  close  the  wound 
with  deep  and  superficial  sutures  and  immobilize  with  plaster  of  Paris  in  correct 
position. 

The  following  remarks  are  based  on  material  placed  at  the  disposal  of  the 
writer  by  his  friend,  Robert  Jones,  of  Liverpool. 

Before  any  bone  operation  is  adopted  in  club-foot  one  should,  at  a  prelimi- 
nary sitting,  correct  the  deformity  as  much  as  possible  by  means  of  the  tenotome 
and  wrench.  Less  bone  will  then  have  to  be  removed  and  the  result  is  much 
more  artistic. 

In  club-foot  there  is  often  present  a  twist  in  the  leg.  This  rotation  is 
entirely  below  the  knee  and  confined  to  the  tibia  and  fibula.  Unless  this  deform- 
ity is  corrected  there  will  be  persistent  trouble  even  after  complete  correction  of 
the  equinus  and  varus.  "It  is  therefore  well  to  anticipate  this  problem  the 
moment  we  begin  treatment.  Every  time  the  Equino-varus  is  manipulated  the 
malleoli  should  be  grasped  in  one  hand,  while  the  leg  should  be  held  below  the 
knee  with  the  other.  The  lower  ends  of  the  tibia  and  fibula  are  rotated  outwards 
and  the  knee  inwards.  The  leg  is  thus  twisted  on  its  long  axis  by  an  action  not 
dissimilar  to  that  used  when  one  wrings  a  wet  cloth.  If  this  is  done  each  day, 
by  the  time  the  foot  is  straight  the  inversion  of  the  foot  will  also  have  disap- 
peared. No  club-foot  can  be  pronounced  cured  until  the  patient  walks.  Walk- 
ing is  the  act  which  completes  the  cure." 

Sometimes  osteotomy  or  osteoclasis  is  necessary  to  correct  the  twist  in  the 
tibia  and  fibula. 

Robert  Jones  sums  up  his  practice  in  the  treatment  of  club-foot  in  the  follow- 
ing words: 

"The  operation  I  perform  in  obstinate  cases  is  very  simple  and  can  be  com- 
pleted in  about  ten  minutes. 

"  (a)  The  removal  of  half  the  scaphoid. 

"  {b)  The  removal  of  anterior  and  lower  part  of  astragalus  leaving  the  tibial 
articulation. 

"  (c)  Osteotomy,  if  necessary,  through  outer  part  of  tarsus, 

"  (d)  Forcing  foot  into  everted  position  when  the  scaphoid  will  articulate 
with  the  remainder  of  the  astragalus. 


1234 


TENOTOMY 


"The  simple  case  is  one  which  we  can  quite  easily  replace  in  good  position 
and  which  shows  but  little,  if  any,  adduction  at  the  mid-tarsal  joint.  Such  a 
case  will  probably  not  require  a  division  of  even  the  tendo  Achillis.  If,  however, 
there  is  marked  adduction  at  the  mid-tarsal  and  a  rotation  inwards  of  the  tibia 
and  fibula,  the  case  may  be  looked  upon  as  affording  the  surgeon  an  oppor- 
tunity for  work.  In  the  simple  case,  where  the  surgeon  cannot  pay  frequent 
visits,  the  nurse  should  be  taught  the  manipulations  which  she  can  practise 
several  times  a  day.  The  tibia  and  fibula  should  be  grasped  at  the  epiphysis 
which  may  otherwise  easily  be  separated  and  the  foot  should  be  alternately 
everted  and  flexed.  Following  this,  the  heel  should  be  grasped  in  one  hand  and 
the  anterior  portion  of  the  foot  in  the  other  and  abduction  secured  at  the  mid- 
tarsal  joint.  Five  minutes  spent  three  times  a  day  in  doing  this  should  be  fol- 
lowed by  gentle  massage  of  the  flexors  of  the  foot  and  the  peroneal  group.  This 
should  be  followed  by  the  application  of  a  bandage  or  of  a  rectangular  splint. 


Fig.  1583. — 'J'rcatmcnt  of  club-foot  by  bandages.     (Jones.) 


Surgeons  often  fail  to  appreciate  how  much  can  be  done  by  the  simple  applica- 
tion of  a  calico  bandage.  If  the  surgeon  desires  to  turn  the  foot  in,  he  should 
start  the  bandage  on  the  outside;  if  he  desires  to  evert  the  foot  he  should  begin 
on  the  inside.  In  the  case  of  eq.  varus  he  should  start  on  the  inner  side  of  the 
ankle,  pass  under  the  sole  of  the  foot,  over  the  front  of  the  ankle  and  so  evert  it. 
Every  turn  of  the  bandage  so  applied  pulls  the  foot  outwards,  whereas,  if  the 
bandage  be  started  from  the  outer  side,  the  deformity  is  at  each  turn  increased. 
I  have  on  several  occasions,  for  demonstration  purposes  in  club-foot  of  moderate 
severity,  quite  overcome  and  cured  the  deformity  by  the  simple  expedient 
of  a  bandage.  Care  should  be  taken  if  a  bandage  be  used,  with  or  without  a 
splint,  not  to  carry  it  much  above  the  ankle  lest  the  muscles  be  thereby  weakened 
(Fig.  1583),  Should  the  surgeon  be  able  with  but  little  effort  to  restore  the  foot 
to  its  normal  position,  it  will  not  be  necessary  to  divide  a  tendon.  Should  the 
degree  of  resistance  be  more  marked,  division  of  the  tendo  Achillis  becomes 


TALIPES    CAVUS  I  235 

imperative.  A  great  deal  has  been  written  of  the  advantage  of  correcting  the 
varus  before  dividing  the  tendo  Achillis.  Although  in  full  possession  of  the 
arguments  for  this  view,  I  quite  fail  to  appreciate  their  force,  and  on  the  con- 
trary maintain  that  the  Achilles  tendon  often  helps  to  perpetrate  the  inversion. 

"  The  Club-foot  Shoe. — I  use  a  club-foot  shoe  which  I  have  modified  from 
the  Thomas.  The  details  of  its  application,  simple  as  they  appear,  require 
study.  It  can  be  made  by  any  country  blacksmith  at  a  very  trivial  cost.  It  is 
made  of  flexible  sheet-iron  (Figs,  1575,  1576,  1577).  After  the  foot  has  been 
manipulated  into  the  best  possible  position,  a  piece  of  plaster  should  be  started 
on  the  dorsum,  passed  under  the  sole,  and  given  to  an  assistant  at  hand.  He 
should  be  directed  to  pull  at  right  angles  to  the  leg,  while  the  surgeon  places  the 
retention  splint  in  position.  This  should  be  done  for  fully  six  weeks,  either  by 
the  surgeon  or  someone  he  can  trust;  the  splint  being  changed  every  day.  I 
very  much  prefer  this  method  of  retention  to  that  of  plaster  of  Paris  which  I 
rarely  use.  At  the  end  of  two  months  the  most  troublesome  of  this  class,  i.e., 
cases  which  the  surgeon  sees  during  the  first  two  years,  will  present  a  pliable 
foot  which  can  be  placed  into  normal  position  without  encountering  resistance, 
and  if  the  child  be  sufficiently  old  he  can  be  taught  to  walk  in  such  a  manner 
that  each  step  he  takes  tends  to  improve  the  shape  of  the  foot." 

Talipes  Calcaneus  (Congenital). — In  this  form  of  club-foot  the  foot  is  in 
a  position  of  dorsal  flexion;  the  tendo  Achillis  is  elongated,  the  anterior  tendons 
are  contracted.  It  is  wise  to  begin  treatment  by  manipulation  a  few  days  after 
birth.  The  manipulation  consists  in  patiently  and  persistently  coaxing  the 
foot  into  a  position  of  plantar  flexion,  thus  stretching  the  anterior  tendons. 
As  soon  as  the  deformity  has  been  ozjcrcorrected,  apply  some  fixed  dressing  to 
retain  the  overcorrected  position  until  the  tendo  Achillis  has  had  time  to  con- 
tract. In  severe  cases  the  manipulation  may  be  carried  out  forcibly  under  an 
anesthetic.     Tenotomy  of  the  anterior  tendons  is  very  rarely  necessary. 

Talipes  Cavus  (Hollow-foot). — The  arch  of  the  foot  is  unnaturally  high; 
the  anterior  part  of  the  foot  being  approximated  to  the  heel.  The  worst 
samples  of  the  deformity  are  those  produced  as  a  mark  of  beauty  in  the  Chinese 
women  of  high  rank.  Talipes  cavus  may  occur  along  with  the  other  forms  of 
club-foot.  Operation  is  only  required  in  severe  cases  and  consists  of  subcu- 
taneous division  of  the  plantar  fascia,  forcible  rectification  and  retention  in  a 
plaster-of-Paris  dessing,  until  such  time  as  the  corrected  position  is  established. 
Ducroquet  ("La  Presse  Med.,"  July  23,  19 10)  finds  that  in  talipes  cavus  asso- 
ciated with  equinus  the  foot  can  be  extended  (dorsal  flexion)  to  a  right  angle 
with  the  leg  but  cannot  be  flexed.  When  the  foot  is  at  right  angle  to  the  leg 
the  inferior  surface  of  the  first  metatarsus  makes  a  prominence  on  the  sole  of  the 
foot.  The  great  toe  is  hyperextended  on  the  metatarsus.  Ducroquet  believes 
that  it  is  the  lowering  of  the  distal  end  of  the  first  metatarsal  which  gives  the 
foot  its  hollow  form,  and  that  this  lowering  of  the  first  metatarsal  and  the  hyper- 
extension  of  the  corresponding  toe,  are  both  due  to  paralysis  of  the  short  flexor 
of  the  toe  permitting  the  long  extensor  of  the  toe  to  overact.  Hence  he  operates 
as  follows : 

I.  Make  a  longitudinal  dorsal  incision  from  the  middle  of  the  first  metatarsal 
bone  to  the  middle  of  the  proximal  phalanx  of  the  great  toe.     Expose  the  long 


1236 


TENOTOMY 


extensor  tendon.     Divide  the  tendon.     Suture  the  proximal  tendon  stump  to 
the  distal  part  of  the  first  metatarsus.     Close  the  wound. 

2.  Correct  the  rest  of  the  deformities  in  the  usual  manner  by  subcutaneous 
division  of  the  plantar  fascia;  tenotomy  of  the  tendo  Achillis,  etc. 


Jones'  operation  talipes  calcaneo-ca\'us.     (Jones.) 


Arthrodesis  for  Paralytic  Calcaneo  cavus.^ — Robert  Jones'  Operation. 
I.  Paralysis  of  the  calf  muscles  is  complete. 
Operation  in  two  stages,  four  weeks  intervening. 

Stage  I. — Step  i. — If  the  plantar  fascia  is  contracted,  divide  it  subcutaneously 
and  straighten  the  sole  as  much  as  possible  by  manual  or  instrumental  force. 


Fig.  1585. — Jones'  op>eratlon 


.;aneo-ca\ 


Step  2. — On  the  inner  side  of  the  foot  make  a  3-inch  incision  to  the  bone;  the 
centre  of  the  cut  being  opposite  the  angle  of  convexity.  Separate  the  son 
parts  from  the  tarsus  with  an  elevator  until  the  inner,  dorsal,  and  planlin 
surfaces  are  accessible. 

Step  3. — With  a  chisel  remove  a  wedge  of  bone  (base  above)  (Fig.  158^) 


JONES     OPERATION 


1237 


(Robert  Jones,  "Am.  Journ.  Orlhop.  Surg.,"  April,  igo8)  large  enough  to  com- 
pletely correct  the  cavus. 

Step  4. — Close  the  wound.  Correct  the  cavus  by  flexing  the  foot  dorsally 
(Fig.  1585)  and  after  applying  dressings  bandage  the  foot  to  the  tibia.  The 
cavus  is  cured,  but  the  calcaneus  is  apparently  much  worse. 


Fig.  1586. — Jones'  operation  talipes  calcaneo-cavus.     (Jones.) 

Stage  II. — (Four  weeks  later.) 

Step  I.— Make  a  longitudinal  cut  at  the  back  of  the  heel,  the  centre  being 
opposite  the  ankle-joint.     Open  the  joint. 


Fig.  1587. — Jones'  operation  talipes  calcaneo-cavus.     {Jones.) 


Step  2. — ^From  the  astragalus  cut  away  a  wedge  of  bone  suflacient  to  permit 
the  foot  being  brought  at  a  right  angle  to  the  leg  (Fig.  1586)  and  arthrodese  to 
tibia. 

Step  3.— Close  the  wound.  Correct  the  deformity  (Fig.  1587).  Apply 
dressing.     Immobilize  until  union  is  complete. 

2.  The  paralysis  of  the  calf  muscles  is  not  complete. 


1238  CONTRACTURES 

Stage  1. — As  in  previous  operation. 

Stage  II. — (Four  weeks  later.) 

Step  I. — Opposite  the  ankle-joint  make  a  posterior  transverse  incision  long 
enough  to  expose  the  posterior  capsule  of  the  joint.  Reflect  the  skin  upwards 
and  downwards.  Place  and  hold  the  foot  in  good  position.  Shorten  the  elon- 
gated posterior  capsule  by  throwing  it  into  folds  and  fixing  the  folds  by  sutures. 

Step  2. — Shorten  the  tendo  Achillis. 

Step  3. — Excise  enough  skin  from  the  upper  and  lower  edges  of  the  trans- 
verse incision  so  that  when  sutures  are  introduced  and  healing  has  taken  place 
the  skin  itself  will  aid  in  maintaining  the  correct  position. 

Step  4.- — Apply  dressings.  Immobilize.  After  three  weeks  begin  massage 
of  the  gastrocnemius.  "For  some  weeks  after  walking  has  commenced  the 
foot  should  be  protected  against  strain." 


CHAPTER  CIX 
CONTRACTURES 

Dupuytren's  contracture  is  due  to  a  contraction  of  the  palmar  fascia  whereby 
the  fingers  become  fixed  and  incapable  of  extension.  The  ring  finger  is  first 
affected.  The  fascia  is  normally  connected  by  bands  with  the  skin  of  the  palm. 
When  the  fascia  contracts,  the  skin,  being  adherent  to  it  at  points,  is  naturally 
thrown  into  wrinkles  and  folds.  Operation  is  indicated  when  the  deformity 
causes  distinct  disability.  In  a  handicraftsman  operation  will  be  called  for  at 
a  much  earlier  stage  of  the  disease  than  in  one  whose  work  does  not  demand 
free  use  of  the  hands. 

Adam's  Operation. — Clean  the  hand  thoroughly.  Note  the  points  where  the 
skin  is  not  closely  adherent  to  the  subjacent  fibrous  band.  At  such  places 
introduce  a  fine  tenotome  between  the  skin  and  the  fibrous  band.  Turn  the 
edge  of  the  tenotome  against  the  fibrous  hand.  Make  the  band  tense  by  extend- 
ing the  affected  finger,  and  at  the  same  time  give  a  slightly  sawing  motion  to  the 
tenotome.  Be  careful  not  to  cut  too  deeply  lest  the  flexor  tendons  be  injured. 
The  operation  must  be  repeated  at  several  points.  Apply  aseptic  dressings. 
Fix  the  hand  and  fingers  in  a  position  of  extension  by  means  of  a  dorsal  splint. 
After  the  lapse  of  three  weeks  careful  and  thorough  massage  is  indicated;  the 
splint  may  be  discarded  during  the  day,  but  a  suitable  appliance  to  maintain 
extension  must  be  worn  at  night  for  several  weeks. 

Recurrence  of  the  trouble  often  takes  place,  but  in  other  cases  the  result  is 
permanent  and  various  nodes  of  scar  tissue  or  callosities  disappear  in  a  surprising 
manner.  The  operation  is  simple,  can  be  performed  under  local  anesthesia, 
and  ought  to  be  tried  in  most  cases  before  more  severe  measures  are  adopted. 

Dupujrtren's  Operation.— Cleanse  the  hand  thoroughly.  Extend  the  af- 
fected finger  as  much  as  possible.  Make  a  transverse  incision  one  inch  in 
length  opposite  the  metacarpo-phalangeal  joint.  This  incision  divides  both 
the  skin  and  the  contracted  fascia,  but  must  not  injure  the  flexor  tendons. 
Apply  aseptic  dressings.     Fix  the  hand  and  fingers  in  a  position  of  extension 


DUPUYTREX  S  CONTRACTURE  I  239 

by  means  of  a  suitable  splint.  When  the  wound  has  healed,  the  treatment  to 
be  adopted  is  the  same  as  after  Adam's  operation. 

Open  Operation,  Hardie's  Operation.^ — "An  incision  begun  half  an  inch 
above  the  principal  transverse  fold  of  the  palm,  immediately  over  the  tense 
bridle  of  fascia,  proceeding  to  the  finger  mainly  involved.  This  is  carried  along 
the  bridle  to  a  little  beyond  the  base  of  the  last  phalanx  which  is  afifected.  The 
lips  of  the  incision  having  been  opened  up,  the  knife  is  then  carried  close  to 
bridle  along  its  whole  extent  so  as  to  separate  from  it  the  adjacent  skin,  cellular 
tissue,  and  fat,  first  on  one  side  and  then  on  the  other.  In  doing  this  it  is 
necessary  to  go  some  depth  near  the  upper  end  of  the  incision,  so  as  to  divide 
the  little  bands  which  attach  the  web  of  the  finger  to  the  processes  of  fascia 
inserted  into  the  sides  of  the  first  phalanx."  Cut  across  the  tense  fascia  at  the 
digital  end  of  the  incision.  Make  further  transverse  incisions  opposite  the  mid- 
dle of  the  first  and  second  phalanges  as  may  be  required.  Divide  the  fascia 
transversely  wherever  it  seems  to  prevent  complete  extension  of  the  fingers. 
Isolated  portions  of  fascia  may  be  removed  if  convenient.  Close  the  wound 
with  sutures  after  attending  to  hemostasis.  Apply  aseptic  dressings  and  band- 
age to  a  straight  splint.  After  the  wound  has  healed,  make  use  of  massage  and 
retain  the  splint  for  two  or  three  weeks. 

Excision  of  the  Diseased  Fascia. — Complete  excision  of  the  diseased 
fascia  is  impracticable,  but  an  extensive  excision  is  both  practicable  and  bene- 
ficial. Several  methods  of  operating  have  been  devised.  Some  surgeons  ad- 
vise the  formation  of  a  V-shaped  flap  having  its  base  towards  the  fingers;  others 
advise  a  straight  longitudinal  incision  over  the  most  prominent  cicatricial  band. 
Each  method  is  proper  in  suitable  cases.  Whichever  incision  is  used,  the  scar 
tissue  is  exposed  as  completely  as  possible  by  reflecting  the  skin  in  the  manner 
described  in  Hardie's  operation.  The  cicatricial  tissue  is  divided  at  its  inser- 
tion into  the  phalanges,  carefully  dissected  from  the  subjacent  structures,  and 
removed  if  possible  in  one  piece.  Hemostasis  is  attended  to  and  the  wound 
closed.  If  the  V-shaped  incision  has  been  used,  the  flap  thus  formed  will 
generally  be  found  incapable  of  completely  filling  the  bed  from  which  it  was 
removed,  so  that  it  is  necessary  to  close  the  proximal  end  of  the  wound  as  if  it 
was  a  linear  incision.     The  resulting  scar  is  Y-shaped. 

J.  D.  Griffith  excises  the  cicatricial  tissue  through  a  longitudinal  incision 
as  described  above,  but  instead  of  at  once  closing  the  wound,  he  adopts  the 
following  procedure:  From  the  end  b  (Fig.  1588)  of  the  longitudinal  incision 
A  B  he  makes  the  curved  incision  b  c  through  the  skin,  and  thus  forms  the  flap  f, 
with  its  base  a  c.  In  the  same  manner  he  makes  the  flap  e,  having  its  base  at 
B  D.  These  flaps  are  reflected  from  the  subjacent  tissues  and  tiirned  so  that 
the  end  of  the  flap  e  covers  the  raw  surface  left  by  the  reflexion  of  the  end  of  the 
flap  F,  and  the  end  of  the  flap  f  covers  the  raw  surface  left  by  the  reflexion  of  the 
end  of  the  flap  e  (Fig.  1588).  Whether  the  transposition  of  the  skin-flaps  is  of 
much  value  or  not,  the  method  has  given  good  results  in  the  hands  of  Griffith, 
and  in  one  case  in  which  the  author  used  it  the  result  seemed  excellent.  In 
most  cases,  however,  any  attempt  to  transpose  the  skin-flaps  is  unwise,  as  the 
skin  is  so  thin  and  ill-nourished  that  death  of  the  flaps  is  very  likely  to  ensue. 


1240 


CONTRACTURES 


Lotheissen's  Operaticn. — (''Centralblatt  f.  Chir.,"  1900,  No.  20.)  Make 
the  curved  incision  a,  b,  c  (Fig.  1589).  Reflect  the  palmar  flap  thus  outlined. 
E.xcise  the  palmar  aponeurosis.  Extend  the  fingers.  Replace  the  flap.  With 
the  fingers  extended  there  will  be  a  small  defect  (.\b)  where  the  edges  of  the 
wound  do  not  come  together.  Apply  sutures  as  shown  in  the  figure.  The 
Esmarch  bandage  is  used  to  permit  of  bloodless,  careful  dissection.  Before 
the  flap  is  replaced,  hemostasis  must  be  most  carefully  attended  to,  as  a  sub- 
cutaneous hematoma  or  the  application  of  a  compressive  dressing  endangers 
the  vitality  of  the  flap. 


Fig.  1588. — Griffith's  method. 


Fig.  1 389. — Lothcisen's  operation. 


Bruce  Gill's  Operation  Annals  of  Surg.,  Aug.,  1919,). — Do  not  use  a  tourni- 
quet. Make  a  transverse  incision  along  the  distal  palmar  crease.  Through 
this  incision  e?q505e  and  excise  the  palmar  fascia  without  button-holding  the 
skin  or  injuring  the  underlying  tendons,  etc.  (If  the  proximal  interphalangeal 
joint  cannot  be  extended,  excise  the  head  of  the  first  phalanx  through  a  trans- 
verse dorsal  incision.)  Obtain  a  free  flap  of  fat  from  the  thigh  and  insert  it 
smoothly  under  the  palmar  skin.  Close  the  skin  incision.  Dress.  Apply  a 
splint  for  about  one  week. 

Volkmann's  Contracture. — Shortening  of  forearm  to  obviate  effects  of  the 
contracture. 

Step  I. — Make  an  incision  for  13-14  cm.  (5-5M  in)  upwards  from  the 
base  of  the  styloid  process  along  the  outer  side  of  the  radius.  Separate  the 
flexor  tendons  from  the  bone  and  retract  them  forwards  and  inwards  along  with 
the  radial  arten,-.     Retract  the  supinator  longus  backwards. 

Step  2. — Expose  the  radial  insertion  of  the  pronator  quadratus  and  divide 
it  close  to  the  bone.  Separate  this  muscle  from  its  anterior  and  posterior  con- 
nection but  not  from  the  ulna. 

Step  3. — Cover  the  lower  part  of  the  wound  with  gauze.  Expose  and  divide 
the  insertion  of  the  pronator  radii  teres  in  the  outer  surface  of  the  middle  of  the 
radius.     Endeavor  to  supinate  the  forearm.     If  supination  is  impossible  or 


PLASTIC    SURGERY  1241 

incomplete  divide  with  a  knife  (hugging  the  median  border  of  the  radius)  the 
radial  attachment  of  the  interosseous  ligament  near  the  middle  of  the  forearm. 
This  permits  complete  supination  ("Jean  Berger,  Journ.  de  Chir.,"  May,  191 2). 

Step  4. — Excise  a  segment  of  radius  l'^  to  i  inch  in  length  near  the  insertion 
of  the  pronator  radii  teres.     This  may  be  done  subperiosteally  with  a  Gigli  saw. 

Step  5. — On  the  ulnar  side  of  the  arm  make  an  incision  from  about  ^  inch 
above  the  styloid  process  for  about  18  cm.  (7  inches)  along  the  surface  of  the 
ulna.  Separate  the  flexor  tendons  from  the  bone  and  pass  a  blunt  hook  from 
the  ulnar  to  the  radial  wound  so  as  to  elevate  all  the  soft  parts  anterior  to  the 
pronator  quadratus.     Excise  the  pronator  quadratus  completely. 

Step  6. — Using  as  a  measure  the  segment  of  radius  which  was  excised  in 
Step  4,  excise  a  similar  segment  of  ulna  from  a  point  near  the  insertion  of  the 
pronator  quadratus.  It  is  important  that  the  wounds  of  the  radius  and  ulna 
should  not  be  at  the  same  level. 

Step  7. — Unite  the  two  fragments  of  the  radius  by  means  of  chromic  catgut, 
wire,  or  Lane's  plate.     Do  the  same  with  the  ulna. 

Step  8. — Close  the  wounds  in  the  soft  parts.  Apply  dressings.  Apply  a 
moulded  plaster-of -Paris  splint  (or  any  suitable  splint)  from  well  above  the 
elbow  down  to  near  the  tips  of  the  fingers.  The  forearm  should  be  semiflexed 
and  completely  supinated.  The  wrist  and  fingers  should  be  extended  and  the 
thumb  left  free.     There  must  be  no  constriction  anywhere. 

In  a  child  the  splint  may  be  removed  at  the  end  of  a  month,  though  before 
that  it  may  require  readjustment  and  the  arm  may  be  temporarily  exposed  for 
the  use  of  passive  movements. 

Tendon  lengthening,  in  place  of  bone  shortening,  has  given  some  excel- 
lent results. 


CHAPTER  CX 

PRINCIPLES  OF  PLASTIC  SURGERY 

Plastic  operations  are  such  as  are  undertaken  to  close  up  or  fill  defects 
resulting  from  errors  in  the  development  (hare-lip,  etc.)  or  from  the  destruction 
of  tissues  by  disease,  operation,  or  accidental  injury.  While  plastic  operations 
are  applied  to  each  and  every  kind  of  tissue  (bone  transplantation,  tenoplasty, 
etc.),  yet  in  most  of  them  the  skin  plays  the  chief  role. 

Do  not  undertake  plastic  operations  in  the  debilitated,  or  in  those  with  active 
disease  present  {e.g.,  suppuration,  syphilis,  etc.). 

The  two  main  principles  at  the  base  of  all  plastic  work  are:  {a)  Proper 
preparation  or  vivification  of  the  tissues  to  be  united;  {b)  thorough  relief  of  ten- 
sion.    Failure  to  carry  out  these  principles  leads  to  certain  disappointment. 

When  the  defect  is  oval,  but  not  very  extensive,  and  the  neighboring  skin  is 
not  firmly  bound  to  the  deeper  structures,  the  edges  of  the  oval  may  be  brought 
together  directly  and  sutured.  If  on  attempting  approximation  tension  makes 
itself  evident,  this  tension  must  be  relieved.  Tension  may  be  relieved  by 
burrowing  with  knife  or  scissors  between  the  skin  and  the  deep  fascia,  thus 


1242 


PRINCIPLES   OF  PLASTIC   SURGERY 


undermining  the  skin  all  around  the  defect  (Fig.  1590).  In  some  localities, 
e.g.,  the  pectoral  region,  very  large  defects  may  be  thus  obliterated.  Often 
this  burrowing  must  be  supplemented  by  making  a  cut  through  the  skin 
parallel  to  and  on  one  or  both  sides  of  the  defect.  Such  relaxation  incisions 
should  be  in  positions  where  their  scar  will  be  more  or  less  hidden.  Figs. 
1 591  ®;  ®,  ®,  ®,  ®,  ®  indicate  how  various  defects  may  be  closed.  Large 
defects    require    other   means    of    treatment,    either    being    closed    by    skin- 


Fig.  1590. 

grafting  or  by  the  use  of  pedunculated  flaps  of  healthy  skin,  obtained 
preferably  in  the  near  neighborhood,  occasionally  from  more  remote  parts. 
The  skin  chosen  to  form  the  flaps  must  be  such  as  to  match  that  lost.  It 
would  not  gratify  a  patient  much  to  have  a  successful  rhinoplasty  per- 
formed on  him  if  the  hairy  scalp  was  used  to  supply  the  necessary  skin  for 
the  nose.     The  objection  to  many  of  the  operations  for  ectopia  vesicae  or 


for  epispadias  is  that  skin  capable  of  growing  hair  is  used  to  line  the  new 
bladder  or  urethra.  Hairless  skin  is  often  used  to  replace  lost  mucous  mem- 
brane, but  if  healthy  mucous  membrane  can  be  obtained,  such  is  far  better. 
The  flaps  should  consist  of  the  whole  thickness  of  the  skin,  but  without  too  much 
subcutaneous  fat  attached  to  them;  they  ought  to  be  about  one-sixth  larger  than 
the  defect  they  are  to  fill,  and  should  have  a  pedicle  through  which  nourish- 
ment is  freely  supplied.  This  advice  has  been  universal  but  Gillies  considers 
it  wrong.  Twisting  of,  or  tension  on  the  pedicle  occludes  its  blood- 
vessels, cutting  off  nourishment  and  impeding  the  natural  drainage;  hence  it  is 
necessary  in  tracing  out  the  flap  to  do  so  in  such  a  position  that  it  can  be  fixed 


PLASTIC    SURGEKY 


1243 


Fig.  i59i(D>  A,  B,  C. 


^-^^f^^^ 


B 


iMC.  iSQiG^  A,  li. 


Fig.  1591©,  A,  B. 


Fig.  1591®.  A,  B,  C. 


Fig.  1591®.  A,  B. 


1244  PRINCIPLES    OF    PLASTIC    SURGERY 

in  its  new  location  without  running  these  hazards.  Part  or  all  of  a  skin-flap 
even  with  a  good  pedicle  and  with  its  raw  surface  in  contact  with  a  correspond- 
ing healthy  raw  surface,  often  fails  to  live.  After  the  lapse  of  a  few  hours  the 
surface  becomes  discolored,  edematous,  blisters  form,  and  death  of  all  the  tissues 
takes  place.  This  death  is  not  from  want  of  nourishment;  it  is  from  want  of 
normal  absorption  or  drainage  from  the  flap.  The  drainage  is  of  even  more 
importance  than  the  nourishment  obtained  through  the  pedicle.  Under  simi- 
lar circumstances  a  flap  of  skin  completely  detached  from  the  body  and  im- 
planted into  a  defect  (Wolf's  grafts)  lives  and  does  not  show  the  above  phe- 
nomena. This  is  due  to  the  fact  that  there  is  no  damming  up  of  lymph  in  the 
detached  portion  of  skin.  The  grafted  skin  soon  becomes  united  to  its  new 
bed,  thus  obtaining  a  sufficiency,  but  not  an  excess,  of  nourishment.  C.  H. 
Mayo  scarifies  the  surface  of  flaps  which  are  provided  with  pedicles,  thus 
providing  for  immediate  lymph  drainage  and  avoiding  the  dangers  of  necrosis 
from  lymph  stasis.  This  scarification  need  not  be  deep; 
mere  scratches  suffice. 

Sometimes  flaps  are  provided  with  two  pedicles — 
"visor-shaped"  flaps.  A  good  example  of  this  variety  is 
seen  in  Regnier's  operation  for  cancer  of  the  lower  lip. 

Fear  may  be  entertained  as  to  the  viability  of  a  flap  if 
it  is  transferred  to  its  new  site  as  soon  as  it  is  formed,  and 
thus  in  some  cases  it  is  wise  to  trace  out  the  flap,  separate 
it  from  the  deep  structures,  but  leave  it  attached  at  both 
^  "  ends;    the    bridge   of   skin    thus   formed   must    be    kept 

separated  from  the  subjacent  tissues  by  a  layer  of  oiled  silk.  After  about 
two  or  three  weeks  one  of  its  pedicles  is  divided  and  the  flap  put  in  place 
(Fig.  1592).  This  plan  (Croft's)  is  specially  suitable  when  the  flaps  required 
are  long  and  narrow. 

W.  D.  Gillies  (Surg.,  Gyn.  and  Obst.,  Jan.,  1920)  from  his  vast  experience 
at  Sidcup  during  the  war  has  modified  and  improved  the  use  of  flaps  by  using 
the  tubed  pedicle.  The  use  of  these  flaps  will  be  described  as  for  facial  de- 
formities, but  they  may  be  used  elsewhere  as  efficiently. 

Step  I. — From  an  unscarred  place  on  the  upper  part  of  the  neck  make  two 
parallel  incisions  about  three  inches  apart,  downwards  on  to  the  chest.  By 
undermining  mobilize  the  skin  leaving  it  attached  at  its  upper  and  lower  ends 
(Figs.  1593  and  1594).  Partly  divide  the  upper  end  of  the  pedicle  thus  formed. 
Fold  the  pedicle  transversely  on  itself  to  form  a  tube  with  the  epidermis  external. 
Suture  together  the  edges  of  the  skin  of  the  tube.  By  undermining  and  the 
use  of  relaxation  and  other  sutures  close  the  wound  from  which  the  "pedicle" 
was  raised.  Apply  dressings.  Anytime  after  the  lapse  of  three  weeks  the 
further  stages  of  the  operation  may  be  begun. 

Step  2. — (A)  There  is  a  comparatively  small  area  to  be  repaired,  e.g.,  over 
the  chin.  Excise  all  the  scar  tissue  of  the  area.  Divide  the  distal  or  chest 
end  of  the  pedicle.  Undo  the  tubing  of  that  end  of  the  pedicle  by  excising 
the  suture  line  and  any  core  of  scar  tissue  which  may  have  formed  inside  the 
tube.     This  end  of  the  pedicle  when  spread  out  suffices  to  fill  the  defect  on  the 


GII.I.IES     MF.THOnS 


1245 


chin.     Suture  the  new  fornud   llaj)  in   its  new  |)ositi()n  unrlcr  slight  tension. 
(Figs.  1593-  1594). 

(B)  The  defect  is  larger.  There  is  not  sufficient  material  in  the  lube  to 
fill  the  defect.  At  the  end  of  the  pedicle  trace  on  the  chest  wall  an  area  of  skin 
sufficient  to  fill  the  defect  and  dissect  it  free  leaving  it  attached  to  the  pedicle. 
Use  this  flap  to  fill  the  defect. 

(C)  During  tubulization  of  the  pedicle  nourishment  is  obtained  from  both 
ends.  If  it  is  feared  that  the  neck  end  of  the  pedicle  will  not  transmit  enough 
nourishment  when  the  chest  flap  is  mobilized  so  as  at  once  to  cut  off  all  its 
connections  except  with  the  pedicle,  then  it  is  wise  to  undermine  all  the  area 


Fig.  1593. — First  stage:  Four  inch 
parallel  chest  flap  tubed.  Complete  closure 
by  advancement.  (Gillies,  Surg.  Gyn.  and 
Obst.) 


Fig.  1594. — Second  Stage:  Excision  of  scar 
tissue  for  reception  lower  extremity  of  flap  B. 
Flap  A  swung  to  left.  Chest  flap  partly  un- 
tubed  and  sewn  into  place.  (Drawn  by  Lieut. 
Lindsay,  A.  A.  M.  C.)  {Gillies,  Surg.  Gyn. 
and  Obst.) 


destined  to  form  the  flap  but  to  leave  its  distal  portion  continuous  with  the 
surrounding  skin.  The  part  of  the  flap  nearest  the  pedicle  may  be  tubuhzed. 
In  a  few  days  the  flap  will  become  accustomed  to  its  lessened  blood  supply  and 
its  distal  connections  can  be  divided. 

(D)  Instead  of  undermining  the  flap  trace  it  out  by  incising  the  skin  all 
around  it,  only  dissecting  the  flap  free  after  a  few  days. 

(E)  Two  tubed  pedicles  may  be  employed  for  one  flap  (Figs.  1595  to  1599). 

(F)  After  forming  one  tubed  pedicle  as  above  but  before  dividing  its  chest 
connection  Gilhes  has  deliberately  divided  its  base  and  implanted  that  base 
into  a  more  vascular  region.  He  has  found  this  shifting  of  the  base  of  supplies 
useful. 


1246 


PRINCIPLES    OF    PLASTIC    SURGERY 


Fig.  1595.  Fig.   1596. 

Fig.  1595. — Cordite  burn,  soon  after  injury  in  battle  of  Jutland.  {Gillies,  Surg.  Gyn.  and 
Obst.) 

Fig.  1596. — Healed  with  very  severe  ectropion  and  upper  facial  bum.  Bilateral  tube 
pedicles  to  chest  flap,  first  stage.     {Gillies,  Surg.  Gyn.  afid  Obst.) 


Fig.   1597.  Fig.   1598. 

Fig.  1597. — Second  Stage:  Pedicles  and  flap  in  position.     {Gillies,  Surg.  Gyn.  and  Obst.) 
Fig.  1598. — Third  Stage:  Pedicles  opened  and  returned  to  chest.     Note  development  of 

facial  expression,  a  free  blush  was  present  in  this  flap  in  the  third  week.     {Gillies,  Surg.  Gyn. 

and  Obst.) 


GILLIES     TUBED    FLAPS 


1247 


Step  3. — The  flap  has  been  swung  into  position  to  fill  the  defect  and  has 
united  in  its  new  site. 


^ 


y-^i..:.. 


Fig.  1599. — Six  months  after  first  operation.     Note  grafts  to  eyelids  and  adaptation  of  flap 
to  new  position.     Artificial  eyebrows.     {Gillies,  Surg.  Gyn.  and  Obst.) 


/^ 


x 


Fig.  1600.  Fig.  1601. 

Fig.  1600. — Total  facial  cordite  burn.     Battle  of  Jutland.     (Gillies,  Surg.  Gyn.  and  Obst.) 
Fig.  1 601. — Large  chest  flap  applied  to  face  with  two  tube  pedicles.     The  skin  over  the 
nose  has  sloughed.     The  left  pedicle  has  been  divided.     {Gillies,  Surg.  Gyn.  and  Obst.) 


(A)  Divide  the  pedicle  close  to  the  face  and  replace  it  in  the  opened  out 
wound  of  the  neck. 


1248 


PRINCIPLES    OF    PLASTIC    SURGERY 


(B)  Divide  the  pedicle  at  its  base  on  the  neck  and  use  it  for  repairing  other 
parts  of  the  face  or  nose  (Figs.  1600  to  1606.) 

Step  4. — Consists  of  various  minor  or  "touching  up"  operations  to  make 
the  new  material  as  comely  as  possible. 


Flo.   1O02.  Fig.  1603. 

Fig.  1602. — Both  pedicles  divided.     Note  ectropion  of  eyelids.     {Gillies,  Surg.  Gyn.  and 

Obst.) 

Fig.  1603. — Method  of  converting  the  left  pedicle  into  a  nose.  A  suitable  epithelial  lining 
was  prodded  for  the  new  lip  and  alse.  (Drawing  by  Prof.  H.  Tonks.)  (Gillies,  Surg.  Gyn. 
and  Obsl.) 


Fig.  1604. — Left  pedicle  swung  to  the  nusc.     yU.^ii<s,  Surg.  Gyn.  and  Obst.) 

The  "tubed  flap"'  may  be  well  used  in  repairing  or  replacing  a  lost  upper 
or  lower  lip.  In  this  case  the  flap  is  not  to  be  untubed  or  spread  out  as  in  its 
folded  condition  it  provides  an  epithelial  lining  both  towards  the  mouth  and 
externally  as  well  as  a  smooth  lip  margin. 

Dufourmenlel's  Operation  ("Journ.  de  Chir.,"'  xv.,  171,  1920)  is  a  good 
example  of  plastic  surgery.  Where  the  whole  chin  and  horizontal  ramus  of  the 
lower  jaw  has  been  destroyed  Dufourmentel  operates  as  follows: 

Stage  I. — Step  i. — Restore  the  floor  of  the  mouth  by  flaps  taken  from  the 
cheek  (Fig.  1607). 


dufourmentel's  operation 


1249 


Step  2. — Make  two  parallel  incisions  through  the  whole  thickness  of  the 
hairy  scalp  from  one  temporal  region  to  the  other.  The  resultant  flap  ought  to 
be  about  3  inches  (7-8  cm.)  wide.  Elevate  the  flap  from  the  skull  and  pull 
it  forwards  and  downwards  (Fig.  1608)  over  the  face  like  a  loop  or  a  visor. 


Fig.   1605.  Fig.  1606. 

Figs.  1605  and  1606. — Final  Stages.  The  right  pedicle  has  been  spread  over  the  chest. 
The  new  nose  has  been  trimmed  and  supported  by  cartilage.  Four  new  eyelids  have  been 
provided  by  an  outlay'  operation.     New  eyebrows  have  been  grafted. 


Wf'ji^ 

// 

y/        /' 

Fig.  1608. 

Fig.  1607. 

Suture  the  flap  to  the  reconstituted  floor  of  the  mouth.  Do  not  try  to  give  any 
particular  or  esthetic  shape  to  the  flap.  That  can  be  done  later  All  that  is 
desired  at  present  is  to  provide  abundant  and  living  skin  and  mucosa  (Fig.  1609). 
Stage  2. — After  at  least  two  weeks  divide  and  replace  the  pedicles  and 
endeavour  to  fashion  reasonably  esthetic  lips. 


I250 


PRINCIPLES    OF    PLASTIC    SURGERY 


Fig.  1609. 


Fig.  1610. 


SKIN    GRAFTING  I  25  I 

Stage  3. — From  the  lower  ciul  of  the  remnants  of  the  ascending  ramus  of  the 
jaw  on  one  side  make  a  tunnel  between  the  flap  forming  the  lining  of  the  floor  of 
the  mouth  and  that  forming  the  skin  of  the  chin  etc.,  to  the  lower  end  of  the 
ascending  ramus  of  the  jaw  on  the  other  side.  Through  this  tunnel  pull  a  bone 
graft  obtained  with  its  periosteum  from  the  tibia.  The  graft  must  be  broken  in 
two  places  to  give  it  the  necessary  shape.  Suture  the  ends  of  the  graft  to  the 
remnants  of  the  ascending  rami.  When  the  new  bone  has  become  consolidated 
in  place,  a  series  of  small  'touching  up'  operations  will  be  necessary.  The  result 
in  one  of  Duformentel's  cases  is  shown  in  Fig.  1610. 

Gillies  ("Plastic  Surgery  of  the  face,"  Oxford  Press,  1920)  has  performed 
similar  operations. 

Remarks. — To  the  author  it  seemed  that  the  new  lining  for  the  floor  of  the 
mouth,  being  obtained  from  the  cheek,  would  be  entirely  unsuitable  because  of 
the  hair,  but  Dufourmentel  in  a  letter  says  "I  have  never  bothered  myself 
fighting  against  the  development  of  hair  on  the  cutaneous  flaps  included  in  the 
buccal  cavity  x  x  x  the  hairs  cause  absolutely  no  disability.  When  their 
length  becomes  annoying  the  patients  themselves  trim  them  with  scissors. 
The  results  of  the  operation  have  remained  excellent." 

Instead  of  pedunculated  flaps,  areas  of  skin  entirely  detached  from  their 
normal  connections  may  be  used.  This  is  truly  skin-grafting.  The  grafts 
may  be  obtained  from  the  patient  himself,  from  a  recently  amputated  healthy 
limb,  or  from  obliging  friends.  Autogenous  flaps  are  the  best.  If  the  grafts 
are  homogenous  it  is  advisable  to  choose  a  donor  having  blood  belonging  to 
the  same  class  as  that  of  the  recipient  (p.  860).  Grafts  obtained  from  animals 
(rabbits,  frogs)  have  been  employed,  but  when  used  after  the  Thiersch  method, 
even  if  they  have  adhered  to  the  raw  surface,  they  have  not  reproduced  epi- 
thelium and  have  been  ultimately  absorbed. 

Wolf's  Grafts.— Wolf,  of  Glasgow  ("Brit.  Med.  Journ.,"  Sept.  18,  1875),  de- 
vised the  following  method  of  repairing  recent  defects,  especially  in  the  eyelids: 

On  some  suitable  region — the  forearm,  inner  side  of  upper  arm,  or  thigh — 
trace  with  the  scalpel  an  area  of  skin  at  least  one-sixth  larger  than  the  defect  to 
be  filled  and  of  suitable  shape.  Quickly  and  completely  separate  the  flap 
outlined  from  the  subjacent  tissues.  With  the  scissors  carefully  remove  all 
fat  from  the  under  surface  of  the  graft;  in  fact,  trim  this  surface  until  the  pale, 
deep  surface  of  the  cutis  vera  is  visible.  Fit  the  graft  into  the  defect  and  hold 
it  accurately  in  place,  either  by  a  few  fine  sutures  or  by  suitable  dressings. 
In  the  repair  of  defects  in  the  eyelid  the  writer  has  often  seen  the  Wolf 
graft  sutured  in  place  and  protected  by  a  few  layers  of  gold-beater's  skin, 
which,  when  dry,  acts  as  an  efficient  splint  to  the  part. 

Grafts  such  as  above  are  usually  employed  to  cover  raw  areas  resulting  from 
operations  and  not  to  cover  granulating  surfaces.  It  is  of  prime  importance 
that  hemorrhage  be  completely  stopped,  otherwise  effused  blood  will  lift  the 
graft  from  its  bed  and  prevent  adhesions.  H.  D.  Gillies  (Surg.,  Gyn.  and  Obst.^ 
Feb.,  1920)  emphasizes  the  following  points,  (i)  The  graft  should  exactly  fit 
the  defect.  (2)  The  skin  edges  should  be  accurately  sutured.  (3)  Moderate 
tension  is  advisable  as  it  keeps  open  the  tiny  spaces  through  which  anastomotic 
processes  may  occur  and  tissue  fluids  come  and  go.     (4)  Pressure  should  be 


I2s2 


PRINCIPLES    OF    PLASTIC    SUKGERY 


kept  up  on  the  graft  to  keep  it  firmly  })reiised  on  its  new  bed  until  adhesion 
takes  place.     Application  of  pressure  is  easy  on  the  forehead. 

"On  the  nose  one  method  entails  the  use  of  a  molded  splint  made  of  dental 
modelling  composition,  which  is  in  its  turn  held  in  place  by  strapping  by  a 
spectacle  frame,  or  best  by  a  splint  taking  its  fixation  point  from  the  upper 
teeth.  On  the  cheek  and  chin,  pressure  is  applied  with  difficulty.  In  any  case 
a  dental  apphance  carrying  an  arm  to  press  the  mold  on  to  the  graft  is  indicated. 
Further,  a  splint  fixing  the  mandible  in  the  open  bite  position  will  inhibit  most 
cheek  movements,  while  the  head  itself  may  be  secured  by  a  jury  mast.  An- 
other and  effective  method  of  graft  fixation  is  illustrated  in  Fig.  1611,  in  which 


Fig.  1611. 


-Wolfe  graft  to  chin,  "Stent"  or  dental  mold  composition  pressing  the  graft  to  it's 
bed.     {Gillies,  Surg.  Gyn.  and  Obst.) 


a  large  Wolfe  graft  was  applied  to  the  lower  lip  and  chin,  and  pressed  there 
by  a  rhold  of  dental  composition,  which  is  itself  fixed  by  cross  sutures  from  areas 
beyond  the  margin  of  the  graft.  In  Fig.  161 1  little  rolls  of  gauze  were  used  to 
prevent  cutting  through  of  the  retaining  sutures." 

Large  Wolfe  grafts  may  be  used  and  are  specially  good  applied  to  the  fore- 
head.    Pedunculated  flaps  are  better  for  nose  and  cheek  repair. 

Thiersch's  Graft.- — Thiersch  ("  German  Surg.  Soc,"  1874, 1888)  suggested  the 
use  of  grafts  consisting  of  epidermis,  corresponding  in  thickness  to  the  covering 
of  a  blister  and  cut  from  some  suitable  region  in  as  large  strips  as  possible. 
This  is  the  most  common  and  convenient  method  of  skin-grafting.  The  grafts 
may  be  applied  to  a  fresh  wound,  e.g.,  open  wound  left  after  amputation  of  the 
breast,  or  to  any  clean  granulating  surface.  When  a  granulating  surface  is  to  be 
covered  by  grafts,  it  must  be  prepared  by  thorough  cleansing  and  the  removal  of 
exuberant  granulations  by  means  of  rubbing  with  gauze  or  by  the  sharp  spoon. 
All  bleeding  must  have  ceased,  whether  the  wound  is  recent  or  granulating.  If 
oozing  of  blood  persists,  the  wounded  surface  must  be  covered  by  a  protective 
layer  of  rubber  tissue,  silver-foil,  or  such  like  material,  over  which  sterile  gauze  is 
applied,  and  the  skin-grafting  put  off  until  the  next  day. 

The  grafts  are  generally  obtained  from  the  inside  of  the  thigh.  If  the  skin  to 
be  employed  is  hairy,  shave  the  hair.     As  the  portion  of  epidermis  to  be  taken  is 


SKIN    GRAFTING 


1253 


too  thin  to  contain  any  hair-bulbs,  no  hair  will  be  grafted,  no  matter  from  what 
region  the  graft  is  obtained.  Cleanse  the  area  selected.  With  the  hands, 
McBurney's  tractor,  or  a  paper-knife  make  the  skin  tense.  Shave  off  the 
thinnest  possible  layer  of  epidermis  with  a  very  keen  razor,  moistened  with  salt 
solution  (Halsted  uses  an  amputation  knife).  This  forms  the  graft  and  should 
be  as  large  as  possible.  Carry  the  graft,  lying  in  folds  on  the  razor  blade,  to  the 
wound.  Keep  it  moist  with  salt  solution.  Hold  the  sharp  edge  of  the  blade 
close  to  the  wound.  With  a  needle  pull  the  end  of  the  graft  gently  on  to  the 
wound,  temporarily  fixing  it  there;  as  the  blade  is  slowly  pulled  away  parallel  to 
the  wound  the  graft  smoothly  slips  oflf  it  and  lies  flat  on  the  wound.  If  there  are 
any  little  folds  in  the  graft,  get  rid  of  them  with  needles  in  the  same  manner  as  is 
done  when  spreading  sections  of  tissue  on  the  slide  for  microscopic  work.  Some- 
times if  the  graft  becomes  tangled  on  the  razor  blade  it  is  well  to  put  it  in  a  basin 
of  salt  solution  and  float  it  on  to  a  piece  of  oiled  silk.     The  oiled  silk  with  the 


Fig.  i6i2. 


graft  lying  smoothly  on  it  is  laid  (with  the  graft  under)  on  the  wound,  the  edge  of 
the  graft  is  held  in  place  on  the  wound  with  a  needle,  and  the  oiled  silk  removed 
gently,  leaving  the  graft  in  the  position  desired. 

When  the  whole  wound  is  covered  with  grafts,  place  over  them  strips  of  rub- 
ber tissue,  of  silver-foil  or  of  cotton  mesh  impregnated  with  rubber  or  celloidin 
and  outside  this  the  ordinary  gauze  dressings.  The  dressings  ought,  if  possible, 
to  remain  unchanged  for  a  week.  No  antiseptic  lotions  ought  to  be  employed, 
only  salt  solution.  The  same  kind  of  dressings  must  be  applied  until  the  healing 
process  is  complete.  Very  large  surfaces  can  be  made  to  heal  in  a  short  time 
by  the  Thiersch  method  of  skin-grafting. 

When  possible  it  is  far  better  to  avoid  the  use  of  any  dressing  or  tissue 
applied  to  the  grafted  area  which  should  be  left  freely  exposed  to  the  air.  To 
protect -the  wound  against  flies  and  mechanical  irritation,  it  may  be  surrounded 
by  a  thick  wall  of  cotton  or  such  like  material  which  supports  a  roof  of  fine  wire 
netting  (mosquito  screen)  (Fig.  161 2).  Some  surgeons  have  advised  the  use  of  a 
plate  of  celluloid  instead  of  the  wire  netting,  but  this  prevents  the  desired  free 
circulation  of  air. 


12  54  PRINCIPLES    OF    PLASTIC   SURGERY 

Carl  Haeberlin  (Bad  Nauheim)  finds  that  all  granulating  wounds  heal  best 
when  exposed  to  the  direct  rays  of  the  sun  (without  any  interposed  material)  for 
about  two  or  three  hours  daily;  during  the  rest  of  the  day  he  covers  the  wounds 
loosely  with  gauze  ("Miinchener  med.  Woch.,"  15  Oct.,  1907). 

The  original  method  of  skin  grafting  is  that  of  Reverdin  ("Soc.  de  Chir.," 
Paris,  1869).  It  consists  in  transplanting  fragments  of  skin  about  the  size  of 
the  head  of  an  ordinar}-  pin;  the  fragment  includes  a  little  of  the  cutis  vera. 
Numbers  of  the  grafts  are  implanted  on  the  area  to  be  covered  and  each  if  it  lives 
acts  as  a  centre  for  the  growth  of  epithelium.  Thiersch's  method  has  practically 
displaced  Reverdin 's. 

Denuded  areas  on  the  hand  or  forearm  may  be  covered  with  skin  by  the 
following  efficient  but  distinctly  uncomfortable  method:  If  the  defect  is  on 
the  back  of  the  hand  or  forearm,  choose  a  place  on  the  front  of  the  abdomen 
or  chest  where  the  hand  or  forearm  may  lie  and  be  supported  without  too  great 
strain.  Through  the  skin  of  the  trunk  make  two  parallel  incisions  and  under- 
mine the  skin  between  them,  thus  forming  a  flap  with  two  pedicles  (Fig.  1613). 


Fig.  1613. 

Push  the  hand  under  the  flap  and  adjust  and  suture  the  flap  to  the  denuded  area. 
Apply  dressings,  and  with  adhesive  plaster  fix  the  hand  and  arm  to  the  trunk. 
When  union  has  taken  place  between  the  flap  and  the  denuded  area,  divide  the 
pedicles,  close  the  abdominal  wound  in  the  usual  manner,  trim  the  flap,  and 
complete  its  union  to  the  denuded  area.  If  the  denuded  area  is  on  the  palmar 
aspect  of  hand  or  forearm,  the  flap  must  be  made  on  the  back  of  the  trunk. 

In  cicatricial  ectropion  of  the  eyelids,  GiUies  (personal  communication)  uses 
a  modification  of  Esser's  method  of  utiUzing  Thiersch  grafts.  The  upper  lid  is 
taken  as  an  example;  its  skin  surface  has  been  burned  and  the  resultant  scar 
tissue  has  everted  the  lid. 

Step  I. — Make  an  incision  immediately  above  the  ciliary  margin  from  one 
canthus  to  the  other.  Insert  a  horse  hair  suture  through  the  edge  of  the  lid 
and  use  this  to  pull  the  hd  downwards.  As  traction  is  apphed  scar  tissue  bands 
become  prominent.  Divide  these  horizontally  until  the  eversion  is  entirely 
overcome.  (It  is  usually  necessary  to  undermine  the  skin  of  the  eyelid  upwards 
and  downwards  from  the  incision.) 

Step  2. — Mould  a  piece  of  dental  composition  to  fit  the  raw  area  created  in 
the  eyelid.  This  mould  must  conform  to  the  contour  of  the  eyeball,  terminate 
in  a  rounded  point  at  each  end  and  be  of  such  a  shape  and  size  that  the  edges 
of  the  skin  wound  may  be  sutured  over  it.  Dr>'  the  mould  after  it  has  been 
'"set"  in  cold  water. 


^^  k  I N  K  LKS  1255 

Step  3. — Cut  a  Thiersch  graft  and  wraj)  il  smootlily  around  the  mould. 
Trim  away  any  excess  of  graft  as  any  overlapping  of  the  epithelium  is  objection- 
able. Be  sure  that  the  epidermal  or  superficial  surface  of  the  graft  is  next  the 
mould. 

Step  4. — Pass  two  horse  hair  sutures  from  one  skin  edge  to  the  other  of  the 
incision  but  do  not  yet  tie  them.  Place  the  mould  with  its  covering  of  graft, 
into  position  in  the  wound  and  have  the  assistant  tie  the  two  sutures  already 
in  place.  This  step  is  delicate  as  it  is  important  that  the  graft  be  not  disturbed 
and  that  there  be  neither  wrinkles,  nor  folds  in  it.  Complete  the  closure  of  the 
skin  wound  over  the  mould  and  graft.  After  the  lapse  of  8  or  10  days  reopen 
the  wound  completely  and  permit  the  lid  to  drop  to  the  position  into  which 
it  was  lowered  in  Step  i.  The  former  raw  surface  is  now  firmly  and  completely 
covered  with  epithelium,  Fig.  1614.  Further  treatment  consists  in  dry 
cleanliness  followed  later  by  massage  which  aids  in  smoothing  the  lid. 


Fig.  1614. — Illustrating  functional  cure  of  ectropion.     {Gillies,  Surg.,  Gyn.  and  ObsL) 

In  cases  of  X-ray  burns  E.  G.  Blair  (personal  communication)  has  had 
much  success  from  skin  grafting.  He  carefully  excises  the  affected  area  of  skin 
plus  the  subjacent  fat  so  that  the  deep  fascia  is  exposed.  After  this  he  sutures 
the  skin  edges  to  the  deep  fascia  (with  interrupted  stitches  of  catgut)  all  round 
the  defect  until  little  or  no  fat  is  visible.  The  result  is  a  depression  the  floor 
of  which  consists  of  the  deep  fascia  and  it  is  easy  to  cover  this  floor  with 
Thiersch's  skin  grafts. 

WRINKLES 

Passot  (La  Pr.  Med.,  ^May  12,  1919)  has  pubhshed  the  experience  of  More- 
stin,  de  Martel  and  himself  regarding  operative  effacement  of  wrinkles.  The 
lessons  taught  by  such  work  may  have  broader  application.  Most  of  the 
wrinkles  on  the  cheeks  as  well  as  those  external  to  the  eyes  (crows  feet)  and 
naso-labial  folds  can  be  lessened  or  obliterated  by  excising  a  fold  of  skin  in  the 
pre-auricular  region.  Figure  1615  shows  the  chief  site  for  operation  as  well  as 
some  other  sites  where  subsidiary  work  may  be  done. 

The  Operation. — At  a  point  above  and  in  front  of  the  tragus  pinch  a  fold 
of  skin  between  finger  and  thumb  and  so  find  how  much  must  be  excised  in 


1256 


METHODS    OF   DRAINAGE 


order  to  remove  the  deformities.     The  direction  of  the  long  axis  of  the  fold 
must  also  be  noted.     Mark  the  contours  of  the  fold  with  a  dermatographic 

pencil  and  also  mark  the  points  where  the 
principal  sutures  should  enter  and  emerge. 
Usually  the  area  of  skin  to  be  removed 
forms  an  ellipse  with  its  long  axis  running 
obliquely  upwards  and  forwards,  the  ellipse 
being  from  3  to  4  cm.  long  by  il4  to  3 
cm.  wide.  The  area  is  often  an  ovoid  \vith 
the  narrow  end  anterior. 

First  neatly  excise  the  skin  of  the  se- 
lected area  and  then,  separately,  the  sub- 
cutaneous fat.  This  precauiion  is  taken  so 
as  more  easily  to  avoid  penetration  of  the 
aponeurosis  under  which  lie  branches  of  the 
facial  nerve.  Attend  to  hemostasis  and 
close  the  wound  with  interrupted  sutures. 
Probably  an  intradermic  continuous  suture 
would  be  best.  Both  sides  should  be  oper- 
ated on  at  the  same  sitting. 


Fig.  1615. — (After  Passot.) 


CHAPTER  CXI 


METHODS  OF  DRAINAGE 


The  collection  of  fluids  in  dead  spaces  in  wounds  is  potentially  dangerous, 
and  hence  drainage  should  be  provided  for  such  spaces.  Collections  of  pus  or 
other  noxious  fluids  in  any  part  of  the  body  require  removal,  usually  by  means 
of  drainage.  Drainage  in  its  simplest  form  is  exemplified  by  the  open  treatment 
of  wounds;  here  absorbent  dressings  are  applied  directly  to  the  wound  surface 
or  cavity  and  absorb  all  exuded  fluids  as  soon  as  secreted.  Where  dressings 
cannot  be  applied  directly  to  the  secreting  surfaces,  the  secretions  must  be 
guided  to  the  dressings.  According  to  the  nature  and  surroundings  of  the  fluid 
to  be  drained,  the  method  of  drainage  provided  must  vary.  For  such  fluids  as 
serum,  capillary  drains  suffice;  for  thick  pus,  tubular  drains  are  essential. 
When  a  collection  of  pus  is  evacuated  through  the  peritoneal  cavity,  the  method 
of  drainage  must  provide  protection  to  that  cavity,  hence  a  combination  of 
tubular  or  capillary  drainage  with  protective  packing  becomes  necessary.  The 
following  are  the  principal  means  of  drainage: 

A.  Capillary  Drains. —  i.  Horse-hair;  silkworm-gut;  catgut.  A  few  strands 
of  these  materials,  in  a  bundle,  act  as  an  efficient  drain  for  small  quantities  of 
serous  exudates. 

2.  Gauze  or  wick.  A  strand  of  absorbent  gauze  or  a  portion  of  lampwick 
may  be  used  as  a  capillary  drain,  but  if  these  are  left  in  place  too  long,  fluids 
readily  coagulate  in  their  meshes,  and  instead  of  draining,  they  act  as  a  plug  to 
prevent  drainage. 

3.  Cigarette  drains  consist  of  gauze  surrounded  (Fig.  16 16)  by  a  sheet  of  thin 


DRAINS 


1257 


rubber  tissue  which  enhances  their  efl&ciency  and  prevents  the  gauze  becoming 
adherent  to  surrounding  structures.  Instead  of  rubber  tissue  the  gauze  may  be 
surrounded  by  a  split  rubber  tube  (Fig.  1617).  Strands  of  woolen  yarn  are 
more  efficient  than  gauze. 

B.  Tubular  Drains. — i.  Rubber  tubes.  Very  small  tubes  are  useless,  as  they 
become  plugged  by  coagulated  discharges.  The  most  useful  are  those  the  size 
of  an  ordinary  lead-pencil  or  of  the  little  finger.  It  is  rare  that  larger  tubes 
are  necessary,  and  then  only  in  the  form  of  split  tubes  covering  a  wick  gauze. 
The  tubes  must  be  perforated  laterally  and  their  distal  ends  should  be  trimmed 
in  a  tish-tail  fashion  (Fig.  1618).  The  tube  may  be  prevented  from  slipping 
into  the  body  by  being  stitched  to  the  skin  or  provided  with  a  guard  in  the 


Fig.  1616. 


Fig.  1617. 


Fig.  1618. 


Fig.  1619. 


form  of  a  safety-pin.  L.  L.  McArthur,  after  sterilizing  rubber  tubes,  soaks 
them  for  a  week  or  more  in  liquid  petrolatum.  This  treatment  makes  the 
tubes  softer  and  prevents  clotting  in  them. 

2.  Split  rubber  tubes  are  the  ordinary  tubes  spUt  up  one  side.  The  spUt  ren- 
ders the  tubes  less  rigid  and  less  liable  to  cause  pressure  necrosis. 

3.  Dressed  drains  consist  of  a  rubber  tube  surrounded  by  a  few  layers  of 
absorbent  gauze  (usually  iodoform)  (Fig  16 19)  the  gauze  being  in  turn 
covered  by  thin  rubber  tissue.  The  dressed  tube  is  practically  a  cigarette 
drain  with  a  tubular  core.  They  are  of  great  value,  especially  in  abdominal 
surgery. 

4.  Wetherill's  drain  is  useful  in  many  locations.     It  is  prepared  as  follows: 
Cut  two  holes  in  a  long  piece  of  drainage  tubing  as  indicated  at  A  and 

B  (Fig.  1620,  i).  Draw  one  end  of  the  tube  through  A  and  out  at  B,  thus 
inverting  that  portion  of  the  tube  between  the  holes  as  seen  in  (Fig.  1620,  2). 
Bend  the  legs  of  the  tube  down  so  that  the  holes  A  and  B  will  be  left  open  for 
drainage  (Fig.  1620,  3).  If  bent  in  one  direction  they  are  open,  if  in  the  other, 
dosed.     Tack  with  a  fine  stitch  at  C. 


1258 


METHODS    OF    DRAINAGE 


5.  Rigid  tubes  of  glass,  hard  rubber,  celluloid,  etc.,  are  often  employed. 
These  may  be  provided  with  a  collar,  made  from  a  segment  of  rubber  tube, 
through  which  a  safety-pin  or  stitch  may  be  inserted  to  provide  (Fig.  162 1) 
against  the  slipping  of  the  tube  into  the  wound. 

C.  Combined  capillary  and  tubular  drainage  may  be  effected  by  surrounding 
any  of  the  ordinary  capillary  drains  with  a  tubular  drain,  e.g.,  a  rubber  tube 
containing  a  bunch  of  silkworm-gut  threads. 

^ ^ 


\ 


Fig.  1620. — Wetherill's  drain. 

D.  Absorbable  Drains. — The  use  of  catgut  as  a  capillary  drain  has  already 
been  noted.  Neuber  suggested  drains  of  decalcified  bone  and  Macewen  intro- 
duced the  inexpensive  chicken-bone  drain. 

Preparation  of  Chicken-bone  Drainage  tubes. — Clean  the  flesh  off  the  tibiae 
and  femora  of  chickens  (cooking  the  chicken  does  not  injure  the  bone).  Soak  in 
a  20  per  cent,  solution  of  hydrochloric  acid  until  soft.  Cut  off  the  articular  ends 
of  the  bone  with  scissors.  Raise  the  endosteum  at  one  end  and  push  it  through 
to  the  other  extremity  along  with  its  contents.     Sterilize  by  boiling  in  a  satu- 


FiG.   1621. — Glass  drain  with  rubber  collar. 


rated  solution  of  ammonium  sulphate.  With  sterile  water  or  antiseptic  solution 
wash  off  the  sulphate  of  ammonium.  Preserve  in  alcohol  or  in  a  solution  of 
iodoform  in  alcohol  or  ether  and  alcohol.  These  tubes  last  for  about  eight  days 
in  the  tissues.  If  greater  durability  is  desired  {e.g.,  when  they  are  used  to  drain 
cerebral  abscesses),  soak  in  a  sterile  solution  of  chromic  acid. 

Macewen  recommends  that  when  bone  drains  are  used  in  fresh  wounds  they 
be  threaded  with  horse-hair  to  prevent  plugging  with  clotted  blood  and  to 
encourage  capillary  drainage.  After  a  day  the  hairs  are  removed,  leaving  the 
tube  patent. 


ACUTE    ABSCESS  12  59 

CHAPTER  CXII 
ACUTE  ABSCESS 

Acute  abscesses  ought  to  be  drained  as  early  as  possible  after  diagnosis.  The 
operation  should  be  performed  under  antiseptic  precautions.  This  is  important 
because  of  the  danger  of  causing  increased  or  mixed  infection,  e.g.,  grafting  a 
streptococcic  on  to  a  staphylococcic  infection. 

Local  anesthesia  is  usually  sufficient  to  prevent  suffering.  When  an  abscess 
is  superficial,  pass  the  knife  steadily  through  the  skin  and  subjacent  tissues  until 
pus  is  reached.  This  should  be  done  at  the  most  prominent  or  most  dependent 
part  of  the  swelling.  As  the  knife  is  withdrawn  the  wound  may  be  enlarged.  A 
good  guide  as  to  the  size  of  the  opening  to  be  made  is  the  size  of  the  surgeon's 
fingers.  In  a  small  and  not  deeply  situated  abscess  the  little  finger  can  explore 
the  whole  cavity;  in  larger  abscesses  the  index  finger  must  be  used.  The  open- 
ing should  be  made  of  sufficient  size  to  admit  the  exploring  finger. 

When  the  abscess  is  deep,  Hilton's  method  of  operating  is  safe  and  excellent. 

An  incision  about  i  or  1^2  inches  in  length  is  made  over  the  most  prominent 
or  dependent  part  of  the  swelling.  The  incision  penetrates  the  skin  and  deep 
fascia.  A  grooved  director,  which  must  not  be  too  sharp,  is  insinuated  through 
the  tissues  in  the  direction  of  the  pus  until  pus  flows  along  its  groove.  The  point 
of  a  narrow-bladed  hemostat  or  blunt-pointed  scissors  is  passed  along  the  di- 
rector into  the  abscess  cavity.  The  blades  of  the  instrument  are  now  opened  and 
made  to  dilate  the  opening  to  an  appropriate  size.  Frequently  counter-openings 
are  required.  Such  may  be  made  by  passing  the  point  of  a  hemostat  into  the 
abscess  and  pushing  it  out  through  the  tissues  until  the  skin  is  reached.  The 
skin  elevated  by  the  point  of  the  forceps  is  divided,  the  blades  of  the  forceps  are 
opened  to  enlarge  the  passage,  a  drainage-tube  is  seized  by  the  forceps,  and  as 
the  instrument  is  withdrawn,  the  tube  is  pulled  into  position.  An  abscess  having 
been  opened,  its  cavity  ought  to  be  douched  thoroughly  with  warm  water  or  a 
mild  antiseptic  solution  until  the  solution  returns  clear.  Dakins'  solution  is 
often  of  value  especially  when  used  by  Carrel's  method.  Any  gross  sloughs  or 
masses  of  debris  should  be  removed  with  forceps,  finger,  or  sharp  spoon.  The 
last-named  instrument  should  not  be  used  too  vigorously  lest  nature's  defense 
against  absorption,  viz.,  granulation  tissue,  be  too  thoroughly  removed,  or  vio- 
lent hemorrhage  or  persistent  oozing  started. 

Drainage-tubes  must  be  inserted  through  the  openings.  Young  practition- 
ers often  delight  in  the  use  of  tubes  about  the  size  of  a  crow-quill;  such  are 
almost  useless,  as  the  fluid  to  be  drained  is  thick  and  speedily  chokes  them. 
Rubber  tubes  which  vary  from  the  size  of  an  ordinary  lead-pencil  to  that  of  the 
little  finger  are  the  best;  no  object  is  to  be  attained  by  using  sizes  much  larger. 
The  external  end  of  the  tube  must  be  kept  from  slipping  into  the  wound,  either 
by  being  stitched  to  the  skin  or  by  having  a  large  safety-pin  passed  through  it. 

Bier  and  Klapp  obtain  excellent  results  by  merely  puncturing  the  abscess 
and  then  sucking  out  the  pus  by  means  of  cupping  glasses.     In  palmar  abscess 


I26o  PSOAS    ABSCESS 

this  treatment  is  specially  good.  The  suction  ought  not  to  be  vigorous  enough 
to  cause  pain;  it  ought  to  be  applied  for  five  minutes  and  left  off  for  two  minutes 
alternately,  for  about  forty-five  minutes  night  and  morning.  (Bier,  "Hyper- 
amie  als  Heilmittel.") 

J.  B.  Murphy  instead  of  opening  and  draining  abscesses,  aspirates  the  pus 
and  then  injects  formalin  glycerine  (formalin,  2;  glycerine,  98)  in  quantity 
sufficient  to  produce  slight  tension.  The  solution  ought  to  be  kept  at  least 
24  hours  before  being  used.  If  a  tuberculous  bone  lesion  is  present  he  adds 
10  per  cent,  of  iodoform  to  the  above  mixture.  He  employs  this  treatment  in 
empyemata  of  the  chest  and  of  joints. 

Dressings. — Ordinary,  voluminous  antiseptic  dressings  must  be  applied 
in  such  a  manner  as  to  collect  the  discharge  and  at  the  same  time  exercise 
elastic  pressure  on  the  abscess  so  as  to  keep  it  collapsed  as  much  as  possible 
and  prevent  reaccumulation  of  fluid. 

PSOAS  ABSCESS 

Treves'  Operation. — ^The  patient  is  placed  on  his  side  with  the  diseased 
side  uppermost.  Under  the  opposite  loin  there  is  placed  a  sand-bag.  An 
^m.  incision  23^^  to  3  inches  in  length  is  made  parallel  to  and  beside  the 
ijmi  outer  edge  of  the  erector  spina  muscle  (i.e.,  about  3  inches  from  the 
spinous  processes).  The  middle  of  this  cut  corresponds  to  a  point 
midway  between  the  last  rib  and  the  iliac  crest.  The  dense  aponeu- 
rosis covering  the  erector  spinae  is  divided  throughout  the  whole 
length  of  the  wound.  The  outer  edge  of  the  muscle  is  demonstrated 
and  then  strongly  retracted  towards  the  spine.  This  exposes  a 
layer  of  fascia  (middle  layer,  fascia  lumborum)  which  covers  the 
quadratus  lumborum.  By  palpation  find  the  transverse  processes  of 
the  lumbar  vertebras  and  divide  the  fascia  as  close  to  them  as  possi- 
ble. The  thin  quadratus  lumborum  muscle  now  comes  into  view, 
and  according  to  Treves  it  must  be  divided  close  to  a  transverse 
process.  The  next  tissue  met  is  the  psoas  muscle,  and  when  some 
of  its  tendinous  fibres  have  been  divided  close  to  a  transverse  process, 
the  fingers  can  be  "introduced  beneath  the  muscle  and  gently  insinu- 
ated along  the  process  until  the  anterior  aspect  of  the  bodies  of 
the  vertebrae  is  reached." 

Where  there  is  a  large  psoas  abscess  the  patient  is  almost 
always  much  emaciated  and  the  tissues  over  the  abscess  are  thin, 
Fig.  1622  'so  that  after  the  quadratus  lumborum  muscle  has  been  exposed,  a 
curette"^  grooved  director  may  be  insinuated  into  the  abscess  cavity  and  an 
entrance  gained  by  Hilton's  method.  Having  gained  access  to  the 
abscess,  it  is  thoroughly  douched  with  hot  water  or  a  hot  antiseptic  solution. 
The  writer  often  uses  a  sherry-colored  solution  of  tincture  of  iodine  in  hot 
water.  The  lining  membrane  of  the  abscess  is  to  be  scraped  away  with 
finger-nail  and  sponge  (Treves)  or  with  the  irrigating  curette  (Barker)  (Fig. 
1622).  This  must  be  done  cautiously,  as  the  anterior  wall  of  the  abscess  is 
usually  thin.  All  pockets  leading  from  the  main  abscess  are  explored  and 
opened  up  by  the  finger.     All  accessible  portions  of  the  spine  are  palpated,  and  if 


NKOI'LASMS  1 261 

any  tuberculous  nodules  are  found  they  are,  if  possible,  to  be  removed.  Having 
douched  and  cleaned  and  douched  again,  until  the  fluids  return  clear,  the  cavity 
is  dried,  two  or  three  ounces  of  iodoform  emulsion  are  thrown  into  it,  and  the 
wound  is  closed  without  drainage.  The  abscess  may  recur  and  require  a  second 
operation. 

The  after-treatment  consists  in  rest  under  hygienic  conditions,  and  must  be 
carried  out  for  many  months. 

The  great  advantage  of  the  Treves  operation  is  the  access  it  gives  to  the 
spinal  column — ^to  the  focus  of  the  disease. 

Should  the  abscess  have  opened  of  itself  in  the  thigh,  it  must  be  treated 
on  the  ordinary  surgical  lines,  i.e.,  counteropenings  must  be  made  to  provide 
efficient  drainage. 


CHAPTER  CXin 
OPERATIVE  TREATMENT  OF  NEOPLASMS 

Indications  for  the  Excision  of  Tumors. — It  is  frequently  said  that  all 
neoplasms  ought  to  be  removed.  The  general  rule  is  correct  but,  to  it  there  are 
many  exceptions.  The  warts  on  a  small  boy's  hands  disappear  spontaneously. 
A  lipoma  or  fibroma  may  cause  little  or  no  inconvenience,  and  yet  be  so  situated 
anatomically  that  its  excision  might  give  rise  to  serious  danger  to  life,  or  might 
so  injure  or  destroy  neighboring  structures  (nerves,  etc.)  as  to  far  outweigh  any 
benefit  to  be  hoped  from  its  removal.  The  removal  of  many  neoplasms  is  a 
matter  of  choice  as  they  are  unlikely  to  become  malignant,  and  excision  is  only 
sought  because  of  their  inconvenience,  size  or  unsightliness.  One  must  not 
forget  that  the  most  innocent  looking  neoplasm  may  have  hidden  in  it  the 
possibilities  of  malignancy.  In  other  circumstances  the  anatomic  situation  of 
a  non-malignant  tumor  may  demand  immediate  operation,  e.g.,  it  may  cause 
pressure  on  the  trachea,  etc. 

Warts,  moles,  fibromas  and  such-like  non-malignant  neoplasms  of  the  skin 
and  accessible  mucous  membrane  are  easily  excised.  It  is  important  to  remove 
the  whole  thickness  of  the  skin  with  the  tumor  otherwise  even  a  small  wound 
becomes  difficult  to  close.  If  the  growth  is  large  the  residting  wound  must  be 
closed  either  by  one  of  the  methods  described  under  plastic  surgery  or  by  skin 
grafting.  Keen  recognizing  that  pigmented  moles  often  recur  after  excision 
and  give  rise  to  very  malignant  melanotic  growths  advocates  their  thorough 
removal.  Bevan  thinks  that  a  single  pigmented  mole  is  much  more  likely  to 
be  the  precursor  of  malignancy  than  are  multiple  moles. 

It  has  been  suggested  that  moles  should  be  destroyed  by  the  cautery  and  the 
resultant  scar  immediately  excised  (Bevan).  The  object  of  this  is  of  course  to 
prevent  the  disturbance  and  dissemination  of  the  cellular  elements  of  the  mole. 
As  a  rule  the  author  prefers  destroying  small  non-malignant  moles  by  means  of 
carbon  dioxide  snow  to  excising  them. 

In  excising  a  non-malignant  neoplasm  it  is  only  necessary  to  remove  the 
tumor  itself,  it  is  not  necessary  to  '  'cut  wide  of  the  mark"  or  to  concern  oneself 
with  the  lymphatics. 


1262  OPERATIVE  TREATMENT  OF  NEOPLASMS 

The  basal-celled  epitheliomata  of  the  face  (rodent  ulcer,  etc.)  are  commonly 
onlv  of  local  malignancy  and  free  excision  gives  good  results,  the  lymphatics 
not  being  involved  at  least  until  late.  These  are  the  tumors  which  are  often 
cured  by  means  of  the  X-rays. 

Sampson  Handley  ("Universal  Med.  Record,"  191 2,  p.  385)  strongly  urges 
"  the  inadvisability  of  trusting  long  to  radio-active  therapeutics  as  the  first  line 
of  defence,"  even  in  superficial  and  early  malignant  growths,  "unless  the  disease 
rapidly  and  completely  yields." 

Melanoma  of  Skin.  (Melanotic  Sarcoma). — Handley  is  of  the  opinion 
that  melanotic  tumors  spread  by  lymphatic  permeation,  i.e.,  by  growing  into 
and  along  the  lymphatic  channels  centrifugally  in  all  directions,  and  that  dis- 
semination through  the  vascular  system  is  a  later  phenomenon.  Based  on  this 
opinion  he  operates  as  follows : 

I.' Make  a  circular  incision  around  and  about  one  inch  from  the  tumor. 
If  necessary  supplement  the  circular  incision  by  two  radial  linear  incisions  on 
opposite  sides  of  the  tumor.  These  cuts  (circular  and  linear)  penetrate  the 
skin  alone  (Fig.  1623). 

tnv  2.  INS. 


Fig.  1623. 

2.  Elevate  the  skin  with  a  thin  attached  layer  of  subcutaneous  fat,  from  the 
deeper  structures  for  a  distance  of  about  two  inches  in  all  directions  from  the 
original  circular  incision. 

3.  At  the  extreme  base  of  the  elevated  skin  flaps  make  a  circular  incision 
penetrating  the  subcutaneous  fat,  the  deep  fascia  and  a  few  fibres  of  the  sub- 
jacent muscles. 

4.  Beginning  at  the  outer  circular  incision  elevate  the  deep  fascia  from  the 
muscles,  dissecting  towards  the  tumor,  until  a  point  is  reached  immediately 
beneath  the  first  circular  or  skin  incision.  Remove  the  whole  mass  by  scooping 
out  with  a  knife  a  circular  area  of  muscle  immediately  beneath  the  tumor. 

5.  Close  the  wound.  Thoroughly  excise  the  chain  of  lymph  glands  next  in 
order,  into  which  the  affected  area  drains.  The  glands  ought  to  be  removed 
whether  apparently  affected  or  not,  "and  this  is  most  important — the  appar- 
ently healthy  set  of  glands  above  those  obviously  enlarged  should  be  completely 
removed."  The  following  case  of  Sampson  Handley's  is  so  important  and 
striking  that  it  demands  attention: 

"Miss  C,  aged  forty,  *  *  *  October  21,  1909.  In  September.  1907,  Dr.  Moreton  Palmer 
removed  an  ulcerated  papilloma  which  had  been  present  on  the  dorsum  of  the  left  wrist  for 
three  or  four  years.  In  September,  1908,  some  small  lumps  were  removed  just  above  the  epi- 
trochlear  gland.     These  lumps  were  subcutaneous  and  were  not  glandular.     .\  week  or  two 


LIGATURES    AND    SUTURES  1 263 

later,  a  small  dark  nodule  appeared  just  below  the  incision.  It  was  removed  under  local 
anesthesia  and  was  reported  by  the  Clinical  Research  Association  as  a  malignant  melanoma. 
Subsequently  the  patient  suffered  much  pain  in  the  bicipital  region,  thought  to  be  due  to  an 
involvement  of  nerves  in  the  scar.  On  examination  I  found  a  vague  induration  running  up  the 
axillary  vessels  about  the  middle  of  the  upper  arm,  midway  between  the  axilla  and  the  scar  of 
the  second  operation,  and  it  appeared  probable  that  the  growth  was  recurrent  in  this  situation. 
Moreover,  a  large  gland,  nearly  as  big  as  a  chestnut,  could  be  felt  in  the  axilla.  I,  therefore, 
advised  a  thorough  operation  which  should  include  removal  of  the  supraclavicular  glands, 
clearing  of  the  axilla,  and  excision  of  the  deep  fascia,  extending  from  the  axilla  almost  to  the 
elbow.  The  patient  consented  to  undergo  the  operation  and  was  admitted  to  the  Boling- 
broke  Hospital.  A  semilunar  flap  of  skin,  involving  most  of  the  inner  aspect  of  the  arm. 
was  turned  backwards,  and  the  deep  fascia  was  widely  removed  with  exposure  of  the  brachial 
vessels  and  accompanying  nerves.  The  axilla  was  next  opened  by  a  prolongation  of  the  first 
incision  into  its  fornix,  and  was  completely  cleared  of  its  fat  and  glands,  which  were  removed 
in  continuity  with  the  deep  fascia  of  the  inner  side  of  the  arm.  The  supraclavicular  triangle 
was  no\y  cleared  of  its  fat  and  glands  through  a  separate  incision.  The  patient  made  a  good 
recovery  from  the  operation.  About  a  year  later  a  recurrent  nodule  appeared  over  the  lower 
part  of  the  triceps  at  the  back  of  the  arm.  It  was  excised  on  December  15,  1909,  and,  on 
section,  was  a  typical  sarcoma,  unpigmented  and  degenerated  at  the  centre.  (It  is  well  known 
that  unpigmented  metastases  are  not  rare  in  melanotic  sarcoma.)  Since  this  time  the  patient 
has  remained  well,  and  the  neuralgic  pains  from  which  she  suffered  in  the  arm  have  greatly 
improved,  especially  since  a  visit  to  Sidmouth,  where  she  had  hot  sea-bathing  treatment." 

In  support  of  Handley's  views  regarding  lymphatic  permeation  and  the 
value  of  operation  the  following  case  may  be  of  interest.  In  Aug.,  1916  the 
author  removed  a  melanoma  from  in  front  of  the  ear  and  at  the  same  time  ex- 
cised lymph  nodes  below  the  angle  of  the  jaw,  these  nodes  being  densely  black 
and  enlarged.  At  the  time  it  was  felt  that  more  extensive  excision  was  desir- 
able but  the  condition  of  the  patient  would  not  permit.  In  Feb.,  1917,  there 
was  no  evidence  of  recurrence.  In  Oct.,  1918,  a  metastatic  skin  lesion  near  the 
left  nipple  was  removed  during  the  author's  absence  in  the  army.  Death 
ensued  from  multiple  metastases  in  Aug.,  1919,  three  years  after  the  original 
operation. 

CHAPTER  CXIV 
LIGATURES  AND  SUTURES 

I.  Non-absorbable. — The  principal  non-absorbable  ligatures  or  sutures  are : 
(a)  Silk;  (b)  Pagenstecher's  or  Braun's  celluloid  hemp;  (c)  silkworm-gut;  (d) 
horse-hair;  (e)  wire  (silver,  gold,  aluminium-bronze).  All  the  above  materials 
are  strong,  of  uniform  size,  capable  of  being  easily  and  securely  tied  or  fastened, 
and  sterilized  by  being  boiled  or  steamed. 

Silk  is  the  material  most  commonly  used  for  intestinal  sutures  and  for  non- 
absorbable ligatures.  Celluloid  hemp  (in  the  smaller  sizes)  possesses  all  the 
advantages  of  silk,  and,  in  addition,  it  has  less  capillarity,  and  being  stiffer, 
can  be  readily  threaded  into  fine  needles  even  when  wet.  These  two  peculiar- 
ities are  of  great  value  in  operations  on  the  intestine.  The  want  of  capillarity 
prevents,  to  some  extent  at  least,  infection  passing  along  the  thread,  as  in- 
testinal sutures  very  commonly  include  part  of  the  mucosa  even  when  intro- 
duced with  the  greatest  care.  The  convenience  of  being  able  to  thread  a 
needle  with  the  wet  material  is  self-evident.     Celluloid  hemp  is  stronger  than 


1264  LIGATURES    AND    SUTURES 

silk,  but  its  surface  is  not  so  smooth.  Thick  celluloid  hemp  ligatures  are  not 
so  easily  drawn  into  a  tight  knot  as  are  silk  ones  and  possess  no  advantage  over 
the  latter.  Braun's  thread  is  smooth  and  easily  knotted.  For  sterilization 
celluloid  hemp  requires  to  be  boiled  longer  than  does  silk. 

The  most  convenient  sizes  of  silk  or  hemp  are  Nos.  i,  2,  3,  and  4.  For 
intestinal  sutures  and  the  ligature  of  small  vessels,  Nos.  i  and  2  are  e.xcellent. 
No.  4  is  used  for  tying  large  pedicles. 

Preparation  of  Silk  or  Hemp. — Wind  the  thread  on  glass  spools  or  tubes, 
preferably  in  one  layer.  Boil  in  water  or  4  per  cent,  soda  solution  for  fifteen 
or  thirty  minutes  (along  with  the  instruments).  Soak  in  corrosive  sublimate 
solution  I  :  1000.  The  advantage  of  using  the  antiseptic  solution  is  that  it 
inhibits  the  growth  of  any  bacteria  which  may  accidentally  gain  access  to  the 
ligature  during  the  operation. 

Kocher  is  the  most  enthusiastic  advocate  of  silk.  He  prepares  his  ligatures 
as  follows:  Soak  the  silk  in  ether  for  twelve  hours;  then  in  alcohol  for  a  like 
period.  Boil  for  ten  minutes  in  a  i  :  1000  solution  of  sublimate  (the  sublimate 
solution  must  neither  be  colored  nor  acidulated).  Use  the  silk  directly  from  the 
sublimate  solution.  As  pulling  thread  between  the  fingers  of  the  operator  is 
liable  to  infect  it,  Kocher  always  wears  gloves  when  tying  ligatures,  even  when 
he  does  not  wear  them  for  the  other  steps  in  the  operation. 

When  silk  is  to  be  used  for  intestinal  work,  it  may  be  sterilized  by  steam,  and 
being  dry,  is  easily  threaded  on  needles.  If  to  be  sterilized  by  boiling,  the 
requisite  numbers  of  needles  should  be  threaded  beforehand  and  stitched  into 
a  towel  in  such  a  manner  that  they  can  be  easily  pulled  out  but  cannot  become 
entangled  while  being  boiled. 

Waxed  Silk,  Hemp  or  Linen.  (McArthur,  Surgery,  Gynecology  and  Obste- 
trics, 1913,  Volume  XVI,  page  460). — This  material  was  devised  by  Moses 
Gunn.  "  The  silk  is  cut  in  proper  lengths,  wound  upon  pieces  of  cardboard 
which  are  then  folded  in  pieces  of  paraffin  paper  and  put  in  an  envelope  with  the 
size  and  length  of  the  suture  inscribed  upon  it  These  packets  are  then  dry  steri- 
lized in  bulk  in  an  ordinary  dry  sterilizer.  When  a  sufficient  quantity  has  been 
made,  the  envelopes  are  opened,  the  silk  cards  are  immersed  in  the  10  per  cent, 
carbolized  melted  beeswax  under  the  usual  modern  aseptic  precautions,  and  when 
saturated  are  returned  to  the  envelopes.  Before  using,  the  silk  should  be 
rapidly  drawn  through  a  sterile  towel.  This  produces  enough  friction  to  partly 
melt  the  wax  and  thus  polish  the  silk,  just  as  the  shoemaker  polishes  his  wax  end. 

This  suture  material  then  possesses  all  the  desirable  qualities  of  any  suture 
material.  It  is  solid  like  silver  wire,  smooth  like  silkworm;  unirritating,  it  may 
be  buried,  is  stronger  for  the  size  than  the  unwaxed,  and  has  as  its  nearest 
imitator,  Pagenstecher  Hnen.  It  makes  the  ideal  suture  for  delicate  structures 
like  the  peritoneum,  intestinal  anastomosis,  dura  and  skin.  It  seems  to  have 
just  sufficient  antiseptic  efifect  from  the  carbolic  acid  to  permit  its  remaining 
from  10  to  14  days  without  exciting  suppuration  if  the  skin  be  sterile  at  the  time 
of  insertion. 

"Emphasis  should  be  laid  upon  the  necessity  of  securing  true  beeswax,  not 
the  "improved"  bleached  variety  which  is  usually  paraffin,  as  well  as  100  per 
cent,  phenic  acid." 


CATGUT  1265 

Silkworm-guL — This,  the  common  fishing  gut,  is  prepared  from  the  silk- 
worm when  it  has  got  into  condition  to  begin  spinning.  The  material  used  is, 
in  fact,  the  silk  before  it  is  spun.  Silkworm-gut  is  an  ideal,  smooth,  strong, 
non-porous,  non-absorbable  suture.  It  is  easily  sterilized  by  boiling,  which 
at  the  same  time  softens  it  and  renders  it  easy  to  tie.  If  used  dry,  the  gut  is 
hard  and  too  brittle  to  tie.  It  may  be  obtained  in  various  sizes,  from  the  thick 
and  very  strong  gut  used  by  salmon  fishers  to  the  extremely  fine  "drawn  gut" 
of  the  English  dry  fly  fishermen. 

Horse-hair  possesses  the  advantages  of  fine  silkworm-gut,  but  is  better  in 
that  its  elasticity  prevents  cutting  of  the  tissues.  It  is  ideal  material  for  fine 
skin  sutures,  as  it  leaves  little  scar.  It  is  prepared  for  use  by  a  thorough  wash- 
ing in  soap  and  water  and  then  by  boiling. 

Silver  Wire. — This  is  the  most  common  suture  used  for  uniting  bones. 
Some  surgeons  use  it  extensively  for  buried  sutures.  Its  ends  are  easily  secured 
by  twisting.  Sterilization  is  effected  by  boiling.  The  metallic  silver  is  an 
antiseptic  per  se. 

II.  Absorbable  Ligatures  and  Sutures. — {a)  Catgut;  {b)  Tendon. 

Catgut. — The  most  common  absorbable  ligature  is  made  from  the  sub- 
mucous coat  of  the  intestine  of  sheep.  The  best  catgut  comes  from  Germany 
and  Sweden.  The  American  sheep  suffer  from  some  intestinal  disease  which 
renders  their  submucosa  useless  for  the  manufacture  of  catgut.  The  most 
convenient  sizes  of  catgut  are  Nos.  o,  i,  2,  3.  No.  4  is  occasionally  of  service, 
but  is  very  thick. 

Catgut  may  be  used  plain  or  may  be  treated  with  some  material  which 
renders  its  absorption  by  the  tissues  more  slow  (chromic  acid,  formalin).  There 
are  a  very  great  number  of  methods  by  which  sterilization  may  be  effected; 
only  a  few  of  these  will  be  detailed  here.  Several  manufacturers  prepare  reliable 
catgut  in  convenient  receptacles,  e.g.,  in  hermetically  sealed  glass  tubes,  in 
air-tight  envelopes,  etc.  Such  catgut  is  usually  sterilized  by  dry  heat  in  the 
fractional  method.  The  process  is  more  or  less  complicated  and  will  not  be 
described,  as  simpler  and  equally  efl&cacious  methods  are  available.  The 
cumol  method  of  sterilization  seems  to  be  reliable,  but  requires  considerable 
experience  to  be  carried  out  in  safety.  Bartlett's  iodized  catgut  is  very  reliable 
and  may  be  obtained  ready  for  use  in  tubes. 

Preparation  oj  Catgut. — Wind  the  catgut  in  a  single  layer  on  glass  tubes. 
In  doing  this  it  is  very  important  to  rotate  the  tubes  and,  holding  the  gut 
tight,  allow  it  to  be  wound  on  to  the  tube.  If  one  twists  the  gut  on  to  the  tube, 
as  it  passes  through  the  fingers  its  fabric  is  liable  to  become  untwisted  and  its 
strength  ruined.     Fasten  the  end  of  the  thread  so  that  it  will  not  come  undone. 

Methods  of  Sterilization. — (I)  Elsberg's  method  (modified) :  Make  a  saturated 
solution  of  sulphate  of  ammonium  in  water.  Boil  this  solution  and  see  that 
it  is  saturated  while  boiling.  Boil  the  catgut  in  this  for  twenty  minutes.  With 
sterile  forceps  place  the  gut  in  sterile  water  or  antiseptic  solution  to  remove  the 
sulphate  of  ammonium.  This  does  not  consume  more  than  a  minute.  Pre- 
serve the  gut  in  alcohol  or  in  a  saturated  solution  of  iodoform  in  alcohol  and 
ether.  Elsberg  before  boiling  soaks  the  gut  for  twenty-four  hours  in  a  mixture 
of  chloroform  and  ether.     This  is  unnecessary. 

80 


1266  LIGATURES   AND   SUTURES 

II.  Claudius'  method  (I,  KI,  catgut):  Soak  the  gut  (wound  on  tubes)  for 
eight  days  in  the  follo\\'ing  solution:  iodine,  i  part;  iodide  of  potassium,  i  part; 
water,  loo  parts.  The  gut  is  now  ready,  and  may  be  used  directly  from  the  solu- 
tion or  after  washing  in  sterile  water  or  some  antiseptic  solution.  The  author 
prefers  using  it  directly  from  the  iodine  solution.  It  is  claimed  that  the  catgut 
may  be  kept  indefinitely  in  the  solution,  but  this  is  incorrect. 

Salkindsohn  modifies  the  above  in  a  happy  fashion  by  using  a  mixture  of 
tincture  of  iodine  i  part  in  15  parts  of  proof  (i.e.,  50  per  cent.)  spirit.  Iodized 
catgut  has  given  great  satisfaction  to  the  author. 

G.  G.  Macdonald  has  tested  Salkindsohn's  catgut.  His  results  are  shown 
in  the  accompanying  table  (p.  1267). 

III.  Yelverton  Pearson  ("Brit.  Med.  Journ.,"'  Dec.  25,  1909)  advocates  the 
use  of  "iodine-formalin"  catgut  when  a  resistant  suture  is  desired.  The  gut 
is  prepared  as  follows: 

1.  Soak  in  an  alcoholic  solution  of  iodine  (i  per  cent,  iodine,  54  per  cent, 
alcohol). 

2.  After  eight  days  remove  from  the  iodine  solution  and  wash  in  a  weak  car- 
bolic solution  or  in  running  sterile  water  "  to  remove  the  alcohol  and  iodine  from 
the  outer  layers  so  as  to  permit  more  freedom  for  the  action  of  the  formalin." 

3.  Soak  in  3  per  cent,  formalin  solution  for  from  24  to  48  hours,  according  to 
the  thickness  of  the  gut. 

4.  Wash  in  running  water  for  a  few  hours  to  remove  the  formalin. 

5.  Place  in  50  per  cent,  alcohol  containing  }4  per  cent,  iodine  and  5  per  cent. 
glycerine.     This  preserves  the  gut  indefinitely. 

IV.  Iodine-acetone  catgut.  McDonald's  method  ("Am.  Journ.  of  Surg.," 
May,  1910): 

Sol.  I. — Iodine  4  per  cent,  in  acetone,  soak  eight  days,  drain  off  solution. 

Sol.  2. — Acetone,  soak  four  days,  drain  off  then  cover  with. 

Sol.  3. — Acetone  85  per  cent.,  Columbian  spirits  10  per  cent.,  glycerine  5 
per  cent. 

Dissolve  glycerine  in  spirits  then  add  to  the  acetone.  Keep  the  gut  in  this 
indefinitely. 

V.  Biniodide  catgut: 

Mercuric  iodide,  1 . 

Potassium  iodide,  4. 

Alcohol,  1000. 
Soak  the  catgut  in  this  solution  for  one  week  before  using.     The  same  solution 
preserves  the  gut  indefinitely. 

C.  H.  Watson  (Surg.  Gyn.  Obst.,  XXII,  p.  114)  finds  that  a  1  :  1000  alco- 
holic solution  of  potassium  mercuric  iodide  is  not  only  far  more  powerful  than 
I  per  cent,  iodine  but  that  it  increases  the  tensile  strength  of  the  gut. 

VI.  Saul's  method:  Put  the  gut  (wound  on  tubes)  into  a  pot  provided  with 
a  condenser.  Cover  the  gut  with  a  solution  of  carbolic  acid  5  parts,  90  per  cent, 
alcohol  100  parts.  Boil  for  twenty  minutes.  Preserve  the  gut  in  alcohol  or  in  a 
solution  of  iodoform  in  alcohol  or  alcohol  and  ether.  Experiment  shows  that 
gut,  soaked  in  a  culture  of  anthrax  and  covered  with  grease,  is  sterilized  by  the 
above  method  after  seven  minutes  of  boiling. 


CATGUT 


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1268  WOUNDS 

VII  Chromicized  catgut:  Sterilize  the  gut  by  the  Elsberg  or  Saul  method. 
Soak  for  twelve  to  twenty-four  hours  in  a  sterile  watery  solution  of  chromic  acid 
(i:  10,000).  Such  gut  lasts  from  seven  to  ten  days,  according  to  its  size.  The 
strength  of  the  solution  may  be  varied  according  to  the  ideas  of  the  surgeon. 
Preserve  in  alcohol  or  in  a  solution  of  iodoform  in  alcohol  or  alcohol  and  ether. 

VIII  Formalinized  catgut:  Sterilize  the  gut  by  the  Elsberg  or  Saul  method. 
Soak  for  twelve  hours  in  a  i  per  cent,  watery  solution  of  commercial  formalin. 
Preserve  in  alcohol,  etc.     The  durability  of  this  gut  is  about  seven  to  ten  days. 

The  usual  method  advised  for  the  preparation  of  formalinized  catgut  is  to 
soak  it  for  twelve  to  forty-eight  hours  in  a  2  per  cent,  watery  solution  of  forma- 
lin, wash  in  flowing  water  for  twelve  hours,  boil  for  twenty  minutes  in  water, 
and  preserve  in  alcohol.  Boeckman,  however,  points  out  that  the  formalin 
acting  on  the  gut  makes  its  surface  water-proof,  that  the  boiling  water  does  not 
penetrate  the  gut,  and  that,  as  a  consequence,  the  inside  of  the  ligature  is  only 
exposed  to  a  dry  heat  of  212°  F.,  which  does  not  sterilize. 

The  methods  of  sterilization  here  described  have  all  been  tested  by  the 
author  and  found  satisfactory.  In  none  of  them  is  it  necessary  to  touch  the 
gut  with  the  fingers  from  the  time  the  sterilization  begins  until  it  is  being  used 
in  operating.  Any  one  of  the  methods  described  is  as  safe  as  the  others.  The 
biniodide  method  is  perhaps  the  easiest  and  cheapest. 

Tendon. — The  tendons  of  such  animals  as  the  kangaroo,  reindeer,  and  whale 
have  been  much  used  for  sutures  and  ligatures.  Many  surgeons  prefer  them  to 
catgut.  Sterilization  may  be  effected  as  with  catgut.  The  main  objection  to 
the  use  of  tendon  is  its  expense. 


CHAPTER  CXV 
WOUNDS 


The  treatment  of  wounds  involving  such  structures  as  bones,  joints  etc., 
has  been  sufficiently  described  in  other  chapters.  In  the  present  chapter  an 
endeavour  will  be  made  to  outline  the  treatment  of  the  more  serious  wounds  of 
the  soft  parts,  both  recent  wounds  and  those  which  have  become  infected. 

Every  war  wound  and  most  wounds  in  civil  life  must  be  considered  con- 
taminated and  if  the  contamination  is  not  removed  within  about  eight  hours, 
they  must  be  considered  infected.  Except  when  a  wound  is  made  by  a  sharp 
cutting  instrument  there  is  always  a  zone  of  bruized,  more  or  less  devitalized 
tissue  next  to  the  cut  surface.  This  zone  varies  in  extent  and  is  a  fertile  field  for 
the  development  of  bacteria.  Lessons  gathered  from  war  experience  may  well 
be  used  in  civil  life. 

1.  The  wound  is  clean  cut  and  free  from  foreign  bodies,  such  as  clothing. 
Paint  the  surrounding  skin  with  tincture  of  iodine,  or  with  2  per  cent,  of  picric 
acid  in  alcohol,  or  with  alcohol  or  benzine.     Close  the  wound  with  sutures. 

2.  The  wound  is  recent,  but  is  lacerated  and  bruized.  Dirt  has  been  en- 
grained into  it.  The  patient  is  in  good  general  condition  and  can  be  kept  under 
observation  for  a  few  days.  Sterihze  the  skin  as  above.  Excise,  if  possible  in 
one  piece,  all  the  severely  injured  tissues  including  the  edges  of  the  skin  wound. 


WOUNDS  1269 

(Debridement).  A  healthly  bleeding  surface  should  be  attained.  Open  and 
clean  all  pockets.  Attend  to  hemostasis.  Close  the  wound  with  or  without 
drainage. 

3.  The  wound  is  as  in  '2 '  but  the  patient  cannot  be  kept  under  observation 
until  the  danger  of  acute  infection  is  passed.  Treat  as  above,  but  instead  of 
closing  the  wound  fill  it  loosely  with  sterile  gauze  and  apply  dressings.  Instead 
of  plain  gauze  one  may  use  gauze  soaked  in  liquid  paraffin,  in  hypertomic  salt 
solution,  in  a  I  :  5000  watery  solution  of  flavine,  in  Dakin's  solution,  etc.  Many 
surgeons  institute  the  Carrel-Dakin  method  at  once.  During  a  'war  of  move- 
ment' the  wounds  are  usually  treated  as  above  in  the  Evacuation  Hospitals  and 
the  patients  are  sent  as  quickly  as  possible  to  Base  Hospitals,  where  the  wounds 
are  sutured  if  clean,  or  are  steriUzed  and  later  closed.  If  the  wounds  have 
remained  clean  after  the  'debridement'  and  circumstances  permit  of  their  being 
sutured  within  3  or  4  days  (delayed  primary  suture)  closure  is  easy  and  safe  as 
there  has  been  no  time  for  granulation  tissue  and  scar  tissue  to  be  formed.  Late 
or  secondary  suture  is  more  troublesome  to  carry  out. 

4.  The  wound  is  infected.  Every  nook  and  cranny  of  the  wound  must  be 
rendered  freely  accessible.  Loose  gauze  dressings  moistened  and  kept  moist 
with  antiseptics  must  fill  every  part  of  the  cavity  or  the  Carrel-Dakin  method 
may  be  utilized  as  foUows : 

"Preparation  of  Dakin  solution  (technique  of  Daufresne):  The  solution  of  sodium  hypo- 
chlorite for  surgical  use  must  be  free  of  caustic  alkali;  it  must  only  contain  0.45  to  0.50  per  cent. 
of  hypochlorite.  Under  0.45  per  cent,  it  is  not  active  enough  and  above  0.50  per  cent,  it  is 
irritant.  "With  chloride  of  lime  (bleaching  powder)  having  25  per  cent,  of  active  chlorine, 
the  quantities  of  necessary  substances  to  prepare  10  litres  of  solution  are  the  following:  200 
grams  chloride  of  lime  (bleaching  powder)  (25  per  cent,  active  chlorine).  100  grams  sodium 
carbonate  dry  (soda  of  Solway).     80  grams  sodium  bicarbonate  dry. 

Put  into  a  12  litre  flask  the  two  hundred  grams  of  chloride  of  lime  and  five  litres  of  ordinary 
■  water,  shake  vigorously  for  a  few  minutes  and  leave  in  contact  for  sLx  to  twelve  hours,  one  night 
for  example.  (Shake  until  dissolved — at  least  until  the  big  pieces  are  dissolved.  Not  all  the 
pieces  will  dissolve,  large  pieces  float,  notice  only  floating  pieces.) 

At  the  same  time,  dissolve  in  five  litres  of  ordinary  cold  water  the  carbonate  and  bicarbonate 
of  soda.  After  leaving  from  six  to  twelve  hours,  pour  the  salt  solution  in  the  flask  containing 
the  macerated  chloride  of  lime,  shake  vigorously  for  a  few  minutes  and  leave  to  allow  the 
calcium  carbonate  to  be  precipitated.  In  about  one-half  hour  siphon  the  liquid  and  filter  with 
a  double  paper  to  obtain  a  good,  clear  liquid,  which  should  always  be  kept  in  a  dark  place. 

"  Titration  of  chloride  of  lime  (bleaching  powder) .  Because  of  the  variation  of  the  products 
now  obtained  in  the  market,  it  is  necessary  to  determine  the  quantity  of  active  chlorine  con- 
tained in  the  chloride  of  lime  which  is  to  be  used.  This  must  be  done  in  order  to  employ  an 
exact  calculated  quantity  according  to  its  concentration. 

"The  test  is  made  in  the  following  manner:  Take  from  different  parts  of  the  jar,  a  small 
quantit}'  of  bleaching  powder  to  have  a  medium  sample,  weigh  20  of  it,  mix  as  well  as  possible 
in  a  litre  of  tap  water  and  leave  in  contact  a  few  hours.  Measure  10  cubic  centimeters  of  the 
clear  liquid  and  add  20  cubic  contimeters  of  a  10  per  cent,  solution  of  potassium  iodide,  2  cubic 
centimeters  of  acetic  acid  or,  to  free  all  hydrochloric  acid,  then  put  drop  by  drop  into  the  mix- 
ture a  decinormal  solution  of  sodium  hyposulphite  (2.48  per  cent.)  until  decoloration.  The 
number  A^  of  cubic  centimeters  of  hyposulphite  employed,  multiplied  by  1,775  will  give  the 
weight  iV  of  active  chlorine  contained  in  100  grams  of  chloride  of  lime. 

"The  test  must  be  made  every  time  a  new  product  is  received.  When  the  result  obtained 
differs  more  or  less  than  25  per  cent.,  it  will  be  necessary  to  reduce  or  enlarge  the  proportion  of 
three  products  contained  in  the  preparation.     This  can  easily  be  obtained  by  multiplying  each 


1270  WOUNDS 

of  the  three  numbers,  200,  100,  80  by  the  factor  25.V  in  which  .V  represents  the  weight  of  the 
active  chlorine  per  cent,  of  chloride  of  lime. 

"TUraiion  of  Dakin  Solution. — Measure  10  cubic  centimeters  of  the  solution,  add  20  cubic 
centimeters  of  potassium  iodide  i  :  10,  2  cubic  centimeters  of  acetic  acid  and  drop  by  drop  a 
decinormal  solution  of  sodium  hyposulphite  until  decoloration.  The  number  of  cubic  centi- 
meters used  multiplied  by  0.03725  will  give  the  weight  of  hypochlorite  of  soda  contained  in 
100  cubic  centimeters  of  the  solution. 

''Never  heat  the  solution,  and  if  in  case  of  urgenc}'  one  is  obliged  to  resort  to  trituration  of 
chloride  of  lime  in  a  mortar,  only  employ  water,  never  salt  solution. 

'Tm/  of  the  Alkalinity  of  Dakin  Solution — To  differentbte  easily  the  solution  obtained 
by  this  process  from  the  commercial  hj-pochlorites,  pour  into  a  glass  about  20  cubic  centimeters 
of  the  solution  and  drop  on  the  surface  of  liquid  a  few  centigrams  of  phenolphthalein  in  powder. 

"The  correct  solution  does  not  give  any  coloration,  while  Lebarraque's  solution  and  eau  de 
Javel  will  give  an  intense  red  color  which  shows  in  the  last  two  solutions  existence  of  free  caustic 
alkali. 

"The  stock  solution  should  be  kept  in  blue  or  brown  colored  bottles,  well  corked."'  {Sher- 
man, Surg.  Gyn.  and  Obst..  xxiv.  2S^.) 

The  Carrel  apparatus  consists  of  a  graduated  container  connected  with  a 
glass  distributor  by  means  of  a  rubber  tube  which  is  interrupted  by  a  glass  drip 
to  indicate  the  rate  and  amount  of  solution  flowing  from  the  container.  Tubes 
of  pure  rubber  about  15-25  cm.  to  (6  to  10  inches)  long  are  prepared  by  having 
their  distal  ends  tied  oflF  with  silk  or  linen  and  having  a  number  of  very  tiny  holes 
punched  in  such  parts  of  the  tubes  as  are  to  lie  in  the  wound.  The  proximal 
ends  of  the  tubes  are  attached  to  the  distributor.  The  number  of  the  tubes 
depends  on  size  and  depth  of  the  wound. 

Arrange  the  tubes  in  the  wound  in  such  a  manner  that  they  can  distribute 
the  Dakin's  solution  evenly  to  every  part  of  it.  Place  strips  of  gauze  loosely 
between  the  tubes  so  as  to  keep  them  in  position.  Fill  the  wound  cavity  loosely 
with  gauze.  Xo  packing  is  permissible.  Apply  an  outer  dressing  of  Turkish 
toweling  or  of  a  few  layers  of  gauze  covered  by  a  layer  of  «£>»-absorbent  cotton, 
lightly  held  in  place  by  a  bandage.  Protect  all  the  skin  around  the  wound  with 
strips  of  gauze  soaked  in  sterile  vaseline.  Charge  the  container  with  Dakin's 
solution  and  permit  enough  of  the  solution  to  flow  through  the  tubes  to  fill  the 
wound.  Note  the  amount  of  solution  required  for  this  purpose.  Every 
two  hours  both  night  and  day  fill  the  wound  with  the  required  among  of 
solution.  The  container  should  never  be  elevated  more  than  3  feet  above  the 
patient. 

Re-dressing. — Each  day  remove  the  dressings  with  sterile  forceps.  Clean 
and  sterilize  the  tubes.  Remove  vaseline  from  the  skin  with  ether.  Cleanse 
the  wound  and  the  skin  by  mopping  with  neutral  oleate  of  soda  solution.  Mop 
the  wound  with  Dakin's  solution.  Apply  vaselinized  gauze  to  the  skin  and 
reintroduce  the  tubes  as  before. 

As  soon  as  the  wound  appears  clean  it  is  wise  to  take  'smears'  from  various 
parts  of  it  and  examine  such  microscopically,  when  each  microscopic  field  shows 
no  more  than  2  or  3  cocci  for  several  days,  it  may  be  considered  clinically  sterile. 
The  presence  of  true  streptococci  especially  hemolysing  streptococci,  forbids 
attempts  at  suture.  Cultures  made  from  the  exudates  are  particularly  valuable. 
Of  course  no  instillations  should  be  made  for  several  hours  before  ciJtures  are 
taken. 


LOCALIZATION    OF   FOREIGN  BODIES  I  27 1 

Secondary  Suture. — As  soon  as  a  wound  is  clinically  sterile,  endeavours 
should  be  made  to  close  it:  Sterilize  the  skin.  Wipe  the  wound  clean.  Excise 
the  skin  margins.  Remove  excess  of  granulation  tissue.  Excise  scar  tissue. 
With  buried  sutures  of  catgut  or  with  relaxation  sutures  of  silk  or  silkworm  gut 
carefully  bring  together  the  tissues  layer  by  layer,  obliterating  all  dead  spaces. 
To  accomplish  this,  it  may  be  necessary  to  undermine  both  fascia  and  skin. 
Relaxation  incisions  may  often  be  required.  Properly  applied  strips  of  adhesive 
plaster  are  often  of  great  value.  Frequently  in  large,  gaping,  old  wounds  it  may 
be  impossible  to  obtain  apposition  even  in  the  depth  of  the  wound,  but  if  the 
wound  is  narrowed  it  will  be  possible  to  close  it  by  a  subsequent  operation. 

CHAPTER  CXVI 
LOCALIZATION  OF  FOREIGN  BODIES 

By  the  Late  Walter  S.  Sutton,  M.  D.,  F.  A.  C.  S.  and 
Edward  H.  Skinner,  M.  D. 
Aside  from  the  visual  recognition  of  incompletely  covered  foreign  bodies, 
there  are  three  general  methods  of  localization. 

(i)  By  palpation,  directly  or  by  means  of  instruments. 

(2)  By  magnets. 

(3)  By  the  use  of  the  Roentgen  ray. 

I.  Palpation. — Of  manual  palpation,  nothing  need  be  said.  Palpation  by 
means  of  probes  falls  into  two  classes.  That  by  means  of  a  simple  probe,  and 
that  in  which  the  telephone  probe  is  employed. 

In  spite  of  the  dictum  of  von  Bergmann,  it  is  undeniable  that  the  naked 
probe  has  a  useful  function  in  the  localization  of  foreign  bodies  in  war.  Fine- 
pointed  probes  undoubtedly  have  a  tendency  to  open  new  planes  to  infection, 
but  large  probes,  with  bulbous  extremities  not  less  than  14  inch  in  diameter, 
have  proved  harmless  and  efficient  in  locating  foreign  bodies  at  the  bottom  of 
well-defined  penetrating  wounds.  If  the  probe  is  held  so  lightly  between  thumb 
and  index-finger  that  it  may  be  gently  rolled  back  and  forth  as  its  pouit  is 
advanced,  it  will  not  make  false  passages  and  will  frequently  permit  the 
expeditious  localization  of  suspected  foreign  bodies. 

The  Telephone  Probe. — To  obviate  the  difficulty  not  infrequently  ex- 
perienced in  recognizing  the  contact  of  probe  and  foreign  body,  MacKenzie 
Davidson  has  urged  the  employment  of  the  telephone  probe  and  has  devised 
means  of  using  the  telephone  attachment  on  any  instrument  employed  in  this 
operation.  The  action  of  this  instrument  depends  on  the  fact  that  small  electric 
currents  are  generated  by  contact  of  dissimilar  metals.  The  apparatus  consists 
of  one  or  two  small  telephone  receivers  adjusted  to  the  ear  or  ears  of  the  operator, 
one  pole  of  the  circuit  being  connected  with  a  moistened  carbon  plate  on  the 
patient's  skin  and  the  other  with  a  probe  or  other  instrument.*  One  or  two 
dry  cells  introduced  into  the  circuit  increase  the  effectiveness  of  the  apparatus. 
When  the  instrument  employed  for  palpation  touches  a  foreign  body,  a  distinct 
click  is  heard  in  the  receivers.     Care  need  only  be  taken  that  the  click  heard 

*  Mr.  Gillies  has  shown  that  the  moveable  end  of  the  circuit  may  be  applied  through  the 
medium  of  a  copper  plate  to  the  arm  of  the  operator  instead  of  directly  to  probe.  In  this 
case,  of  course,  rubber  gloves  cannot  be  used. 


1272  LOCALIZATION    OF    FOREIGN    BODIES 

is  not  elicited  by  accidental  contact  of  the  probe  with  a  retractor  or  other 
instrument.  To  prevent  confusion  from  this  source,  probes  for  the  purpose  are 
sometimes  covered  with  vulcanite  or  some  other  non-conductor  except  at  their 
tip,  a  device  which  also  removes  uncertainty  as  to  what  portion  of  the  probe 
has  touched  the  foreign  body. 

2 .  Magnets. — ^Localization  of  magnetic  projectiles  by  means  of  simple  electro- 
magnets is  of  limited  usefulness  in  war  on  account  of  the  depth  of  the  foreign 
bodies  and  the  limited  range  of  the  magnets,  but  Prof.  Bergonie  of  Bordeaux, 
by  introducing  a  motor-driven  current-reversing  device  in  the  circuit,  has 
greatly  extended  the  scope  of  this  means  of  localization.  As  the  pole  of  the 
magnet  is  passed  over  the  surface  of  the  body,  a  finger  being  interposed,  near- 
ness of  a  magnetic  foreign  body  is  revealed  by  a  purring  sensation  transmitted 
through  the  skin.  The  pole-extension  of  the  magnet  may  be  sterilized  and  as 
the  incision  is  carried  down,  the  purring  becomes  stronger  until  on  near  ap- 
proach, a  visible  vibration  of  tissue  reveals  the  site  of  the  foreign  body  to 
the  eye. 

3.  Localization  by  use  of  Roentgen  rays  may  be  fluoroscopic  or  radiographic. 
For  obvious  reasons,  the  former  is  preferable  in  cases  where  the  latter  does 
not  present  special  advantages. 

Fluoroscopic  Methods. — In  some  cases  sufficient  information  may  be  ob- 
tanied  by  very  rapid  and  simple  methods. 

Palpation  Under  the  Screen.  Near  Point  Method  'U.  S.  Army). — Super- 
ficial foreign  bodies  not  recognizable  by  simple  palpation,  may  be  located  by 
palpating  or  percussing  the  overlying  tissues  under  the  fluoroscopic  screen.  The 
point  on  the  surface  at  which  pressure  or  percussion  produces  the  greatest  excur- 
sion of  the  shadow  of  the  foreign  body,  is  obviously  most  directly  above  the 
latter.  This  point  is  marked  with  silver  nitrate  and  the  patient  placed  on  the 
operating  table  in  the  attitude  in  which  the  observation  was  made.  Incision 
carried  down  normal,  i.e.,  perpendicular,  to  the  surface  at  this  point  will  usually 
reach  the  foreign  body,  WTien  possible,  as  in  most  extremity  cases,  the  body 
should  be  so  placed  that  the  axial  ray  traverses  a  plane  parallel  to  the  tangential 
plane  of  the  surface  at  the  point  nearest  the  foreign  body,  i.e.,  if  the  foreign  body 
is  in  the  lateral  portion  of  the  thigh,  the  patient  should  lie  on  back  or  face.  In 
this  relation  excursions  of  the  shadow  are  most  readily  detected. 

Parallax  Method  (U.  S.  Army). — Ascertaining  Relative  Depth  by  Movement 
of  X-ray  Tube. — It  is  well  known  that  the  farther  an  opaque  body  is  from  the 
screen,  the  greater  will  be  its  excursion  where  the  tube  is  moved  in  a  plane  paral- 
lel to  that  of  the  screen.  Thus,  if  it  is  desirable  to  find  whether  a  foreign  body 
lies  above  or  below  the  bone,  a  greater  excursion  of  the  foreign-body  shadow  than 
that  of  the  bone  when  the  tube  is  moved  as  described,  indicates  a  deeper  position 
of  the  foreign  body.  Conversely,  if  the  excursion  of  the  foreign-body  shadow  is 
less  than  that  of  the  bone  shadow,  the  foreign  body  must  be  superficial  to  the 
bone.     If  both  are  equal,  the  foreign  body  lies  in  the  plane  of  the  bone. 

Fluoroscopic  Localization  in  One  Plane. — Fluoroscopic  Triangulation. 
Tube  Shift  method  with  Mechanical  Triangulation  (U.  S.  Army).  This  method 
was  first  advanced  by  MacKenzie  Da\-idson.     In  its  simplest  form,  it  is  carried 


FLUOROSCOPIC    LOCALIZATION 


1273 


out  as  follows.  With  the  tube  underneath  the  table  and  a  fluoroscopic  screen 
firmly  supported  above  the  patient  in  a  horizontal  position  and  at  a  known 
distance  from  the  tube,  find  the  shadow  of  the  foreign  body.  Close  the  dia- 
phragm (which  must  be  centered  with  the  target  of  the  tube)  to  the  smallest 
aperture  that  will  show  the  shadow  of  the  foreign  body.  Mark  on  the  screen 
the  position  of  some  definite  point  on  the  contour  of  the  latter.  For  the  sake  of 
accuracy,  this  marking  is  best  done  by  means  of  sharp-pointed  metal  indicators 
which  may  be  fastened  to  the  frame  of  the  screen. 

Move  the  tube  in  the  horizontal  plane  a  known  distance  and  mark  the  new 
position  of  the  chosen  point  of  the  shadow  contour.  Make  a  chart  as  shown 
below  (Fig.  1624)  indicating  graphically  the  two  positions  of  the  anti-cathode, 


Fig.  1624. — Determination  of  the  depth  of  a  foreign  body  by  radioscopic  triangulation. 

Pb"  is  the  distance  from  level  of  tube  to  level  of  screen  (or  plate,  if  radiographic  method  is  used).  P 
represents  first  position  of  anticathode  and  b"  represents  first  foreign-body  shadow.  P'  represents  second 
position  of  anticathode  and  b'  the  foreign-body  shadow  produced  in  this  position.  If  then  the  lines  Ph" 
and  P'b'  are  drawn,  their  intersection  at  the  point  b  must  indicate  the  locus  of  the  foreign  body.  The 
length  of  the  line  bh"  therefore  indicates  the  actual  distance  of  the  foreign  body  from  the  screen  or  plate. 


the  plane  of  the  screen  and  the  two  positions  of  the  shadow — all  in  their 
actual  measurements. 

Indicate  by  two  straight  lines  the  axial  ray  from  each  position  of  the  anti- 
cathode to  the  corresponding  shadow.  The  intersection  of  these  two  lines  marks 
the  site  of  the  selected  point  on  the  foreign  body.  The  actual  distance  from 
the  screen  to  this  point  is  then  determined  by  actual  measurement  on  the 
chart. 

The  result  may  be  obtained  arithmetically  according  to  H.  R.  Bra m well 
as  follows: 

Multiply  distance  from  anti-cathode  to  screen  by  amount  of  excursion  of 


1274 


LOCALIZATION    OF    FOREIGN    BODIES 


Fig.  1625. — Sutton's  localizing  device. 

c  indicates  latest  form  of  canula  with  sharp  trocar,     cf  is  blunt  trocar  for  use  with  same  canula.     t  is 

a  curved  hemostat  for  grasping  the  trocar,  c.     a  represents  the  hooked  piano  wire  which  is  introduced 

through  the  canula  and  left  as  an  indicator,     d  indicates  wire  cutters  employed  to  snip  off  the  excess  piano 

wire  after  introduction,     b,  b'  indicate  the  original  form  of  the  instrument;  the  large  head  interfered  with 

•sighting." 


Fig.  1626. — Showing  niethod  of  introducing  Sutton's  localizing  canula. 

tesy  of  the  Annals  of  Surgery.) 


(Plate  used  by  cour- 


Sutton's  method  1275 

shadow  on  screen  and  divide  product  by  sum  of  amount  of  displacement  of  tube 
and  amount  of  excursion  of  shadow.     Thus,  if 

A  =  distance  of  screen  from  anti-cathode 
S   =  excursion  of  shadow,  and 
T  =  displacement  of  tube 

A  +  s 
the  formula  q"^,^  =  the  distance  of  foreign  body  from  screen. 

Sutton's  Method.  Canula  and  Trochar  With  Harpoon  (U.  S.  Army). — ^This 
method  was  suggested  by  that  of  WuUyamoz  for  removing  foreign  bodies  from 
the  brain.  In  addition  to  the  tube  and  screen,  a  small  special  instrument  is 
required  which,  however,  is  of  small  cost  and  may  even  be  improvised.  The 
construction  is  sufficiently  clearly  shown  in  Fig.  1626. 

The  procedure  is  as  follows: 

Having  located  the  shadow  of  the  foreign  body  by  means  of  the  axial  ray 
upon  a  large  screen  firmly  supported  about  6  inches  above  the  surface  of  the 
part  examined,  the  surface  is  painted  with  iodine,  cocainized  and  a  small  skin 
incision  made  in  the  center  of  the  shadow.  The  special  canula  bearing  the 
blunt  or  sharp  trocar  as  circumstances  may  indicate,  and  held  by  a  strong  clamp 
at  right  angles,  is  then  entered  through  the  skin  incision.  The  room  is  then 
darkened  and  under  the  guidance  of  the  X-ray  the  instrument  is  driven  through 
the  tissues  (Fig.  1626).  As  long  as  the  point  is  advancing  straight  toward 
the  anode  (and  hence  toward  the  foreign  body)  the  shadow  of  the  point  will  be 
hidden  by  the  shadow  of  the  upper  portion  of  the  instrument. 

When  the  trocar  strikes  the  foreign  body,  the  patient  invariably  complains 
of  a  sharp  pain.  Contact  is  then  verified  by  slight  waving  movements  of  the 
point  of  the  trocar  which  can  be  made  to  cause  the  foreign-body  shadow  to 
describe  a  circular  excursion  on  the  screen. 

The  current  is  now  cut  off,  the  screen  removed  and  the  room  lighted  while 
the  operator  continues  to  hold  the  trocar  immovable.  Next  the  trocar  is  with- 
drawn from  the  canula  and  one  of  the  small  hooked  piano-wire  indicators  in- 
serted in  its  place.  Holding  the  hook  of  the  latter  against  the  foreign  body, 
the  canula  is  withdrawn  and  the  wire  snipped  off  ^  inch  above  the  skin.  Over 
this  a  fairly  thick  dressing  is  applied. 

If  other  foreign  bodies  are  present,  each  may  be  localized  in  the  same  way. 
On  the  operating  table  each  indicator  may  be  readily  followed  to  the  correspond- 
ing foreign  body. 

The  particular  advantages  of  this  method  are: 

(i)  Operations  may  almost  always  be  done  under  local  anesthesia. 

(2)  Changes  in  the  position  of  limbs  or  body  do  not  vitiate  the  result. 

(3)  There  are  no  calculations  to  introduce  a  possible  mathematical  error. 

(4)  The  localization  may  be  carried  out  aseptically  without  steriUzing  the 
hands. 

Radiographic  Methods. 

Stereoscopic  plates  are  particularly  useful  in  cranial  and  thoracic  cases  but 
are  unfortunately,  rarely  applicable  under  war  conditions. 


1276 


LOCALIZATION    OF    FOREIGN    BODIES 


Radiographic  triangidation  is  done  exactly  as  described  for  fluoroscopic  tri- 
angulation  with  the  exception  that  a  plate  is  used  instead  of  the  screen,  two 
exposures  being  made  on  the  same  plate.  This  method  is  more  accurate  than 
the  fluoroscopic  one  on  account  of  the  greater  nicety  of  measurements  on  the 


Fig.  1627. 

plate  as  compared  with  the  screen.      Radiographic  plates  in  two  planes  are 
useful  in  the  extremities. 

Operative  Fluoroscopy. — This  method  requires  the  use  of  the  fluoroscope  for 
direct  localization  during  the  operative  removal  of  foreign  bodies.     It  is  easily 


Fig.   iojS. 


pursued  in  any  operating  room  where  the  operating  table  has  a  non-opaque  top 
and  an  rc-ray  tube  under  the  table.  It  is  not  necessary  to  darken  the  operating 
room  if  the  assisting  radiologist  is  provided  with  a  Dessane  bonnet  (Fig.  1627). 
This  fluoroscopic  bonnet  is  constructed  so  that  whenever  the  fluoroscopic  screen 


OPERATIVE    FLUOROSCOPY  1 277 

is  used  the  red  glass,  which  protects  the  radiologist's  adaptation  to  darkness, 
automatically  springs  from  in  front  of  the  eyes  and  vice  versa.  The  approxi- 
mate localization  of  the  foreign  body  has  been  indicated  to  the  surgeon  before 
the  patient  is  placed  upon  the  operating  table.  After  the  patient  is  in  position 
for  the  most  favorable  operative  attack  the  surgeon  makes  his  incision  to  the 
supposed  location  of  the  foreign  body  and  calls  for  fluoroscopic  advice  if  he  is  not 
immediately  successful.  By  holding  a  metallic  indicator  in  the  wound  so  that 
the  radiologist  can  advise  as  to  the  relative  position  of  the  indicator  tip  to  the 
foreign  body.  Special  right-angled  forceps  may  be  used  under  fluoroscopic 
control  by  the  radiologist  or  by  the  surgeon  if  he  is  also  provided  with  a  Dessane 
Bonnet.  Operations  under  fluoroscopic  control  are  useful  in  the  thorax,  abdo- 
men and  in  difficult  extremity  cases.  The  Standard  U.  S.  Army  X-ray  table  is 
adaptable  for  operative  fluoroscopy  (Fig.  1628). 


INDEX 


Abadie,  excision  of  tongue,  172 

fracture  of  skull,  18 
Abb6,  aneurysmorrhaphy,  829 

common  bile  duct,  577 

intracranial  neurectomy,  75 

laminectomy,  761 

lateral  anastomosis,  412 

oesophageal  stricture,  226 

snapping  finger,  1130 
Abdomen,  operations  on,  343 

cysts,  dermoid,  536 
echinococcic,  589 

paracentesis,  530 
Abdominal  nephrectomy,  632,  657 

pads,  356 

rectopexy,  486 
Abdomino-perineal  rectectomy,  502 
Abduction  splint,  looi 
Abscess,  acute,  1259 

appendicitic,  468,  473 

bone,  945 

breast,  271 

cerebellar,  38 

cerebral,  34 

costal,  323 

ischiorectal,  524 

kidney,  650 

liver,  560 

lung,  326 

pancreas,  546 

psoas,  1260 

retropharyngeal,  222 

subperiosteal,  944 

subphrenic,  562 

temporo-sphenoidal,  36 
Absence,  congenital,  tibia,  912 
Acetabulum,   congenital   dislocation   of  hip, 
1022 

excision,  976 
Achillo-tenotomy,  1221 
Acne  hypertrophicus,  182 
Acoustic  nerve,  tumors,  28 
Acromegaly,  52 

Acromion  proc.  obstetrical  palsy,  796 
Adamantine  epithelioma,  958 
Adami,  mercurial  poisoning,  460 
Adams'  operation,  palmar  fascia,  1238 

osteotomy,  968 

saw,  96s 
Addison's  disease,  553 
Adinitis,  tuberculous  neck,  209 
Adhesions  after  trephining,  10 

between  liver  and  stomach,  588 

gastric  ulcer,  364 

intestinal,  452 

meninges,  prevention  of,  10,  51 
Adrenalectomy,  553 
Aerophagy,  neurectomy  for,  70 
After-treatment,  appendicitis,  476 

arthrectomy  hip,  983-985 


After-treatment,  cerebral  abscess,  38 
cleft  palate,  158 
dislocation,  elbow,  11 16 
hip,  1007 
shoulder,  iioi 
excision,  ankle,  1065 
chin  and  jaw,  128 
tongue,  162,  164,  165 
wrist,  1 1 24 
external  urethrotomy,  719 
fracture,  patella,  932 
hare-lip,  143 
hernia,  610 
hypospadias,  731 
internal  urethrotomy,  717 
laparotomy,  349 
laryngectomy,  235,  237 
necrotomy,  956 
nerve  injuries,  788 
operations,  mastoid,  38 
piles,  520 
stomach,  356,  407 
pneumolysis,  317 
rectopexy,  485 
tendon  lengthening,  1222 

transplant,  1207 
tenorrhaphy,  11 68 
thoracoplasty,  310 
thoracotomy,  298 
thyroidectomy,  252 
wrist  drop,  1219 
Air  embolism,  210 
Albarran,  nephropexy,  636 
prostatectomy,  708 
Albee,  arthritis  deformans,  989 
operation.  Pott's  disease,  780 
ununited  fracture,  901 
Alcohol,  injections,  nerves  in  amputations, 
1148 
neuralgia,  59 
Alexander,  sympathectomy,  220 
Alglave,  fracture  of  femur,  924 
ptosis  kidney,  640 
varicose  veins,  869 
Allingham,  preparation  for  operation  of  piles, 

Alveolus,  inferior  maxillary  resection,  92 

superior  maxillary  resection,  85 
Ampulla,  Vater,  calculi,  577.. 582 
Amputations,  11 43 

breast,  273 

by  transfixion,  1149 

choice  of  site,  1145 

cinematic,  1165 

circular,  1147 

guillotine,  1144 

hip,  1 182 

interscapulo-thoracic,  1162 

length  flaps,  1147 

osteoplastic,  ii77>  "81 


1279 


I28o 


INDEX 


Amputations,  penis,  733 

special,  1152 

treatment  divided  bone,  1148 
Anaimia,  pernicious,  549 

splenic,  549-552 
Anal  excision,  rectum,  490 

fistula,  523 
Anastomosis,  arterial,  815 

arterio-venous,  821 

intestinal,  412 

nerves,  790 

parotid  to  submaxillary  glands,  180 

ureter  to  bladder,  670 
to  intestine,  677 

ureteral,  670 

vas  to  testis,  743 
Anatomy,  bronchi,  244 

congenital  dislocation  hip,  loio 

facial  nerve,  790 

hand,  1132 

kidney,  640 

stomach,  389 

superior  maxillary  nerve,  66 

thyroid,  247 

ureters,  661 
Anchylosis  elbow,  1117 

hip,  990 

knee,  1049 

lower  jaw,  103 

patella,  1052 

wrist,  1 1 25 
Anderson,  E.  W.,  aneurysm,  829 
Andrews,  colohepatopexy,  588 

Gasserian  ganglion,  72 

hernia,  613 
Anel's  operation,  825 

Anaesthesia,   local,   disarticulation   humerus, 
1161 

in  thoracic  operations,  287 

spinal,  757 
Aneurysm,  823 

arterio-venous,  832 

traumatic,  repair,  820 
Angioma  face,  133 

nose,  182 

scalp,  I 
Ankle,  1061 

amputation,  1171 

arthrectomy,  1062 

arthrotomy,  1061 

splint,  Jones',  1063 
Anoci-association,  goiter,  251 

prostatectomy,  685 
Anschutz,  resection,  liver,  558 
Anterior,  gastro-enterostomy,  365 

poliomyelitis,  nerve  anastomosis,  803 
Anton,  callosal  puncture,  33 
Antrum,  Highmore,  82 

mastoid,  34 
Antyllus  operation,  825 
Anuria,  659 
Anus,  artificial,  453,  461 

imperforate,  482 

pruritus,  522 
Aorta,  aneurysm,  Fibrous  cerclage,  832 

exposure  orifices,  331 

suture,  820 

temporary  compression,  11 84 
Apparatus,  Carrel's,  1270 

after  excision  inferior  maxillary,  95 


Apparatus,  after  tendon  lengthening,  Toupet, 
1222 

fixation  fract,  903 
Appendicostomy,  461 
Appendix  vermiformis,  464 
Aqueduct,  Si'lvius,  hydrocephalus,  43 
Arachnoid  infections,  36 
Arlow,  anchylosis  jaw,  io6 
Arm,  amputation,  1147 

fracture,  934 
Armstrong,  G.  E.,  excision  tongue,  169 

ligation,  external  carotid,  842 
Arrou,  hydrocele  neck,  215 
Artery,  axillary,  847 

brachial,  848 

carotid,  common,  836 

external,  75,  86,  91,  134-169,  840 
internal,  843 
temporary  occlusion,  75 

femoral,  853 

iliac,  848 

inferior  thyroid,  254,  845 

lingual,  843 

meningeal,  15 

patching  with  fascia,  820 

pulmonary,  319 

stomach,  391 

splenic,  551,  552 

subclavian,  846 

superior  thyroid,  844 

tibial,  854 
Arteries,  operations  on,  812 

ligation  of,  825,  834 
Arteriorrhaphy,  812 
Arteriotomy,  thrombosis,  820 
Arterio-venous  anastomosis,  821 

aneurysm,  832 
Arthrectomy  ankle,  1062 

elbow,  1108 

hip,  983 

knee,  1039 

shoulder,  1085 

wrist,  1 1 22 
Arthritis  deformans,  hip,  989 
knee,  1045 
wrist,  1 1 24 

dry,  injection,  980 
traumatic,  11 43 

gonorrheal,  1142 

purulent,  knee,  1031 

pyogenic,  1140 

rheumatic,  1143 

septic,  1030 

tuberculous,  1141 

typhoidal,  1143 
Arthrodesis,  calcaneo-cavus,  1236 

elbow,  1 1 14 

shoulder,  1099 
Arthroplasty,  and  bone  transplantation,  913' 

bunion,  1072 

elbow,  1117 

hammer  toe,  1074 

hip,  991 

jaw,  104 

knee,  1052 

shoulder,  1103 

wrist,  1 1 25 
Arthrotomy  ankle,  io6i 

elbow,  1 108 

hip,  981 


INDEX 


I281 


Arthrotomy,  knee,  1025 

shoulder,  1084 
Articular  complications,  fractures,  892 
Artificial  anus,  453-461 

pneumothorax,  311 

respiration  in  thoracic  operations,  287 
Ascending  colon,  425 
Ascites,  528 
Ashhurst,  A.  P.  C,  amputation,  1168 

excision  tongue,  170 
Aspiration,  chest,  292,  293,  295 

pericardium,  334 
Astragalectomy,  1067 

club  foot,  1232 
Astragalus,  1067 
Athetosis,  768 
Atropin  in  ileus,  444 
Auer,  artificial  respiration,  operation  thorax, 

288 
Auriculo-temporal    nerve,    neurectomy,    70, 

180 
Author,  amputation,  11 79 
penis,  734 

aneurysmorrhaphy,  831 

angioma  scalp,  3 

arthroplasty,  11 17,  11 25 

caecostomy,  459 

cysts,  peritoneum,  535 

dangers,  chisel  operation  on  skull,  24 

disarticulation  hip,  1187 

excision  chin  and  jaw,  126 
shoulder,  1056 
superior  maxilla,  87 

odontomata,  108 

open  fractures,  890 

operation,  rodent  ulcer,  89 

prostatectomy,  687 

pyloric  exclusion,  373 

rhinoplasty,  200 

snapping  hip,  979 
Autoplasty  bone,  907 
Auvray,  hemostasis  liver,  557 

nerve  suture,  783 

osteomata,  11 22 
Axhausen  excision  costal  carotid,  324 
Axillary  arterj',  847 

Babcock,  spina  bifida,  776 

varicose  veins,  869 
Babinski-Froment  reflex,  sympathectomy,  220 
Bacon,  operation  external  ear,  78 
Baer,  arthroplasty,  1055 
Bag,  Pilcher's  hemostatic,  688 
Baisch,  tuberculous  peritonitis,  480 
Baldwin,  Aslett,  femoral  hernia,  597 
Balfour,  diaphragm,  hernia,  626 

excision  rectum,  517 

gastrectomy,  400 

pernicious  anaemia,  549 

thyroidectomy,  263 

ulcer  stomach,  363-386 
Ballance,  facial  paralysis,  790 

hydrocephalus,  44 

ligation  common  carotid,  839 

spinal  puncture,  756 
Ball's  operation  for  pruritus,  522 
Bands,  causing  obstruction,  451 
Banti's  disease,  549,  552 
Barasto,  pericardiotomy,  335 
Barber,  resection  stomach,  388 
81 


Bardenheuer,  anastomosis   vas  and  testicle, 

.  743 

excision  elbow,  11 12 
wrist,  1 1 25 

incision,  631 

plastic  cheek,  in 

sacro-iliac  disease,  977 

splenopexy,  548 

upper  jaw,  87 
Barker,  arthrectomy  hip,  983 

bunion,  1070 

derangements  knee,  1035 

fracture  patella,  925 

Hey's  amputation,  1170 
Barnard,  amputations,  1145 
Barth's  operation,  58 
Bartlett,  hernia,  620 

machine,  1017 

pyloric  exclusion,  373 
Barton,  Rhea,  anchylosis  knee,  1049 

osteotomy,  997 
Base  skull  fracture,  19 
Basedow's  disease,  249 

sympathectomy,  220 

thymus,  268 
Bassini,  femoral  hernia,  596 

inguinal  hernia,  605 
Battle,  angioma  nose,  183 

crucial  ligaments,  1036 

incision,  346 
Baudet,  vasectomy,  745 
Baudouin  neuralgia,  59 
Bauer,  removal  clot  aorta,  821 
Bayliss,  gum  acacia  solution,  858 
Beck,  defects  skull,  11-50 

empyema,  307 

epilepsy,  50 

hypospadias,  728 

meningeal  vessels,  15 
Beckman,  results  lip  cancer,  125 
Beck's  paste,  951 
Belfield  vasostomy,  748 
Benign  tumors  bone,  958 
Benisty,  Mme.  Athanassio,  782 
Bennet,  cerebral  topography,  21 
Berard,  empyema,  305 
Berard  and  Dunet,  diaphragm  hernia,  625 
Berg,  duodenal  fistula,  410 
Berger,  anchylosis  elbow,  11 19 

cranial  meningocele,  42 

interscapulo-thoracic  amputation,  1162 

osteotomy,  1000 

sarcoma  bone,  960 
Bergman,  cancer  skull,  5 

dislocation  hip,  1006 

incision,  630 

transplantation  tendon  insertion,  11 98 
Bemay's  cholecystotomy,  567 
Bernheim,  arterio-venous  anastomosis,  822 
Bergonie,  localization  foreign  bodies,  1272 
Berry,  enucleation  goitre,  266 
Bevan,  congenital  cystic  kidney,  660 

incision,  564 

pigmented  moles,  1261 

undescended  testicle,  749 
Beyea,  gastropexy,  362 
Bier,  amputation,  11 77 

hyperemia  hand,  1137 
mastoiditis,  42 

pyloric  exclusion,  373 


1282 


INDEX 


Bier,  treatment  abscess,  1259 
Bile  passages,  operations  on,  562 
Billington,  fracture  jaw,  100 
Billroth,  excision  tongue,  162 
Bindi,  omentopexy,  529 
Biniodide  catgut,  1266 
Biondi  pyloric  exclusion,  374 
Bipp,  osteomyelitis,  946 
Bird,  Golding,  sacro-iliac  disease,  977 
Birmingham  operation,  fracture  jaw,  100 
Bismuth  paste,  951 
Bladder  diverticula,  712 
rupture,  680 
urinary,  673 
hernia,  591 
Blair,  E,  G.,  X-ray  burns,  1255 
Blair,  V.  P.,  undeveloped  jaw,  102 
Blake,  Joseph,  peritonitis,  475 
Bland-Sutton,  1-ract,  malleolus,  933 

odontoma,  108 
Blasius,  excision  lip,  128 
Blechman,  pericardiocentesis,  334 
Bleeding,  longitudinal  sinus,  17 

meningeal,  15 
Block,  prostatotomy,  704 
Blood  groups,  860 

transfusion,  858 
Bloodgood,  cancer  lip,  117 
hernia,  615 
tumors  bone,  958 
Bodies,  foreign,  chest,  291 
in  heart,  333 
localization,  1271 
mediastinum,  340 
oesophagus,  224 
loose  in  joint,  103 1 
suprarenal,  552 
Boeckman  catgut,  1268 
Bogojawlensky's  operation,  52 

position,  52 
Bond,  echinococcic  cysts,  590 
Bone,  carpal  excision,  11 23 
cavities,  950 
chips,  Senn,  950 
fixation  of,  880,  890-997 
fractures,  877 
holding  forceps,  880 
implant,  jaw,  lower,  1248 

skull,  II 
infections,  941 

intermaxillary  hare-lip,  142-148 
non-union,  893 
pelvic,  974 
plugs,  947 

sarcoma  statistics,  959-900 
spread  infection  in,  889 
transplant,  900,  909-912 
clavicle,  1084 
inferior  maxillary,  95-9? 
tumors,  958 
Bonnet,  Dessane's,  1276 
Boracic  acid,  mastoid  operation,  36 
Bothrezat,  arthrodesis  shoulder   iioo 
Bottini's  operation,  702 
Bougies,  rectal,  488 
Bowlby,  Sir  A.,  fractured  femur,  891 
Bow-leg,  972 
Brachial  artery,  898 

plexus,  palsy,  795 
Brain,  exposure  of,  6 


llrain,  infections,  34 

topography,  20 

tumors,  20 
Bramann,  callosal  puncture,  33 

hydrocephalus,  44 
Brasdor's  operation,  825 
Brauer  artificial  pneumothorax,  311 

differential  pressure,  290 

pericardiolysis,  337 
Braun  and  Lossen  neurectomy,  68 

peptic  ulcer,  375 

salivary  fistula,  178 

suture  aorta,  820 
Breast,  extent  of,  284 

operations  on,  271 
Brechot,  rectal  prolapse,  484 
Brenner  flat-foot,  1189 
Brentano,  cholecystenterostomy,  575 
Brewer,  adhesive  plaster,  artery,  814 

chest  wounds,  293 

diverticulitis,  438 

pyloric  exclusion,  372-374 
Brickner,  subacromial  bursitis,  1107 
Brieau-Jaboulay,  artery  suture,  814 
Broca,  sclerogenic  injections,  1025 
Broedel,  anatomy  kidney,  649 
Bronchiectasis,  319-326 
Bronchocele,  247 
Bronchotomy,  posterior,  244 
Bronchus,  foreign  bodies  in,  243 
Brophy,  cleft  palate,  144,  158 
Brown,  cleft  palate,  157 
Briinig,  cardiospasm,  357 
Brunner  hernia,  591 
Bruns,  excision  lip,  127 
Brunton,  operation  valves  heart,  332 
Bryant's  operation,  angioma,  3 
Buchmann,  anchylosis  elbow,  11 20 
Buck,  anchylosis  knee,  1049 
Bull,  W.  T.,  foreign  body,  oesophagotomy,  225 

sliding  hernia,  595 
Bullard,  hemorrhagic  meningitis,  52 
Bullet  in  heart,  333 
Bunge,  amputations,  1148 

dislocation  elbow,  11 15 
Bunion,  1070 

Bur  in  antral  operation,  35 
Burns,  X-ray,  1255 
Burow,  excision  lip,  128 
Burrell,  dislocation  shoulder,  iioo 

spinal  injuries,  766 
Bursa,  transplant,  bunion,  1072 
Bursae,  hand,  1132 
Bursitis,  subacromial,  1106 
Busch,  retropharyngeal  tumors,  223 
Butlin,  amputation  penis,  734 

laryngotomy,  232 

operation  tongue,  158-165 
Button,  Murphy,  415,  420 

Cabinet,  differential  pressure,  290 

Caboche,  rhinoplasty,  187 

Cachexia  strumipriva,  treatment,  266 

Caecectomy,  425 

Caecopexy,  437 

Caecoplication,  438 

Caeco-sigmoidostomy,  441 

Caecostomy,  459 

Caecum  mobile,  479 

Cahier,  diverticulitis,  38 


INDEX 


1 2S^ 


Cammidge's  test,  541 
Cancer,  bladder,  685,  680,  699 

bone,  961 

breast,  273 

cheek,  114 

chest  wall,  325 

kidney,  654 

larynx,  233 

lip,  IIS 
upper,  129 

nose,  181,  183 

CESophagus,  227 

prostatic,  709 

rectum,  501 

scalp,  s 

stomach,  395 

results,  operation,  408 

testicles,  739,  746 

tongue,  158 
neurectomy,  70 
Cannon,  gum  acacia,  858 
Cannula,  Hahn's,  242 

Konig's,  241 

laryngotomy,  232 

Levy-Baudouin's,  61 

tracheotomy,  241 

Trendelenburg's,  241 
Cantvvell's  epispadias  operation,  725 
Calcaneo-cavus  arthrodesis,  1236 
Calcaneum,  933,  1069 
Calculi,  biliary,  568 

pancreas,  546 
Calculus,  bladder,  681 

renal,  646,  651,  658 

ureteral,  661 
Caliper,  extension,  917 

splints,  892 
Calipers,  Ransohoff's,  892 
Callosal  puncture,  33 
Callus  excessive,  915 
Capsulorrhaphy,  shoulder,  11 01 
Caput  obstipum,  204 
Carbon-dioxide  snow,  5,  133 
Carden's  amputation,  1180 
Cardiac  surgery,  330 
Cardiolysis,  337 
Cardiospasm,  357 
Cardiotomy,  ^^3 
Cargile  membrane,  51 
Carlette,  posture,  operation,  chest,  301 
Carnes,  artificial  arms,  1168 
Carotid  artery,  temporary  occlusion,  75 

common,  ligation,  214,  836 

external,  ligation,  75, 86,  91, 134, 169,  840 

internal,  843 
Carpal  bones  excision,  11 23 
Carrel's  apparatus,  1270 
Carrel,  arterial  suture,  812  ei  seq. 

Dakin  treatment  empyema,  299,   300 
fractures,  891 
wounds,  1269 

operations,  heart  330  et  seq. 

operations,  thorax,  288,  296 
Carson,  artificial  pneumothorax,  34 
Carson,  N.  B.,  diaphragm  hernia,  628 
Cartilage,  displaced  knee,  1033 

floating,  103 1 

transplantation  elbow,  11 19 
Carwardine,  operation,  parotid,  174 
Castration,  703,  739 


Catgut,  i2bs 

Catterina,  excision  slioulder,  1090 

Causalgia,  sympathectomy,  220 

Cautery,  operation,  stomach  ulcer,  303,  386 

I)iles,  520 
Cavernous  angioma,  scalp,  i 
Cavicchia  laminectomy,  763 
Cavities,  bone,  950 
Cecca  varicose  veins,  867 
Celeotomy,  343 

Celluloid  after  trephining,  11,  24 
Centers,  motor,  20 
Cerebellar  abscess,  38 
Cerebellum,  exposure  of,  28 
Cerebral  decompression,  19,  24 

topography,  20 
Cervical  fistulae,  215 

oesophagotomy,  222 

ribs,  208 

sympathectomy,  217 

tumors,  209 
Cervico-mediastinal  space,  338 
Chaput,  hernia,  602,  615 
Cheatle,  excision  upper  lip,  131 
Cheek  excision,  109 
Chest,  286 

wall,  tumor,  324 
Chetwood's  cautery,  703 
Chevassu,  teratoma  testis,  740 
Chevrier,  abdominal  incision,  346 

empyema,  302 
Cheyne,  breast  amputation,  284 

epispadias,  724 
Cheyne  and  Burghard,  dislocation^hip,  1007 

shoulder,  1092 
Chiene,  cerebral  topography,  22 

retropharyngeal  abscess,  222 
Chin  and  jaw  excision,  126 

repair,  1248 
Chipault,  cranial  meningocele,  42 

injuries,  spine,  766 

spinal  topography,  755 
Chisels,  962 

skull,  9 

mastoid,  38 
Choice  operation,  biliary  system,  586 
cancer  rectum,  502 
enlarged  prostate,  703 
facial  palsy,  794 
fractured  patella,  932 
gastro-enterostomy,  376 
knock-knee,  971 
piles,  521 
Cholecystectomy,  571 
Cholecystenterostomy,  574 
Cholecystostomy,  567 

in  anuria,  580 
Cholecystotomy,  567 
Choledochotomy,  576 
Cholesteatomata,  34 
Chondrectomy,  962 
Chondritis  ribs,  324 
Chondrotomy,  Freund's,  320 
Chopart's  amputation,  11 74 
Chromic  catgut,  1267 
Chutro,  arthrotomy  ankle,  1061 
Cinematic  amputations,  1165 
Circle,  vicious,  372,  375 
Circular  enterorrhaphy,  417 
Circumcision,  737 


1284 


INDEX 


Cirsoid  aneurysm,  823 

growths,  scalp,  3 
Citratcd  blood  transfusion,  864 
Clairmont,  dislocation  shoulder,  iioi 

intestinal  obstruction,  445 

obstruction  duodenal,  410 

operation  angioma,  3 
Clamps,  arterial  suture,  812 

and  cautery,  piles,  520 

intestinal,  351 

Payr's,  398 

pile,  520 
Clark,  F.  H.,  blood  transfusion,  861 
Clark,  M.  H.,  anesthesia  thoracic  operations, 
287 
artiiicial  pneumothorax,  311 
Clark,  W.,  oedema  leg,  875 
Claudius,  catgut,  1266 
Clavicle,  1082 

Claviculo-humeral  nearthrosis,  1104 
Claw  fingers,  12 19 
Clay,  J.,  double  nephrolithiasis,  654 
Cleft  palate,  144 

Clogg,  perforation  duodenum,  410 
Closure  artificial  anus,  461 

bone  cavities,  450 

defects,  skull,  10 

faecal  fistula,  461 

scalp  wound,  14 

wounds  meninges,  17 
Club-foot,  1226 

paralytic,  1207 

shoe,  123s 

splints,  1229 
Clubbe,  intussusception,  449 
Glutton,  sarcoma  bone,  959 
Codivilla,  bone  autoplasty,  911 

congenital  dislocation  hip,  1009 

direct  extension,  917 
Codman,  bone  transplantation,  909 

bursitis,  1106 

excision  stomach,  383 

operation  shoulder,  1106,  1107 
Coffey,  intussusception,  447 
Cole,  fractures  jaw,  96 
Colectomy  complete,  432 

partial,  429 
Coleman,  skull  defects,  13 
Coley,  sliding  hernia,  595 
CoUes's  fracture,  918 
Collier,  sacro-iliac  dislocation,  977 
CoUis,  hare-lip,  137 
Coloboma  ear,  77 
Colohepatopexy,  588 
Colon,  ascending,  425  _ 

congenital  dilatation,  439 

descending,  429 
Colopexotomy,  486 
Colopexy,  sliding  hernia,  595 
Colo-rectostomy,  489 
Colostomy,  453 

corrosive  sublimate  poisoning,  459 

preliminary,  501 

rectal  stricture,  489 
Combined  operation  excision  rectum,  502 
Common  bile  duct,  576 
Common  carotid  ligation,  836 
Compound  fractures,  888 
Condyles  femur  fractures,  924 

humerus  fracture,  935 


Congenital  absence  tibia,  912 

club-foot,  122O 

cystic  kidney,  660 

dislocation  hip,  1009 
knee,  1093 
shoulder,  1098 

eventration,  621 

fistulae  neck,  215 

pyloric  stenosis,  377 
Connell's  suture,  419,  420 
Connor,  gastrectomy,  408 
Conover,  corrosive  sublimate  poisoning,  460 
Contamination  and  infection,  1030 
Contractures,  1238 

cheek,  109 

spastic,  771 

Volkmann's,  1240 
Cooper,  common  bile  duct,  577 
Cooper's  operation  external  iliac  artery,  852 
Cord,  hydrocele  of,  753 
Corlette's  amputation,  1174 
Corner  crucial  ligaments,  1037 

perforation  stomach  and  duodenum,  410 
Coronoid  process,  940 
Corpus  callosum  puncture,  $^ 
Corson,  omentopexy,  530 
Costal  cartilage,  tuberculosis,  324 
Costal  osteitis,  323 
Costectomy,  300 

Cotton,  v.,  fractures  neck  femur,  922 
Coxa  vara,  1002 

Cramer,  anchylosis  patella,  1052 
Cranial  contents,  infections,  34 

defects,  11 

erosions,  middle  ear  disease,  36 

fractures,  17 
Craniotomy,  osteoplastic,  23 
Cranwell,  diaphragm  hernia,  626 
Cred6,  amputations,  1149 

rectal  stricture,  488 
Crile,  clamp,  214,  8x3 

disarticulation  shoulder,  ii6i 

excision  tongue,  165,  168 

hyperthyroidism,  251 

injuries,  vagus,  214 

interscapulo-thoracic  .amputation,  1 163 

morphine  after  laparotomy,  477 

treatment  goitre,  251 
Cripps,  Harrison,  colostomy,  455 
Crisler,  appendicitis,  477 
Croft,  dislocation  ulnar  nerve,  803 

skin  grafts,  1244 
Crooked  heel  shoe,  1074 
Crouse,  gastropexy,  362 

salivary  fistula,  178 
Crows  feet,  1255 
Crucial  ligaments,  knee,  1036 
Cryptorchism,  749 
Cullen,  hemostasis  liver,  557 

nephrotomy,  649 
Cumston,  castration,  740 
Cuneiform  osteotomy,  967 

hip,  looi 
Cun^o,  facial  palsy,  794 

operation,  O79 

teratoma  testis,  740 
Curtis,  I'.,  dislocation  shoulder,  1099 

sympathectomy,  220 
Curtis,  H.,  epithelioma  nose,  183 
Curvature  tibia,  967 


INDEX 


1285 


Gushing,  cerebral  decompression,  19,  25 

exposure  cerebellum,  28 

facial  paralysis,  790 

hemostasis  scalp,  6 

hydrocephalus,  46 

hypophyscctomy,  56 
Cystectomy,  689 
Cystic  goitre,  266 

kidney,  6O0 

lymphangioma,  215 
Cysticotomy,  575 
Cystotomy,  681 

infrapubic,  712 

perineal,  704 
Cysts,  bone,  958 

cerebellar,  31 

dentigerous,  108 

dermoid  abdomen,  536 

echinococcic  abdomen,  589 
lung,  326,  329 

kidney,  654 

pancreas,  535,  537   > 

retroperitoneal,  535 

sebaceous,  i 

thyroglossal,  216 
Czerny,  cesophagectomy,  228 

Da  Costa,  motor  centers,  20 

prostatotomy,  702 
Dakin's  solution,  1269 

empyema,  299,  300 
Dahlgren,  intestinal  obstruction,  444 
Dandy,  hydrocephalus,  43 
Dangers,  cerebral  operation,  24 

duodenal  exclusion,  375 

Eck's  fistula,  530 

internal  urethrotomy,  716 

ligation  common  carotid,  839 

opening  skull  with  chisel,  9 

operations  on  neck,  209 

silk  sutures  stomach,  375 

sympathectomy,  219 

thoracic  wounds,  286 
Daufresne,  Dakin's  solution,  1269 
Davidson,     J.     McK.,     localization     foreign 

bodies,  1271,  1272 
Davies,  h5rper-pressure  apparatus,  290 
Davies,  Morriston,  artificial  pneumothorax, 
312 
thoracentesis,  296 
Davis,  G.  G.,  arthroplasty,  1054 

congenital  dislocation  hip,  1017,  1022 

e version  leg,  1220 

incision,  465 
Davis,  Staige,  transplantation  epiphysis,  914 
Davison,  C,  bone  transplantation,  913 
Davison's  suture,  349 
Dawbarn,  appendix  stump,  471 

operation  Colles's  fracture,  918 
Deaver,  pancreatitis,  545 
Debridement,  chest  wounds,  293 

fractures,  889 

joints,  1030 
Decalcified  bone  chips,  914 

drains,  1258 
Decapsulation  kidney,  635,  651,  659 
Decompression,  cerebral,  19,  24 
Decortication  lung,  302,  307 
Defects  bladder  repair,  699 

dura,  17 


Defects,  meninges,  51 

skull,  10 
Deformities,  cheek,  109 

face,  1244 

fractures,  915 

hip,  990 

nose,  184 
DeFrancesco,  amputation,  1166 
Deguise,  salivary  fistula,  177 
Dehelly,  arthroplasty,  996 
Delageniere,  operation  chest,  325 
Delbet,  exploration  pelvis  kidney,  647 

intestinal  obstruction,  443 

pelvis  kidney,  842 

pyelotomy,  653 

varicose  veins,  866 
Delmar,  exposure  vessels,  834 
Delorme,  cardiolysis,  337 

empyema,  302,  307,  308 
Deltoid  paralysis,  801,  1078 
Demarcation,  line  of,  1144 
DeMartel,  fracture  skull,  20 
Denker,  tumors  nose,  181 
Dennis,  facial  palsy,  793 
Dental  n.  inf.  neurectomy,  70 
Dentigerous  cysts,  108,  958 
Depage,  bone  fixation,  898 

hepatopexy,  555 
Depressed  fracture  skull,  17 
deQuervain,  cesophagectomy,  227 

operations  on  thyroid,  254 
Derge  nephrotomy,  649 
Dermoids  abdomen,  536 
Deruginsky,  sarcoma  pleura,  325 
Desjardirs,  excision  head  pancreas,  542 
Desmarest,  colectomy,  429 
Dessane's  bonnet,  1276 
DeSouza  sympathectomy,  220 
DeVilbiss'  forceps,  10 
Diagnosis,  congenital  dislocation  hip,  loii 
Diakanow,  anchylosis  elbow,  11 19 
Diaphragmatic  hernia,  625 
Didot,  webbed  fingers,  11 28 
Diefi'enbach,  excision  lip,  127 

resection  tongue,  160 

rhinoplasty,  185 
Differential  pressure  cabinet,  290 
Dilatation,  congenital,  of  colon,  439 

oesophageal  stricture,  226 
Dilated  stomach,  gastroplication,  361 
Disarticulations,  1143 

knee,  11 80 
Discission  lung,  302 
Disease,  Addison's,  553 

Banti's,  549-552 

Hirschsprung's,  439 

infective  middle  ear,  34 

Little's,  771,  773,  1223 

Milroy's,  875 

Pott's,  779 

sacroiliac,  977 
Disinfection  pleura,  299,  305 

wounds,  1268 
Dislocation  astragalus,  1067 

clavicle,  1084 

congenital  hip,  1009 
knee,  1045 

elbow,  1 115 

metacarpo-phalanges,  11 27 

old  hip,  IOCS 


1286 


INDEX 


Dislocation,  patella,  1057 

shoulder,  1092 

subastraRalus,  loOS 

ulnar  nerve,  80,^ 
Displacement  tendon  peronous  lonj^us.  i  200 
Diverticula  bladder,  712 

oesophagus,  225 
Diverticulitis,  438 
Division  posterior  nerve  roots,  768 
Dix's  operation  aneurysm,  826 
Doberauer  arteriotomy,  821 
Dobson,  lymphatics  ca;cum,  476 
Dodge,  W.  T.,  empyema,  294,  299 
DoUinger,  dislocation  shoulder,  1095 

operation  chest,  325 

tuberculous  adenitis,  212 
Donoghue,  retro-peritoneal  cysts,  535 
Dorrance,  arterial  suture,  816 

clamps,  813 
Douay,  emphysema,  322 
Dowd,  operation  lip,  118 

retroperitoneal  cysts,  535 
DowneS,  pyloric  stenosis,  377 
Doyen,  perforator,  9 

pyloric  exclusion,  373 
Drainage,  abscess,  acute,  1259 
appendix,  473 
breast,  271 
cerebral,  37 
ischio-rectal,  524 
liver,  560 
lung,  326 

retropharyngeal.  222 
subphrenic,  562 

ankle,  1061 

antrum  Highmore,  82 

ascites,  530 

bladder,  683 
perineal,  705 

common  bile  duct,  578 

cyst  pancreas,  542 

cystic  duct,  575 

elbow,  1 108 

empyema,  297,  302 

frontal  sinus,  57 

gall  bladder,  567 

hepatic  duct,  581 

hip,  981 

hydrocephalus,  43 

infections  hand,  1137 

ischio-rectal  abscess.  524 

kidne)-,  650 

knee,  1025,  1030 

liver  abscess,  560 

meningitis,  758 

methods  of,  1256 

osteomyelitis,  944 

pericardium,  334 

peritonitis,  475 

permanent,  ascites,  530 

pulmonary  abscess,  326 

retropharyngeal  abscess,  222 

shoulder,  1084 

subphrenic  abscess,  5O2 
Dressing,  congenital  dislocation  hip,  1018 

laparotomy,  349 

skin  grafts,  1255 

wounds,  1269 
Drill,  Hudson's,  9 
"Drip"  Murphy,  476 


Duchenne-Krb  paralysis,  795 
Ducroquet  talipes  cavus,  1235 
Duct,  common  bile,  576 

cystic,  575 

hepatic,  581 

thoracic,  210 
Dudley  dislocation  shoulder,  1098 
Dufour  pleurisy  blocqu6es,  296 
Dufourmentel  plastic  operation,  1248 
Dujarier,  bone  staples,  898 

femoral  hernia,  598 
Dunet,  empyema,  305 
Dunn,  Sherwood,  gastrectomy,  404 

exploration  stomach,  356 
Duodeno-jejunal  junction,  locating,  366 
recess  hernia,  622 

jejunostomy,  410 
Duodenum,  exclusion  of,  375 

fistula  of,  410 

mobilization  of,  382 

perforation  of,  409 

ulcer  of,  363 
Duplay,  hypospadias,  727,  729 
Dupuytren  contracture,  1238 

fsecal  fistula,  461 

suture,  354 
Dura  mater,  injuries,  17 
Durante,  laminectomy,  763 
Duret,  gastropexy,  361 

plastic  anal  sphincter,  484 
Duval,  csecopexy,  437 

cardiotomy,  333 

mesosigmoiditis,  451 

mobilization  joints,  924 

operations  thorax,  287 

pericardiotomy,  335 

rectopexy,  487 

serratus  paralysis,  1075 

vasectomy,  745 

wounds  joints,  1030 
Dwight,  bunion,  1070 

Ear,  middle,  infections,  34 

plastic  operation,  76 
Echinococcic  cysts,  abdomen,  589 
kidney,  654 
lung,  326,  329 
Eck's  fistula,  530 
Ectropion,  Esser's  operation.  1254 
Ectopia  Vesicae,  673 
Edebohls',  air  cushion,  629 

decapsulation  kidney,  635,  651,  659 
Efi^ects  sympathectomy,  219 
Egg  membrane  after  trephining,  11 
Ehrenfried,  intratracheal  insufflation,  28J 
Ehrhardt,  thymectomj^  269 
Eiselsberg,  angioma  scalp,  3 

cranial  defects,  12 

osteoplasty,  957 

pyloric  exclusion,  373 

serratus  paralysis,  1075 
Eisenstacdt,  prognathism,  103 
Elastic  ligature,  416 
Elbow,  1 108 

anchylosis,  11 17 

disarticulation,  11 56 

dislocation,  11 15 

fractures,  935 

joint  transplantation,  11 20 

Jones'  position,  935 


INDEX 


1287 


Elephantiasis,  875 

Eliot,  Ellsworth,  intussusception,  449 

preliminary  treatment  aneurysm,  826 
Elliott,  C.  C,  dislocation  elbow,  11 17 
f1         metacarpophalangeal,  1127 
Elmslie,  R.  C,  cysts  bone,  958 
Eloesser,  suture  femoral  vein,  857 
Elsberg,  catgut,  1265 

operation  thorax,  288-301 

osteomyelitis,  948 

pneumothorax,  287 
Elting  anal  fistula,  525 
Embolism,  air,  210 
Empyema  antrum  Highmore,  82 

frontal  sinus,  57 

thoracis,  294 
double,  310 
Emphysema,  fracture  ribs,  294 

pulmonary  operation,  320 
Encephalocele,  42 
Enderlen,  excision  aneurysm,  827 

thymectomy,  269 
Endlich,  dislocation  hip,  1007 
Endo-aneurj^smorrhaphy,  827 
Enlarged  prostate,  703 
Enterectomy,  424 

in  hernia,  593 

for  tuberculosis,  481 
Enterorrhaphy,  417 
Enterostomy,  452 
Enterotomy,  411 
Enucleation  goitre,  265 

tumors  parotid,  174 
Epididymectomy,  742,  746 
Epididymitis,  treatment,  747 
Epididymotomy,  747 
Epilepsy  after  fracture  skull,  17 

Beck,  Carl,  50 

operations  for,  48 

prevention,  10,  51 
Epiphysis  femur,  fracture,  923 

transplantation,  914 
Epiplopexy,  528 
Epispadias,  723 
Epithelioma,  face,  1262 

larynx,  233 

lip,  "S 

nose,  183 

scalp,  s 
Eppinger,  pernicious  anaemia,  549 
Erb,  paralysis,  795 
Eremitsch  pharyngotomy,  231 
Esmarch,  excision  shoulder,  1091 

fissure,  Sylvius,  22 

indications  amputation,  1143 
Esser,  skin  graft,  1254 
Estes,  amputations,  11 45 

disarticulation  elbow,  11 57 
Estimation  volume  blood   and   hemoglobin 

content,  858 
Estlander,  excision  lip,  127 

operation  chest,  306 
Ether,  appendicitis,  477 
Etiology  congenital  dislocation  hip,  1009 
Examination  interior  stomach,  356 
Excision  acetabulum,  976 

aneurysm,  826 

angioma  scalp,  4 

ankle,  1062 

ascending  colon,  425 


Excision,  astragalus,  1067 
bladder,  700 
caecum,  425 
cancer  breast,  273 

nose,  183 
cardiac  end  stomach,  409 
carpus,  1 1 23 
cervical  glands,  209 

rib,  208 

sympathetic,  217 

tumors,  209 
cheek,  109 
clavicle,  1082 

congenital  fistula  neck,  215 
cystic  pancreas,  541 
descending  colon,  429 
elbow,  1 108 
exostosis  OS  calsis,  1069 
fascia  palmar,  1239 
fistula,  526 

foreign  body  heart,  333 
mediastinum,  340 
oesophagus,  224 
gall  bladder,  571 
Gasserian  ganglion,  71 
gastric  ulcer,  383,  386,  388 
glands  neck,  209 
head  pancreas,  502 

scalp,  1 09 1 
hip,  983 
hydrocele,  752 
intussusception,  447 
knee,  1039 
lingual  thyroid,  216 
loose  bodies  joint,  1031 
lower  lip,  115 
melanoma,  1262 
nasopharyngeal,  tumors,  91 
nevus  scalp,  i 
odontoma,  108 
oesophagus,  227 
parotid,  174,  175 
patella,  1046 
pelvis,  975 
piles,  519 
pylorus,  395 
rectal  stricture,  489 
rectum,  489 

retroperitoneal  tumors,  534 
retropharyngeal  tumors,  222 
rodent  ulcer,  89 
sacro-iliac  joint,  977 
scapula,  1078 
semilunar  cartilage,  1033 
shoulder,  1085 
small  intestine,  424 
stomach,  385 
stricture  urethra,  719 
symphysis  pubis,  976 
thymus,  268 
tongue,  158 
tumors,  1 261 

bladder,  685,  689,  699 

bone,  958 

brain,  20 

breast,  272 

chest  wall,  324 

larynx,  233 

liver,  555 

nose,  181 


1288 


INDEX 


Excision,  tumors,  oesophagus,  227 
parotid,  173 

upper  jaw,  85 

urinary  bladder,  689 

varicose  veins,  867,  869 

wens,  I 

wrist,  1 1 22 

X-ray  burns,  1255 
Exclusion  duodenum,  375 

intestinal,  439 

pylorus,  372 
Exopexy,  thymus,  268 
Exopthalmic  goiter,  249 
Exophthalmos    pulsating,    ligature    vessels, 
840 

sympathectomy,  221 
Exostoses,  OS  calcis,  1069 
Exploration,  bile  passages,  566 

empyema,  294 

kidney,  636,  645 

knee,  1029 

Stomach,  355 
Exploratory  craniotomy,  23 

thoracotomy,  296 
Exposure  cerebellum,  28 

hip  and  pelvis,  987 

ureter,  665 
Exstrophy  bladder,  673 
Extension  calipers,  892 

direct  fracture,  117 

in  pseudarthrcsis,  893 
External  haemorrhoids,  519 

urethrotomy,  717 
Extraction  foreign  bodies  oesophageal,  224 
Evans,  parathjToids,  248,  266 
Eve,  Sir  F.,  gastropexy,  362 
Evisceration  congenital,  621 
Eyelids,  solid  oedema,  875 

Fabrique's  suture,  472 
Face  angioma,  133 

deformities,  1244 
Facial  nerve,  ear  diseases,  35 
operations,  parotid,  174 
repair,  789 
tic,  804 
neuralgia,  59 
paralysis,  790 
spasm,  injections,  63 
Fascal  fistula,  closure,  461 
Farabeuf,  Axillary  artery  ligation,  847 

disarticulation  elbow,  1157 
Fascia,  'Cerclage'  aortic  aneurysm,  832 
implants  hernia,  614 
liver,  558 
meninges,  13,  51 
patch  on  artery,  820 
Fasciotomy  plantar,  1223 
Fat,  extrapleural  implant,  319 
Faure  facial  paralysis,  790 
Fedoroff,  pharyngectomy,  231 
Feeding  after  stomach  operation,  356,  370, 

407  , 
Feiss,  deformity.  Pott's  fracture,  920 
Felons  fingers,  1132 
Femoral  artery,  853 
hernia,  590,  596 
Femur,  fracture,  891,  920 
condyles,  924 
neck  osteotomy,  968,  990 


Fenger,  hydronephrosis,  664 

meningocele  cranial,  43 
Fenwick,  Hurry,  Lithotomy,  685 

Geo.,  facial  palsy,  795 

S.,  colectomy,  432 
Ferguson,  A.  H.,  decapsulation  kidney,  659 

excision  superior  maxilla,  86 

hernia,  608 

hydrocephalus,  46 
Ferranini,     anastomosis,     salivary    glands, 

180 
Fever  urethral,  717 
Fiaschi,  sliding  hernia,  595 
Fick,  relative  strength  muscle,  1211 
Field,  rhinophyma,  182 
Finger,     amputation     and     disarticulation, 
1152 

claw,  1219 

infections,  113  2 

snapping,  11 28 

tendons,  11 28 

tendon  implant,  1216 

transplantation  rhinoplasty,  191 

webbed,  1127 
Finney,  Hirschsprung's  disease,  439 

pyloroplasty,  381 

rhinoplasty,  199 
Finsterer,  epilepsy,  51 

volvulus,  451 
Finton,  omental  grafts,  452 
Fiotte,  exposure  vessels,  834,  854 
Fischer,  injections  tic,  63 
Fissure  fracture  skull,  18 

Rolando,  21 

Sylvius,  22 
Fistula  anal,  523 

bone,  941 

cervical,  215 

duodenal,  410 

Eck's,  530 

faecal  closure,  461 

oesophago-bronchial,  224 

pancreatic,  542 

pleuro-pulmonary,  306 

saliv^ary,  177 

thoracic  duct,  210 
Fitzmaurice- Kelly,  amputations,  1144 
Fixation  fractures,  880,  890,  897 
Flail,  elbow,  11 14 

shoulder,  802,  1099 
Flaps,  amputation,  length  of,  1147 

autogenous  and  heterogenous,  1251 

tubed  pedicle,  1244 
Flat  foot,  1 1 89 

paralytic,  1192 
Floating  kidney,  633 

liver,  553 

spleen,  547 
Fluoroscopy,  foreign  bodies,  1272 

operative,  1276 
Flushing  rectum,  490 
Foderl,  laryngectomy,  237 
Foerster's  operation,  768 
Foot,  amputation,  1169 

club,  1226 

flat,  1 189 

hollow,  1235 
Forceps,  DeVilbiss,  10 

holding  bones,  880 

Keen's,  8 


INDEX 


1289 


Foreign  bodies,  locating,  1271 
in  chest,  291 
in  heart,  33s 
in  mediastinum,  340 
in  oisopliagus,  224 
in  trachea,  243 
Forlanini,  artificial  pneumothorax,  311 
Foramen  Morgagni  hernia,  625 

Winslow  hernia,  622 
Formalin,  catgut,  1268 

glycerine,  1024 

injections  abscess,  1260 

injections  angioma,  133 
Fossa,  duodeno  jejunal,  623 

pericaecal,  623 
Fowler,  empyema,  302,  307 

position,  476 

vicious  circle,  372 
Fracture,  astragalus,  1067 

CoIIes,  918 

compound,  889 

condyles  femur,  924 

direct  extension  in,  917 

dislocation  hip,  1008 
shoulder,  1094 

elbow,  935 

femur,  920 

humerus,  934 

internal  splint  and  wiring,  880,  897,  902 

knee,  1030 

lower  epiphysis  femur,  918,  923 
jaw,  96 

malunion,  915 

olecranon,  938 

OS  calcis,  933 

patella,  925 

Pott's  malunion,  920 

rib,  pneumothorax,  293 

simple,  877 

skull,  17 

special,  920 

spine,  765 

tibial  spine,  1037 

treatment  fragments  bone,  889 

tubercle  tibia,  932 

ulna,  940 

ununited,  893 
Frangenheim,  oesophagoplasty,  229 
Frank,  gastrostomy,  358 
Frank,  operation  varicocele,  754 

tracheotomy,  240 
Franke,  disarticulation  hip,  118S 

operation  orbit,  84 
Frazier,  C.  H.,  facial  palsy,  790 

Gasserian  ganglion,  72 

laminectomy,  760 

operation  pituitary,  54 

skull  defects,  13 

spasticity,  768 
Fredet  operation  pyloric  stenosis,  377 
Freeman,  apparatus  fractures,  880,  902 

hemostasis  liver,  558 
skull,  8 

thyroidectomy,  265 

semilunar  cartilage,  1033 

Treitz  hernia,  623 
Freezing  angioma,  4,  133 
French  method  rhinoplasty,  191 
Freudenthal,  Killian's  operation,  58 
Freund,  emphysema,  320 


Freyer  prostatectomy,  687 

Frick,  \\  .  J.,  crucial  ligament,  1036 

Matas'  operation,  831 
Friedel  varicose  veins,  871 
Friedrich,  antrum  Ilighmore,  83 

epilepsy,  48 

cesophagotomy,  224 

pneumolysis,  314 
Frommcr  amputation,  11 77 
Frontal  sinus,  57 
Fuller,  vesiculotomy,  713 

Gade  tumor  pancreas,  542 

Gag,  Whitehead's,  161 

Gall  bladder,  operations  on,  563 

stones,  568 
Gait  trephine,  7 

Galvano-caustic  prostatotomy,  702 
Ganglion,  Gasserian  excision,  71 

injections,  64 
Gangrene  after  ligation  artery,  832 

arterio-sclerotic,  821 

foot,  venous  ligation,  832 

gut,  4SI 

hernia,  592 

indications  amputation,  11 43 

lung,  326 
Gant's  osteotomy,  998 
Gant,  S.,  clamp,  520 
Gardner,  wry  neck,  205 
Garr6,  resection  liver,  559 

thymus  gland,  268 
Gascard,  nerve  injection,  61 
Gaseous  disinfection  pleura,  305 
Gask,  wounds  chest,  291 
Gasserian  ganglion  excision,  71 

injections,  64 
Gastrectomy,  385 

cancer,  results,  408 

complete,  408 
Gastric  lavage,  350 

ulcer,  363,  383,  396  et  seq. 

volvulus,  450 
Gastro-enterostomy,  364  et  seq.  _ 

in  congenital  pyloric  stenosis,  377 
Gastro-gastrostomy,  377 
Gastrolysis,  364 
Gastropexy,  361 
Gastroplication,  361 
Gastrostomy,  357 

foreign  bodies  in  oesophagus,  224 
Gavello,  lobule  ear,  77 
Gehle,  oesophagus,  diverticulum,  226 
Gely's  suture,  355 
Genu  recurvatum,  1057 

valgum,  968 

varum,  972 
Gerster,  J.,  splenectomy,  551 

turnbuckels,  880 
Gibbon,  J.  H.,  amputations,  1145 

ureterotomy,  665 
Gibson,  C.  L.,  Colectomy,  437 
Gigli  saw,  9,  965 

Gill,  Bruce,  Dupuytren's  contracture,  1240 
Gillies  plastic  surgery,  112,  1242  et  seq. 
Giordano,  injuries  vagus,  214 
Giraldes,  hare-lip,  138 
Girard,  mastopexy,  272 

oesophagus  diverticula,  226 
Glands,  cervical,  209 


1 290 


INDEX 


Glands,  lymph  caecum,  426 
larynx,  233 
lower  lip,  116 
melanoma,  1262 
neck,  212 
nose,  183 
penis,  734 
scalp,  5 
stomach,  389 
testicles,  739 
tongue,  r68 
upper  lip,  129 
parathjToid,  248 
parotid,  173 
thymus,  268 
thyroid,  246 
Glaucoma,  sympathectomy,  220 
Gleich,  flat  foot,  11 89 
GlUck,  bronchiectasis,  326 
bronchotoray,  246 
cesophagostomy,  227,  228 
pneumectomy,  329 
thoracoplasty,  310 
Gluteal  aneurysm,  829 
Godlee,  anal  fistula,  523 
Goitre,  247 

sympathectomy,  221 
Goldthwaite,  dislocation  patella.  1059 
Gonorrheal  arthritis,  1142 
Gorget  Teales,  705 
Gosset  nerve  suture,  783 
Gouges,  962 
Gould,  amputation  penis,  733 

mattress  suture,  472 
Goulliond,  ileo-caecal  tube.  481 
Grafts,  fascial,  13 
omental,  452 
skin,  1244,  1251 

ectropion,  1254 
Thiersch,  1252 
Wolf,  1244,  1 25 1 
Grant,  excision  lip,  119 
Graser,  diverticular  bladder,  712 
Graves  disease,  249 
thjTnus,  268 
sympathectomy,  220 
(iray,  Geo.,  prostatectomy,  707 
wounds  hand,  1137 
Sir  H.  M.  W.,  bullet  in  heart,  333 
incision  gall  bladder,  566 
Gregoire,  arterio-venous  aneurysm,  834 
nephrectomy,  655 
teratoma  testis,  740 
Grid-iron  incision,  464 
Griffe  cubitale,  12 19 
Grifl&th,  J.  D.,  palmar  fascia,  1239 
Gritti,  amputation,  1181 
Groups  blood,  860 
Griinbaum,  motor  centers,  20 
Grunert,  dislocation  clavicle,  10S4 
Grunwald,  pharyngotomy,  231 
Guib6  Eck's  fistula,  530 
Guillot,  arthroplasty,  996 
Guillotine  amputations,  1144 
Gum  acacia  infusions,  858 
Gunn,  Moses,  waxed  thread,  1264 
Gunn,  operations  parotid,  174 

Haberer,  th>Tnectomy,  268 
Habitual  dislocation  shoulder,  iioo 


Hacker,  tendon  implant  finger,  1216 
Hadra,  tumor  adrenal,  553 
Ha;berlin,  granulating  wounds,  1254 
Haecker,  oesophagoplasty,  228 
Haemolytic  jaundice,  549 
Hemorrhage,  nephrotomy,  654 
Haemorrhoids,  519 
Hasmothorax,  292 
Haffter's  amputation,  1178 
Hagedorn,  hare-lip,  140 
Hagon,  e.xposure  pancreas,  539 
Hahn's  cannula,  242 

pylorodiosis,  3S0 
Hallux  rigidus,  1074 

valgus,  1070 
Hall  well  and  Lambert  arterial  suture,  812 
Halstead,  A.  E.,  oesophagus  diverticulum,  226 

pituitary,  54 
Halstead,  excision  breast,  274 

hernia,  610 

parathyroid,  248 

suture,  354 

thyroidectomy,  260 

transplantation  parathyroids,  267 
Hammer  toe,  1074 

Hammestahr,  gastroenterostomy,  370 
Hanche  a  ressort,  979 
Hancock,  duodeno  choledochotomy,  582 
Hanel,  epilepsy,  51 
Hand,  amputation,  1155 

infections,  113  2 
Handley,  ascites,  531 

cancer  breast,  283 
face,  1262 
rectum,  501 

excision,  518 

fracture  elbow,  937 
femur,  924 

ileus  duplex,  445 

l>Tnphangioplasty,  873 

melanoma,  1262 

tongue,  158 
Hannequin,  osteotomy,  998 
Hansemann,  Freund's  operation,  320 
Hardie's  operation  Dupuytren's  contracture, 
1239 
*  Hare-lip,  134 
Harrington,  cystectomy,  690 

incision,  465 
Harris,  Erb  paralysis.  795,  799 

injection  Gasserian  ganglion,  64 
Harris,  M.  L.,  dislocation  hip,  1007 

ptosis  kidney,  638 
Harrison,  nephrotomy,  659 

thoracic  duct,  211 
Harsha,  prognathism,  103 
Harte,  injuries  spine,  767 

spinal  tumors,  764 
Hartel,  injection  Gasserian  ganglion,  65 
Hartley  Krause  operation,  71 
Hartmann  gastrostomy,  357 

ligation  splenic  articulation,  552 

nephrectomy,  657 

urethrectomy,  719 
Hart's  anomaly  of  thoracic  aperture,  522 
Harvie  complete  gastrectomy,  409 
Hasslauer,  mastoiditis,  42 
Hawley  table,  1023 
Hay  am,  aerophagy,  70 
Haynes,  hernia,  621 


INDEX 


I  21)1 


Head  and  neck,  i 

I  learn,  excision  superior  maxilla,  86 

ligation  external  carotid,  842 
Heart,  operations  on,  330 

wounds,  293 
Heile,  hydrocephalus,  46 
Heineke-Mikulicz  operation,  380 
Heineke,  nerve  implantation  muscle,  789 
Heitz-Hovelacque  operation,  679 
Helferich,  adrenalectomy,  553 

anchylosis  jaw,  103 
knee,  1050 
Hellin,  double  empyema,  311 
Hematemesis  after  operation  ulcer  stomach 

and  duodenum,  385 
Hematoma  auris,  82 
Hemoglobin  blood,  determination,  858 
Hemolysis,  blood  transfusion,  860 
Hemorrhage,  internal  urethrotomy,  716 

meningeal  artery,  15 
Hemorrhagic  pach>Tneningitis,  52 
Hemostasis  amputation  hip,  1182 

arterial  suture,  812 

operations  liver,  556 

scalp,  7,  25,  28 

shoulder  amputation,  11 57 

skull,  7,  14 

thyroidectomy,  265 
Hemp  waxed,  1264 
Henschen  ascites,  531 

operation,  322 

pneumolysis,  318 
Hepatectomy,  555 
Hepatic  abscess,  560 
Hepaticus  drainage,  581 
Hepato-cholangio-enterostomy,  582 
Hepatopexy,  554 
Hepatoptosis,  553 
Hepatotomy,  560 
Hernia,  590 

bladder  in,  591 

diaphragmatic,  625 

foramen  of  Winslow,  622 

internal,  622 

irreducible,  591 

large,  615,  624 

obturator,  616 

parasternal,  625 

plastic  implantations,  614 

retroperitoneal,  622 

sac,  591,  592,  604,  611 

sliding,  594 

strangulated,  591 

Treitz,  623 

umbilical,  616 
Herniotomy,  590 
Herrick's  clamp,  813 

ureterotomy,  667 
Herten,  sarcoma  bone,  959 
Hertle,  fiat  foot,  1191 
Hey  amputation,  11 70 

internal  derangement  knee,  1033 
Hey-Groves,  fractures,  904 
Heusner  prostatotomy,  713 
Hibbs,  congenital  dislocation  hip,  1017 

operation,  779 
Hildebrand,  dislocation  patella,  1058 

excision  aneurysm,  827 

obstetric  palsy,  800 

tumors  bone,  959 


Hill,  L.,  hydrocephalus,  43 

Hilton,  pelvic  belt,  977 

Hinman,  teratoma  testis,  740 

Hirsch-Bunge,  amputation,  1148 

Hip,  amputation  or  disarticulation,  1 1.S2 

anchylosis,  990 

arthrectomy,  983 

arthritis  deformans,  989 

arthrotomy,  981 

congenital  dislocation,  1009 

dislocations,  1005 

injections,  980 

joint,  979 

snapping,  979 
Hirschsprung's  disease,  439 
Hodgen's  splint  fracture,  890,  891 
Hoffa,  congenital  dislocation  hip,  1015,  1017, 

I02I 

obstetric  palsy,  802 
Hofman,  spasticity,  771 

temporary  resection  palate,  92 
Hollow  foot,  1235 
Hook,  McBurney's,  1094 
Hopkin's  operation,  hernia,  610 
Horse-hair,  1265 
Horse-shoe  fistula,  523,  524 
Horse-shoe  kidney,  660 
Horsley,  Sir  Victor,  Center,  thermotaxic,  24 
cranial  meningocele,  42 
decompression  brain,  24 
sigmoid  sinus  thrombosis,  38 
wax,  7 

Shelton,  nerve  suture,  789 
plastic  cheek,  no 
Horwitz,  epididymectomy,  747 
Hotchkiss  cancer  cheek,  114 
Hour  glass  stomach,  376 
Hubbard,  arterio-venous  anastomosis,  821 
Huber,  pernicious  anaemia,  549 
Hiibscher  congenital  dislocation  knee,  1045 
Hudson's  drill,  9 
Hueter,  bunion,  1070 

rhinoplasty,  186 
Huguier,  anchylosis  elbow,  1118 
Hull,  hernia,  607 
Humerus  fractures,  934 

excision  head,  1085 

fracture  dislocation,  1094 

open  fracture,  888 
Hutchinson,  J.  Jr.,  amputation  shoulder,  1160 

Gasserian  ganglion,  75 
Hunkin  tendon  suture,  1196 
Hunter's  operation  aneurysm,  825 
Huntington,  bone  transplant,  909 

hip  disease,  986 
Hydatid  cysts,  abdomen,  589 
chest,  301 
lung,  329 
spleen,  548 
Hydrocele,  752 

after  hernia  operation,  606 

of  cord,  753 
neck,  215 
Hydrocephalus,  43 

ligature  common  carotid  for,  839 
Hydronephrosis,  640,  656,  662 
Hydrops,  articuli,  1140 

hip,  989 
Hj^peremia  hand,  113  7 

mastoiditis,  42 


1292 


INDEX 


Hj'perpercxia,  injury  thermotaxiccent.,  24 

injuries  ventricles,  24 
Hypernephroma,  654 

bone,  961 
Hyperthyroidism,  220,  249 
Hypertrophied  prostate,  703 

spleen,  548 
Hypoglosso-facial  anastomosis,  792 
Hypo-parathyroidism,  250 
Hypophysectomy,  52 
Hypopituitarism,  52 
Hypospadias,  727 
Hypothyroidism,  249 

lanni,  resection  nerve,  180 
Idiocy,  operations,  43 
Ileo-caecal  tub,  481 
Ileo-colic  and  ca:cal  fossae,  623 
Ileo-colostomy,  439 
Ileo-sigmoidostomy,  439 
Ileum,  in  repairing  bladder,  699 

tuberculosis  of,  481 
Ileus,  444 

duplex,  445 
Iliac  artery,  848 
Ilium,  diseases  of,  974 
Impacted  fracture  femur,  922 
Imperforate  anus,  482 
Implantation,  animal  membranes  joints,  1055 

bone  in  skull,  11 

nerve  into  muscle,  789 

tendons  into  bone,  1197 
Incision,  abdominal,  343 

angular  goiter,  263 

arthrectomy  knee,  1040 

arthrotomy,  1025 

breast,  281 

Codman's  sabre  cut,  1107 

Cripps,  455 

Davis,  46s 

elbow,  1 108 

excision  scapula,  1079 
superior  maxilla,  85 

exposing  gall  bladder,  563 

gridiron,  464 

hip,  Smith-Peterson,  1022 

Jackson,  breast,  281 

Kocher,  collar,  256 

Langenbeck,  hip,  983 

Larghi,  987 

McArthur,  464 

McBurney,  464 

operation,  kidney,  629 

Robson,  563 

Shaw,  465 

Sprengel,  exposing  pelvic  bones,  974 

Warren,  breast,  281 
Indian  method  rhinoplasty,  188 
Indications  amputation,  1143 

arthrotomy  knee,  1025 

callosal  puncture,  33 

cardiotomy,  ^^^ 

closure  defects  skull,  12 

colostomy,  453,  459 

cranial  meningocele,  42 

emphysema  pulmonary,  320,  322 

empyema  thoracic,  294 

enterectomy,  424 

excision  Gasserian  ganglion,  75 
scapula,  1078 


Indications,  exploration  stomach,  357 
fracture,  skull,  18 

intcrscapulo-thoracic  amputation,  1162 
ligation  common  carotid,  839 

external  carotid,  842 

internal  carotid,  843 

subclavian,  847 
lymphangiectomy,  874 
meningeal  hemorrhage,  15 
operation  appendicitis,  477 

biliary  passages,  586 

duodenal  ulcer,  363 

facial  palsy,  793 

fracture  patella,  932 

gastric  ulcer,  376 

Graves'  disease,  252 

infections  middle  ear,  34 

joints,  1 140 

knock-knee,  971 

meningitis,  757 

thyroid,  250 

tumors,  1261 

ulcer  stomach,  363 
spinal  injuries,  765 
splenectomy,  548 
transfusion,  858 
treatment  chest  wounds,  291 

empyema,  305 

tuberculosis  knee,  1044 
Infection  and  contamination,  1030 
Infections,  bone,  941 
costal  cartilage,  324 
cranial  contents,  34 
hand, 1132 
joints,  1 140 
middle  ear,  34 
spreading  of,  in  bone,  889 
Infective  phlebitis,  865 
Inferior  dental  nerve,  70 
maxillary  fracture,  96 

nerve,  61 

operation,  92 
thyroid  artery,  845 
Infra-orbital  nerve,  66 
Infra-pubic  prostatotomy,  712 
Infusion  blood,  858 
Inguinal  colostomy,  454 
eventration,  615 
hernia,  590,  603 
Injections,  alcoholic  nerves  amputation,  1145 
angioma,  133 
ankle,  1061 

boiling  water  goiter,  267 
elbow,  1 108 
formalin,  abscess,  1260 
Gasserian  ganglion,  64 
hip,  980 
hydrocele,  752 

neck,  215 
knee,  1024 
neuralgia,  59 
shoulder,  1084 
Injuries,  diaphragm.  625 
dura  mater,  17 
nerves,  781 
spleen,  548 
spine,  765 

supra-spinatus  tendon,  1107 
thoracic  duct,  210 
vagus.  214 


INDEX 


1293 


Intercolo-epiploic  gastrectomy,  404 
Intercricoid  larj'ngotomy,  232 
Interileo-abdominal  amputation,  1188 
Intermaxillary  bono  hare-lip,  142,  148 
Internal  carotid  artery,  843 

derangement  knee,  1033 

haemorrhoids,  519 

hernia,  622 

jugular  vein  ligation,  840 

urethrotomy,  715 
Intra-medullary  plates  or  tubes,  880,  900 
Interscapulo-thoracic  amputation,  11 62 
Intersigmoid  fossa,  624 
Intertrochanteric  osteotomy,  997 
Intra-cranial  neurectomy,  75 
Intraglandular  enucleation  goitre,  265 
Intranasal  growths,  181 
Intratracheal  insufflation,  287,  288 
Intestines  in  hernia,  594 

operations  on,  409 
Intestinal  anastomosis,  412 

clamps,  351 

exclusion,  439 

obstruction,  443 

stasis,  440 

suture,  352 

tuberculosis,  caecostomy,  460 
Intussusception,  446 
Iodine,  peritonitis,  477 
Iodoform  and  boric  acid  osteomyelitis,  946 
Iodoform  glycerine  solution,  1024 

injection,  hip,  980 

in  mastoid  operation,  36 
Irreducible  hernia,  591 
Ischio-rectal  abscess,  524 
Israel,  intussusception,  449 

nephrectomy,  655,  656 

nephropexy,  633 

plastic  cheek,  112 

rhinoplasty,  201 
Italian  method  rhinoplasty,  191 

Jaboulay's  amputation,  1188 

gastrostomy,  357 

hydrocele,  753 

incision,  346 
Jackson,  Chevalier,  bronchoscopy,  243 

thymectomy,  269 
Jackson,  J.  N.,  amputation  breast,  281 
Jacksonian  epilepsy,  49 
Jacobson,  disarticulation  shoulder,  1157 

excision  elbow,  mo 

injuries  spine,  766 

perotid  tumor,  175 
Jacobson  and  Rowland,  sacro-iliac  disease, 

977 
Jacoel's  staples,  880,  898 
Jaesche,  excision  lip,  127 
James,  A.  B..  epididymotomy,  747 
Jamison,  lymphatics  caecum,  426 
Janeway,  H.  H..  gastrostomy,  360 
Jaundice,  hemolytic,  549 
Jaw  and  chin  excision,  126 
Jaw,  lower  fractures,  96 

operation,  92 

repair,  1248 

undeveloped,  iC2 
Jaw,  upper  excision,  85 
Jeannel,  colopexotomy,  486 
varicose  veins,  871 


Jejunal  ulcer,  375 
Jejunostomy,  452 
Jenning's  splint,  793 
Jianu  facial  pais}',  794 

a'sophaiToplasty,  229 
Johnson,  appendicitis,  477 
Johnston,  B.  J.,  retroperitoneal  lipoma,  534 
Johnston,  G.  Ben.,  necrotomy,  956 
Joint,  ankle,  1061 

astragalo-navicular  dislocation,  1067 

elbow,  935-H08 

fracture  complicating,  892 

hip,  979 

indications  for  operation,  1140 

knee,  1024 

loose  bodies  in,  1031 

mobilization,  924 

sacro-iliac,  977 

shoulder,  1054 

transplantation,  1055 

transplantation  elbow,  11 20 

tuberculosis,  1141 

wounds,  1030 

wrist,  1 1 22 
Jonas,  adrenalectomy,  553 

dislocation,  shoulder,  1097 

operation,  club-foot,  1231 
Jones,  Sir  R  ,  club-foot  splints,  1229 

crucial  ligaments,  1037 

detached  cartilage  knee,  1033 

dislocation  shoulder,  iioi 

flail  elbow,  11 14 

fracture  femur,  891 

fractures,  895 

hammer  toe,  1074 

incision  knee,  1030 

Little's  disease,  773 

nerve  repair,  783 

operation  calcaneo-cavus,  1236 

osteotomy  hip,  1 000-1003 

position,  935 

remarks  club  foot,  1233 

saw,  965 

skin  flap  arthrodesis,  1210 

spasticity,  1223 

splint  ankle,  1063 

splint  elbow,  mi 

tendon  transplantation,  wrist  drop,  121 7 

transplant  tendo-achilles,  1229 
Jones,  W.  D.,  cholecystostomy,  569 
Jonnesco  duodeno-jejunal  fossae,  623 

facial  palsy,  794 

nephropexy,  635 

sympathectomy,  217 
Jordan,  F.,  amputation  hip,  1184 
amputation  shoulder,  1160 

empyema,  307 

ligation  common  carotid,  839 
Jugular  vein  ligation,  38 
Jurasz,  common  bile  duct,  577 

Kammerer's  incision,  346 
Kanavel  infections  hand,  1132 

pituitary,  54 
Karewsky,  fistula  pancreas.  542 
Katzenstein,  dislocation  astragalus,  1067 

flat-foot,  ii8g 

serratus  paralysis,  1076 
Kaufmann.  salivary  fistula,  177 
Keen,  epilepsy,  48 


J  294 


INDEX 


Keen,  forceps,  8,  lo 

Gasserian  ganglion,  71 

hydrocephalus,  46,  47 

laryngectomy,  236 

pigmented  moles,  1261 

wry  neck,  205 
Keetly,  fractures,  902 
Kehr,  hepatopexy,  554 

incision,  565 
Keller,  varicose  veins,  868 
Kelling,  cancer  oesophagus,  229 
Kelly,  umbilical  hernia,  618 

uretero-cystotomy,  672 
Kennedy,  R.,  wry  neck,  206 

facial  paralysis,  790 

obstetric  palsy,  796 
Key,  excision  aneurysm,  827 
Kidd,  ureterotomy,  667 
Kidney,  62g  et  seq. 

anatomj^,  640 

collateral  circulation,  659 

exploration,  636,  645 

horse-shoe,  660 

stone,  646,  651,  658 

tuberculosis,  658 

tumors,  654  el  scq 
Killian's  operation,  58 

tracheoscopy,  243 
Kirmission,  congenital  dislocation  hip,  1021 
Kirschner,  dislocation  shoulder,  iioi 

epilepsy,  51 

hernia,  614 
Klapp,  abscess  treatment,  1259 
Klose,  thymus,  252-268 
Knee,  1024 

amputations  near,  n8o 

anchylosis,  1049 

arthrectomy,  1039 

arthroplasty,  1052 

arthrotomy,  1025 

congenital  dislocation,  1045 

creaking,  1045 

crucial  ligaments,  1036 

disarticulation,  11 80 

excision,  1039 

injections,  1024 

internal  derangements,  1033 
Knight,  C.  P.,  epididymotomy,  747 
Knock  knee,  966,  968 
Knott,  Van  B.,  amputation  gangrene,  1144 

sarcoma  liver,  560 
Kocher,  amputation  breast,  275 

angular  incision  goitre,  263 

arthrotomy  hip,  983 

collar  incision,  256 

disarticulation  elbow,  1157 

epilepsy,  48 

excision  elbow,  iin 
hip,  986 
pelvis,  975 
shoulder,  1088 
tongue,  163,  164 

ligation  common  carotid.  836 
external  carotid,  842 
goitre,  250 

osteoplastic  resection  superior  maxilla,  91 

sutures,  1264 

tetany,  250 

wry  neck,  204,  207 
Kondoleon's  operation,  876 


Konig,  aiii])utaU()ii  foot,  ii6q 

ankle,  excision,  1063 

club-foot,  1232 

excision  hip,  983 

exstrophy,  675 

hare-lip,  138 

osteoplasty  skull,  11 

rhinoplasty,  200 

tracheal  cannula,  241 

tuberculosis  cpididymectomy,  746 
Konig,  Fritz,  arthrotomy  elbow,  11 13 

congenital  fistula  neck,  215 

excision  superior  maxilla,  88 

fractures,  879,  922 

incision,  566,  631 

retroperitoneal  tumor,  534 

rhinoplasty,  184 
Konitzer,  sarcoma  bone,  960 
Kopnew,  hemostasis  liver,  558 
Korte  closure  skull,  12 

exposure  pancreas,  539 
Kramer,  tumors  bone,  958 
Kraske,  excision  rectum,  491 

plastic  cheek,  112 
Krause,  angioma  scalp,  3 

brain  tumors,  20 

empyema,  307 

Gasserian  ganglion,  71 

injections  ankles,  1061 
hip,  980 

spinal  tumors,  764 
Krogius,  angioma,  2 
Kronlein,  gastrectomy,  400 

meningeal  vessels,  15 

operation  orbit,  84 
Krukenburg,  amputation  arm,  1168 
Kulenkamfl,  excision  pelvis,  976 
Kummel,  excision  rectum,  495 

obstruction  duodenal,  410 

operation  thyroid,  250 

resection  artery,  819 

spinal  meningitis,  757 
Kiister,  stricture  ureter,  663 
Kiittner,  sarcoma  bone,  960 

Labey,  arthrotomy  hip,  982 

tendon  transplantation,  1 2 1 5 
Labial  operations,  115 
Lacher,  wound,  dia:phragm,  626 
Lambert,  amputation  arm,  11 69 
Lambotte,  ascites,  531 

fractures,  903,  938 
Laminectomy,  759 
Lane,  Sir  A.,  cleft  palate,  146 

colectomy,  436 

fractures,  880 

ileo-colostomy,  439 

oesophagoplasty,  228 

plates,  902 
Lange,  obstetric  palsy,  796 

rectal  prolapse,  485 

silk  grafts,  1197 
Langenbeck,  anchylosis,  knee,  1040 

arthrectomy,  hip,  983 

arthrotomy,  982 

excision  ankle,  1062 
lip,  128 
tongue,  164 

rhinoplasty,  184,  185 

salivary  fistula,  177 


INDEX 


1295 


Langenbuch,  nephrectomy,  657 
Lannelongue,  sclerogenic  injections,  1025 
Lanphear,  hemostasis  scalp,  6 
Laparotomy,  343 

tuberculous  peritonitis,  480 
Lardennois,  casco-sigmoidostomy,  441 

complete  colectomy,  433 
Larghi,  excision  hip,  987 
La  Roque,  hernia,  607 
Laryngeal  nerve  suture,  789 
Laryngectomy,  233 
Laryngotomy,  232 

preliminary,  165 
Lavage  knee,  1024 
Lec^ne,  pericardiolysis,  338 

thoracic  duct,  210 
Le  Conte,  interscapulo-thoracic  amputation, 
1163 
osteomyelitis,  957 
peritonitis,  476 
Lee,  Roger,  I.,  blood  transfusion,  850 
Le  Fort,  amputation,  11 77 

anterior  mediastinum,  338,  340 

claw  fingers,  1220 

thoracotomy,  296 
Leg,  amputation,  1151,  1177 

eversion  of,  1220 
Lejars,  foreign  bodies  in  trachea,.  243 

rupture  urethra,  722 
Lembert  suture,  353 
Length,  flaps  amputation,  1147 
Lennander,  incision,  346 
Lenormant,  pernicious  anaemia,  549 

voh'ulus  stomach,  450 
Leriche,  nerve  resection,  180 

neurectomy,  70 

periarterial  sympathectomy,  220 
L6vy,  neuralgia,  59 

Lewis,  Dean,  amputation  neuroma,  preven- 
tion, 1 148 

transplantation,  trapezius,  1078 
Lewisohn,  transfusion  blood,  864 
Lexer,  arteriovenous  aneurysm,  833 

bone  transplantation,  912 

epilepsy,  52 

facial  palsy,  794 

joint  transplantation,  1055 

lateral  ligament,  knee,  1039 

rhinoplasty,  186,  196 

tendon  transplantation  finger,  11 30 
Liechtenstern,  renal  tuberculosis,  658 
Ligaments  crucial  knee,  1036 

lateral  knee,  1039 
Ligation,  arteries,  825,  834 

common  carotid,  214 

external  carotid,  75,  86,  91 

inferior  thyroid,  254 

internal  jugular,  38,  840 

piles,  520 

pulmonary  artery,  319 

renal  vessels,  657 

splenic  artery,  551,  552 

superior  pole  thyroid,  844 

varicose  veins,  866 

vessels,  angioma,  134 
goiter,  250 
Ligature,  elastic,  416 

gastro-enterostomy,  371 
Ligatures,  preparation  of,  1263 
LiUenthal,  appendicitis,  469 


Lilienthal,  arterial  suture,  812 

fractures,  890,  903 

operations  on  thorax,  287,  292,  302,  309 
Lindeman,  transfusion  blood,  862 
Line  demarcation,  gangrene,  11 44 
Linear  osteotomy,  966 
Linen,  waxed,  1264 
Lingual  artery  ligation,  843 

nerve,  division  of,  70 

thyroids,  216 
Lip,  IIS,  129 

Lipoma,  retroperitoneal,  534 
Lipotamponade,  319 
Liquid  air  angioma,  4 
Lisfranc's  amputation,  11 70 
Lister,  Lord,  fracture,  patella,  931 
Lithiasis,  urinary,  681 
Lithotomj',  651 

suprapubic,  684 
Little's  disease,  771,  773,  1223 
Littlewood,  colostomy,  458 
Liver,  553 

abscess,  560 
Llobet,  diaphragm,  hernia,  626 
Lloyd,  Jordan,  tourniquet,  11 83 
Lobectomy,  thyroid,  256 
Localization  by  X-ray,  1272 

cerebral,  20 

foreign  bodies,  Sutton,  1275 
1271 
Lockwood,  wounds  heart,  293 
Loiseleur,  pericarditis,  334 
Longitudinal  sinus,  17 
Loose  bodies  in  joints,  1031 
Lorenz,  club-foot,  1231 

congenital  dislocation,  hip,  loio,  1015, 
1016 
Loreta's  operation,  380 
Lotheisen,  Dupuytren's  contracture,  1240 
Lothrop,  CoUes's  fracture,  918 
Low,  V.  W.,  obstetrical  palsy,  795,  799 
Lower  jaw,  fractures,  96 
operations  on,  92 

lip,  115 
Lower,  prostatectomy,  688 
Lowman's  holding  forceps,  880 
Lucke,  neurectomy,  68 
Luckett,  plastic  operation,  ear,  81 
Lumbar  colostomy,  453 

puncture,  755 
fracture  skull,  19 
Lund,  congenital  cyst,  kidney,  660 
Lung  abscess,  326 

gangrene,  326 

tuberculosis,  311 

wounds,  286 
Luxation,  congenital,  hip,  1009 
Lymphangioma,  neck,  215 
Lymphangioplasty,  873 
Lymph  glands  neck,  212 
Lymphatic  obstruction,  873 
Lymphatics  of  caecum,  426 
larynx,  233 
lower  lip,  116 

in  melanoma,  1262 

of  nose,  183 

of  penis,  734 

of  scalp,  s 

of  stomach,  389 

of  testicle,  739 


1296 


INDEX 


Lymphatics  of  tongue,  i68 

of  upper  lip,  129 
Lynch,  operation,  pruritus,  522 

McArthur,  caccostomy  in  tuberculosis,  460 

choledoctotomy,  580 

drainage  tubes,  1257 

excision  shoulder,  1086 

gangrene  lung,  326 

incision,  344   464, 
gall  bladder,  563 

operation  pituitarj',  53 

prostatectomy,  687 

rectopexy,  486 

restoration  common  duct,  584 

waxed  thread,  1264 
McBunny,  duodeno-choledochotomy,  581 

fracture  dislocation  humerus,  1094 

incision,  344,  464 
McCormac  dislocation  ulnar  nerve,  803 
McCosh,  hernia,  619 

injuries  spine,  766 
McCrae,  congenital  cj-sts  kidney,  660 
McDill,  hemostasis  liver,  557 
McDonald  catgut,  1266 
McGavin  transversostomy,  459 
McGraw,  elastic  ligature,  375,  416 
McKillop,  prostatectomy,  711 
McWilliams,  C,  rhinoplasty,  193 
Maas,  hare-lip,  139 
Mabit,  echinococcic  cysts,  590 
Macdonal,  C.  G.,  catgut,  1266 
Macewen,  bone  repair  maxilla,  95 
transplant,  914 

compound  fractures,  889 

compression  aorta,  11 84 

decompression,  24 

defects  skull,  11-12 

drainage  tubes,  1258 

femoral  hernia,  596 

fracture  patella,  927 

infections  ear  and  brain,  34 

inguinal  hernia,  603 

osteotomy,  963,  964,  966,  968,  972 

treatment  aneur>sm,  831 

wounds  pleura,  286 
Mackenzie  fistula,  526 

intestinal  pain,  443 

paraffin  in  empyema,  296 
Mackinnon,  dislocation  shoulder,  noo 
Macnamara,  tuberculosis  hip,  986 
Macrotia,  76 

Madelung  large  hernia,  625 
Magnesium  prosthesis  arteries,  815 
Magnets,  foreign  bodies,  1272 
Magnuson,  ununited  fracture,  901 
Maisonneuve,  urethrotome,  715 
Maitland,  excision  tongue,  169 
Makins,  arterio  venous  aneurj-sm,  832 

sacro-iliac  disease,  977 

vohnjlus,  440 
Makkas'  exstrophy,  677 

pin.  6-14 
Malcolm,  cyst  pancreas,  539 
Malgaigne,  hare-lip,  135,  136 
Malignant  degeneration,  Wens,  i 

tumors  bone,  958 
scalp,  5 
Malleolus,  fracture  of,  933 
Mallets,  963 


Malum  coxae  senilis,  1003 
Malunion  fractures,  915 

jaw,  96 
Mammae,  operations  on,  271 
Mandible,  fractures,  96 
Mangold  rhinoplasty,  237 
Manon  snapping  hip,  980 
Marchant,  rectal  prolapse,  486 
Marfan,  pericardiocentesis,  334 
Marie  nerve  suture,  783 
Marion,  snapping  hip,  980 
Markoe,  obstetric  palsy,  795 
Marmourian  varicose  veins,  869 
Marshall  rhinoplasty,  203 
Marsupialization  goitre,  266 

pancreatic  cyst,  542 
Martel,  clamp,  399 

Erks  fistula,  530 
wrinkles,  1255 
Martin,  E.,  pseudarthrosis,  893 

resection  arter>',  820 
Martini,  decapsulation  kidney,  659 
Martin  and  Petrie,  spread  infection  bone,  8i 
Martinow,  horse-shoe  kidney,  660 
Marwedel  nephrotomy,  649 
Mastoid  antrum  infections,  34 
Mastoiditis  acute,  41 
Mastopexy,  272 
Mastoptosis,  272 
Matas'  artificial  respiration,  287 

cholecystotomy  in  nephritis,  581 

excision  superior  maxilla,  86 
Kondolions  operation,  876 

ligation  common  carotid,  839 
external  carotid,  842 

operation,  827 

transvenous  arteriorrhaphy,  832,  833 
Materials  for  sutures,  ligatures,  1263 
Matti's  operation,  216 
Mauclaire,  sclerogen,  injections,  1025 
Maunsell's  operation,  419 
Maurj-,  gastro-enterostomy,  371,  375 
Maxilla  inferior  bone  implantations,  95-97 
fractures,  96 
operations,  92 
Maxilla  superior  excision,  85 
Maxillary  inferior  ner\e  injections,  61 

neurectom}',  69 
^Maxillary  nerve,  superior  injections,  62 

neurectomy,  66 
Maxwell,  fracture  neck  femur,  922 
Maydl,  jejunostomy,  453 

operation,  677 
Mayo  Banti's  disease,  552 

bunion,  1072 

caecectomy,  428 

cholecystostomy,  569 

choledocotomy,  578 

cleft  palate,  156 

cystectomy,  690 

diverticulitis,  438 

epilepsy,  49 

excision  lip,  124 

excision  rectum,  495 

fractures,  890 

gastro-enterostomy,  370 

hare-lip,  135-136 

hypospadias,  729,  732 

incision  kidney  operation,  631 

Matas's  operation,  829 


INDEX 


1297 


Mayo  omentopexy,  529 

peptic  ulcer,  375 

pyloric  exclusion,  373 

restoration  common  duct,  583 

rules  for  treatment,  Grave's  disease,  252 

skin  grafts,  1  244 

statistics  goitre,  251 

statistics    hemorrhage    after    operation 
ulcer  stomach  and  duodenum,  385 
operation  cancer  stomach,  408 

suture  ureter,  663 

thyroidectomy,  259 

transgastric  resection  stomach,  389 

ulcer  stomach,  363 

umbilical  hernia,  617 

varicose  veins,  866,  867 
Meatotomy,  715 
Median  cervical  fistula,  216 
Mediastinum,  anterior,  338 

foreign  bodies,  340 

posterior,  341 
Megalocolon,  439 
Meige,  nerve  suture,  783 
Melanoma  skin,  1262 
Meltzer-Auer,  artificial  respiration,  operation 

thorax,  288 
Menciere,  serratus  paralysis,  1076 
Membrane,  Cargile's,  51 
Membranes,  Baer's,  implantation,  1055 
Meningeal  arterial  hemorrhage,  15 

defects,  51 
Meningitis,  middle  ear  disease,  35 

spinal,  757 
Meningocele.  774 

cranial,  42 
Meso-colon,  gastroenterostomy,  370 
Meso-sigmoiditis,  451 
Metacarpo-phalangeal  dislocations,  1127 
Metastasis,  sarcoma  bone,  960 
Metatarsal  osteotomy,  1070 
Metatarsalgia,  1074 
Meyer,  Willy,  amputation  breast,  276 

differential  pressure  cabinet,  290 

hemostasis,  liver,  556 

oesophagoplasty,  229 

pulmonary  artery,  319 
Mikulicz,  cardiospasm,  357 

hydrocephalus,  43 

peptic  ulcer,  375 

pyloroplasty,  380 

rectal  prolapse,  487 

repair  bladder,  700 

resection  goitre,  263 

surgery  pancreas,  540 

wry  neck,  204-205 
Miles,  excision  rectum,  <;o8 
Mills,  G.  P.,  nephropexy,  639 
Milton,  exposure  anterior  mediastinum,  338 
Milroy's  disease.  875 
Mintz,  operation  pericarditis,  336 
Mirault,  hare-lip,  136 
Mitchell-Hunner,  Stitch,  417 

oedema  eyelid,  875 
Mixter,  colostomy,  456 

congenital  eventration,  621 

oesophageal  diverticula,  225 
Mobilization,  duodenum,  382 

joints,  924 

purulent  arthritis,  1031 

wounds,  knee,  1030 
82 


Mocquot,  pelvis  kidney,  642 
Mohr-Freund's  operation,  320 
Moles,  operations,  1261 
Momburg,  compression,  aorta,  1184 

dislocation  ulnar  nerve,  803 
Monari,  ureteral  anastomosis,  670 
Monk's  plastic  cheek,  no 
Monod  and  Vanvert,  wry  neck,  207 
Moore,  J.  E.,  fracture,  neck  femur,  922 
Morestin,  abscess  breast,  271 

appendicitis,  477 

injections  angioma,  133 

wrinkles,  1255 
Morgagni  foramen  hernia,  625 
Morison,  R.,  arthritis  deformans,  1045 

empyema,  298 

excision  elbow,  11 12 
hip,  988 

hernia,  620 

incision,  566 

nephrotomy,  633 

operation  ascites,  528 

pericardiolys's.  338 
Morphine  after  abdominal  operation,  477 

chest  wounds,  291 
Morris  anatomy  ureter,  661 

Cargile  membrane,  51 

sarcoma  bone,  959 

ureterotomy,  665 
Moschcowitz,  costal  cartilage,  324 

empyema,  299-300 
Moseti's,  bone  plugs,  947 
Mosny,  pleurisy  Blocquees,  296 
Motor  centres,  20 
Mouth,  floor  excision,  172 
Moynihan,  gastrectomy,  405 

prostatectomy,  687 

ulcer  stomach,  363 
Mozkowicz,  amputation  gangrene,  1144 
Miihsam,  urethrectomy,  721 
MuUer,  arthritis  deformans,  1045 

bone  plasty,  908 

flat  foot,  1 191 

skull,  osteroplasty,  11 
Mummery,  anal  fistula,  523-525 

excision  rectum,  496 

faecal  fistula,  461-464 

rectopexy,  485 
Munro,  J.  C.,  Hemorrhagic  meningitis,  52 

spinal  tumors,  764 
Murphy,  J.  B.,  acute  abscess,  1260 

arterial  anastomosis,  816 

arterio-venous  anastomosis,  822 

arthroplasty,  992-1052 

artificial  pneumothorax,  311 

button,  415,  420,  574 

facial  paralysis,  790 

fracture  olecranon,  938 

injections,  knee,  1024 
tic,  59 

musculo  spinal  nerve,  806 

operation  anchylosis  jaw,  104 

proctoclysis.  476 

spinal  meningitis,  757 

spinal  injuries,  765 

syringomyelia,  767 

tuberculous  epididymus,  746 
patella,  1046 

ununited  fracture,  900 
Muscle  implantation,  hernia,  615 


1298 


INDEX 


Muscles,  paralysis.     See  individual  muscles, 
treatment,  1202 

relative  strength,  1211 

spasticity,  1223 

transplantation,  facial  palsy,  794 
obstetric  palsy,  800 
serratus  paralysis,  1076 
Musculo-spiral  nerve,  804 

paralysis,  121 7 
Myelocele,  774 
Myelocystocele,  774 
Myelogenous  sarcoma,  958 
Myers,  H.,  congenital  absence  tibia,  Q12 
Mynter,  obstruction  ureter,  663 
Myomectomy  wry  neck,  205 
Myositis  ossificans  traumatica,  112:^ 
Myotomy,  dislocation  shoulder,  1092 

spastic  paraplegia,  1223 

wry  neck,  204 
Myxoedema,  249 

treatment,  266 
Myxoma  bone,  960 

Nails,  bone,  880,  898,  900 
Narath,  hernia,  623 

omentopexy,  529 
Nash,  pancreatitis,  541 

Nasopharyngeal    exposure    by    osteoplastic 
operations,  91,  92 

neoplasms,  91 
Nassilov,  posterior  mediastinum,  341 
Nearthrosis,  claviculo  humeral,  1104 
Neck,  congenital  fistula,  215 

femur  osteotomy,  968,  990 

hydrocele  of,  215 

tumors  of,  209 

wry,  204 
Necrotomy,  948 
Negative  pressure  cabinet,  290 
N61aton,  arthroplasty,  991,  11 25 

excision  lip,  119,  132 

hare-lip,  135,  136 

rhinoplasty,  184,  193 
Neoplasms,  operations  on,  1261 

retro-peritoneum,  534 
Nephrectomy,  629-654 
Nephrolithotomy,  651 
Nephropexy,  633 
Nephrostomy,  651 
Nephrotomy,  629,  647 

anuria,  659 
Nerves,  781 

alterative  operation,  803 

anastomosis,  790 

auriculo-temporal,  70,  180 

bridging  of,  786 

disassociation,  803 

facial,  division,  35 

in  operation  on  parotid,  1 74 
paralysis,  790 
repair,  789 

frontal,  65 

implants,  786 

inferior  maxillary,  69 

injections  into,  59 

lingual,  70 

musculo-spiral,  804 

obturator,  772 

ophthalmic,  63 

peroneal,  804 


Nerves,  phrenic,  319,  320 

popliteal,  804 

radial,  804 

recurrent  laryngeal  suture,  789 

roots,  division,  768 

sciatic,  803 

selective  division,  772 

spinal  accessory,  effects  of  division,  170 
wry  neck,  204,  205 
e.xit  from  spine,  755 

stretching,  803 

stumps  in  amputation,  1148 

superior  maxillary,  66 

supraorbital,  65 

supratrochlear,  66 

suture,  781 

tibial,  804 

transplantation,  786 

ulnar  dislocation,  803 

vagus  injuries,  214 
Nervus  acusticus,  tumor  of,  28 
Neuber,  iodoform  starch,  951 

osteoplasty,  953 
Neuhoff,  repair  artery,  820 
Neuralgia,  trifacial  sympathectomy,  220 

trigeminal,  59 

injections  for,  59 
Neurasthenia,  ulcer  stomach,  363 
Neurectomy,  auriculo-temporal  nerve,  180 

intracranial,  75 

phrenic  nerve,  319,  320 

tic,  65 

wry  neck,  204,  205 
Neuritis,  803 

Neuromata,  amputation  prevention,  1148 
Neurorrhaphy,  781 
Nevus  scalp,  i 
Newman,  nephropexy,  633 
Nicoladoni,  flat-foot,  1190 
NicoU,  amputation  penis,  733 

gastro-enterostomy,  367 

hydrocephalus,  46 

ligation  femoral  artery,  1145 
Nicolson,  W.  P.,  ligation  external  carotid,  841 
Nimier,  excision  inferior  maxilla,  95 
Nitrogen  injections  pleura,  311 
Nitze,  tumors  bladder,  686 
Non-union  fracture  jaw,  96 
Nose  angioma,  182 

operations  on,  181 
Nov6-Josserand,  hypospadias,  730 

Oblique  osteotomy,  973 

Obliterative  endoaneurysmorrhaphy,  827 

Obstetric  palsy,  795 

Obstruction  duodenum,  410 

intestinal,  443 

ureter,  662 
Obturator  hernia,  616 

nerve  division  of,  772 
Ochsner,  appendicitis,  477 

empyema,  298 

excision  ankle,  1065 

pseudarthrosis,  893 
O'Conor,  echin,  cysts,  590 

rheumatic  arthritis,  1143 
Odontomata,  108 
(Edema,  blue,  sympathectomy,  220 

obstructive,  873 
(Esophagectomy,  227 


INDEX 


1299 


(Esophago-jejuno-gastrostoiny,  228 
(Esophagoplasty,  228 
(Esophagostomy,  227 
(Esophagotomy,  224 
(Esophagus,  224 

abdominal  excision,  400 

diverticula,  225 
stricture,  226 
ffistreich,  tumor  adrenal,  553 
Ogston,  flat-foot,  1189 

club-foot,  1232 

osteotomy,  970 
Okinczyc,  c£ECO-sigmoidostoniy,  441 
Olecranon,  fracture,  938 
Oliver,  thymectomy,  269 
Olivier,  salivary  fistula,  181 
Oilier,  autoplasty  bone,  Q07 

chondrectomy,  962 

claviculo-humeral  nearthrosis,  1104 

excision  ankle,  1063 
elbow,  II 1 1 
hip,  987 
scapula,  1082 

osteotomy,  973 

resection  shoulder,  1085 
wrist,  1 122 
Ombr^danne,  anchylosis,  elbow,  1119 

excision  lip,  119,  132 

undescended  testicle,  751 
Omental  grafts,  452 

hernia,  592 
Omentopexy,  528 

Omentum,  separation  from  colon,  404 
Operation,  abdominal,  343 

abscess  acute,  1259 

Adam's  contracture,  1238 

alterative,  nerves,  803 

anchylosis  and  deformities  hip,  990 
elbow,  11 17 
lower  jaw,  103 
knee,  1049 
wrist,  1125 

aneurysm,  825 

angioma  nose,  183 

ankle,  1061 

anterior  mediastinum,  338 

antrum  Highmore,  82 

anuria,  659 

appendicitis,  464 

arteries,  812 

arterio-venous  aneurysm,  832 

arthritis  deformans,  1045 
hip,  989 

arthrotomy,  1052 

ascites,  528 

astragalus,  1067 

Earth's,  58 

Bassini's,  596,  605 
'    Beck,  epilepsy,  50 

biliary  passages,  562,  575 

Bogojawlensky's  pituitary,  52 

bone  tumors,  958 

Bottini's,  702 

bow  legs,  972 

breast,  271 

bronchiectasis,  319 

bronchus,  244 

bunion,  1070 

calcaneus  cavus,  1236 

Cantwell's,  725 


Operation,  cardiospasm,  357 

cautery,  ulcer  stomach,  363,  386 
cerebellum,  28 
cervical  rib,  208 

sympathetic,  217 

tumors,  209 
Cheatle's  upper  lip,  131 
cheek,  109 
chest,  286 
chin  and  jaw,  126 
clavicle,  1082 
claw  finger,  1219 
cleft  palate,  144 
club-foot,  1226 
Codman's  stomach,  383 
common  bile  duct,  576 
congenital  dislocation  hip,  10 15 
knee,  1045 

fistula  neck,  215 

pyloric  stenosis,  377 
contractures,  1238 
cranial  meningocele,  42 
Gushing,  hydrocephalus,  46 

nervus  acusticus,  28 
cysticotomy,  575 
decompression  cerebral,  19,  24 
Desjardin's,  543 

detached  semilunar  cartilage,  103^ 
dislocation  astragalus,  1067 

elbow,  1115 

metacarpo-phalangeal,  11 2  7 

patella,  1057 

shoulder,  1092 

ulnar  nerve,  803 
diverticula  bladder,  712 
diverticulitis,  438 
Dowd's  lip,  118 
duodenal  ulcer,  363 
echinococcic  cysts,  abdomen  589 
Edebohls',  635,  651,  659 
elbow,  1 108 
elephantiasis,  875 
empyema  thoracis,  294 
encephalocele,  42 
epilepsy,  48 
epispadias,  723 
Estlander's,  306 
faecal  fistula,  461 
face  deformities,  1244 

Gillies,  1244 
facial  paralysis,  790 
Fenger,  hydronephrosis,  664 
Finney,  pyloroplasty,  381 
fistula  in  ano,  523 
flail  shoulder,  1099 
flat-foot,  1 189 
floating  kidney,  633 
fractures,  877 

elbow,  935 

jaw,  96 

olecranon,  938 

skull,  17 
Frank's  gastrostomy,  358 
Frazier's  pituitary,  54 
Freund's,  320 
frontal  sinus,  57 
Gasserian  ganglion,  71 
Halsted's  breast,  274 
hammer  toe,  1074 
haemorrhoids,  519 


I300 


INDEX 


Operation,  hare-lip,  134 

Hartley- Krause,  71 

heart  and  pericardium,  330 

Heineke-AIikulicz,  380 

hernia,  590 

Hibb's,  779 

Hildebrand,  800 

hip,  979 

Hirschsprung's  disease,  439 

Hotchkiss,  cancer  cheek,  114 

hour-glass  stomach,  376 

hydrocele,  752 
neck,  215 

hydrocephalus,  43 

hypospadias,  727 

imperforate  anus,  482 

infections,  ear  and  brain,  34 
hand,  1132 

inferior  maxillar>',  92 

internal  hernia,  622 

intestinal,  409 

intestinal  obstruction,  443 

intussusception,  446 

jaw,  undeveloped,  102 

joints,  indications,  11 40 

Jonas',  club  foot,  1231 

Jones'  flail  elbow, 

Kanavel,  pituitary,  54 

kidney,  629 

Killian's,  58 

knee,  1024 
knock,  966 

Kondoleon's,  876 

Kraske's,  491 
large  hemise,  624 
Le  Kort's,  338,  340 
Lilienthal,  thoracoplasty,  309 
lingual  thyroid,  216 
lip,  Stewart,  121 
Grant,  119 
lower,  115 
Mayo,  124 

Xclaton-Ombredanne,  1 19-132 
Sutton,  119 
liver,  553 

loose  bodies  in  joint,  1031 
lymphangioplasty,  873 
Macewen,  hernia   596,  603 
malunion,  fracture,  915 
Maunsell's,  419 
Matas",  827 
Maydl's,  677 
Mayo,  bunion,  1072 
McArthur's  pituitary,  53 
mediastinum,  anterior,  338 

posterior,  341 
melanoma,  1262 
Meyer,  W.,  breast,  276 
Milton's,  338 
Morison-Talma,  528 
muscular  paralysis,  1202 
musculo-spiral  paralysis,  121 7 
Muller  Konig,  11 
myositis  ossificans,  11 22 
Mynter's,  663 
necros's,  bone,  948 
neoplasms,  1261 
ner\es,  781 
nervus  acusticus,  28 
nose,  181 


Operation,  obstetric  palsy,  795 
obturator  hernia,  616 
oesophagus,  224 
Ogston,  club  foot,  1232 

flat  foot,  1 1 89 

osteotomy,  970 
old  dislocation,  hip,  1005 
orbit,  84 
OS  calcis,  1069 
osteomyelitis,  941 
pancreas,  536 
parotid,  173 

Payr's  hydrocephalus,  45 
pelvic  bones,  974 
Perkin's,  1056 
peritonitis,  475 
pharj'nx,  230 
Phelps'  club  foot,  1230 
phthisis,  311 
pituitary,  52 
plastic,  1241 

bone,  907 
cavities,  952 

common  duct,  583 

ear,  76 
poisoning,  mercurial,  459 
Pott's  disease,  779 
ptos's,  breast,  272 

stomach,  361 
prognathism,  102 
prolapse  rectum,  483 
prostate,  703 
pruritus,  522 
pseudarthrosis,  893 
psoas  abscess,  1260 
pulmonary  emphysema,  320 
Quenu,  rectectomy,  502 
rectal  stricture,  488 
rectum,  482 
Regnier's,  117 
Regnoli-Billroth,  162 
resection,  rib,  301 
retroperitoneal  tumors,  534 
retrophar>'ngeal,  222 
rhinophyma,  182 
rodent  ulcer,  89 
rupture  bladder,  680 

urethra,  721 
Rutkowski's,  699 
sacro-iliac,  977 
salivary  fistula,  177 
scapula,  1075 
Schede's,  306 
Sedillot's,  162 
seminial  vesicles,  713,  745 
shoulder  joint,  1084 
skull,  6 

snapping  hip,  979 
spastic  paraplegia,  1223 
spasticity,  768 
special  fractures,  920 
spina  bifida,  774 
spine,  755 
spleen,  547 
Stamm-Kader,  359 
Stewart,  C,  lip,  i2i 
Stewart,  F.,  breast,  281 
stomach,  355 
Strauss',  377 
subacromial  bursitis,  1106 


INDEX 


K^Ol 


Operation,  superior  maxilla,  85 

table,  563 

Tansini's,  282 

tendons,  1192 

tenotomy,  1221 

testicles,  739 

Thomas,  breast,  271,  273 

thrombos's  and  embolism,  820 

thymus,  268 

thyroid,  247 

tongue,  158 
Butlin,  165 
Criles',  168 
Maitland,  169 

trachea,  239 

tuberculous  paraplegia,  763 
peritonitis,  480 
ribs,  323 

tumor  spinal  meninges,  764 

Tuttle's,  515 

ulcer  stomach,  363,  383,  386 

ulnar  paralys's,  12 19 

umbilical  hernia,  616 

undescended  testicle,  749 

upper  lip,  129 

ureter,  661 

urethra,  715 

urinary  bladder,  673 

Vallas',  928 

Van  Hook's,  670 

varicocele,  753 

varicose  veins,  866 

veins,  856 

webbed  fingers,  11 27 

Weir's  bunion,  1071 

Whiteheads,  161,  521 

Witzel's,  358 

Wolfler's,  365 

wounds  chest,  291 

wrinkles,  1255 

wrist,  1 1 22 
drop,  1 21 7 

wry  neck,  204 

X-ray  burns,  1255 
Operative  fluoroscopy,  1276 
Ophthalmic  nerve  injection,  63 
Opiates  chest  wounds,  291 
Oppel,  ligation  popliteal  vein,  832 
Orbit,  osteoplastic  exposure,  84 
Orr,  T.  G.,  amputation,  1145 
Os  ca'cis,  1096 

fracture,  933 
Osgood,  osteotomy,  1057 
Osteitis  fibrosa,  958 

ribs,  323 
Osteo-arthrotomy,  970 
Osteoclasis  bow-leg,  973 

knock  knee,  931 
Osteoclasts,  973 
Osteomata  ribs,  325 
Osteoplastic  amputations,  1177,  1181 

closure  bone  cavities,  952 

craniotomy,  13,  23 

exposure  orbit,  84 

laminectomy,  760 

resection  superior  maxilla,  91 

skull  operations,  11 
Osteotomes,  963 
Osteotomy,  962 

anchylosis  knee,  1049,  1056 


Osteotomy,  club  foot,  1233 

dislocation  shoulder,  1093 

malunion,  920 
Osteomyelitis,  941 

hip,  988 

pelvis,  974 
Otis  urethrotome,  716 
Otitis  media,  34 

Oxygen  replacement  aspiration,  296 
Ostwalt,  neuralgia,  59 

Pachymeningitis,  hemorrhagic,  52 
Paci,  congenital  dislocation,  hip,  1016 
Pads,  abdominal,  356 
Pain,  sympathectomy,  220 
Pakowski,  dermoid  cyst  abdomen,  536 
Palate  temporary  resection,  92 
Palmar  fascia  contracture,  1238 
Palmer,  O.  H.,  cauliflower  ear,  82 
Pancreas,  536 

cysts  of,  535,  537 

lithiasis,  546 

in  cancer  stomach,  397 
Pancreatitis,  541 

acute,  545 

chronic,  546 
Pannett,  duodenal  fistula,  410 

incision,  565 
Paracentesis  abdomen,  530 

hydrocephalus,  43 
Paralysis,  deltoid,  801,  1078 

Duchenne  Erb,  795 

facial,  790 

muscle  treatment,  1202 

musculo-spiral,  806,  121 7 

obstetric,  795 
/  serratus,  1075 

simulated,  1201 

trapezius,  1078 

ulnar,  1219 
Paralytic  calcaneo-cavus,  1236 

club  foot,  1207 

eversion  leg,  1220 

flat  foot,  1 192 
Paraphimosis,  738 
Paraplegia  spastic,  1223 

tuberculosis  operation  for,  763 
Parasternal  hernia,  625 
Parathyroids,  248 

transplantation,  266 
Parham,  tumor  chest  wall,  325 
Park,  Roswell,  meningeal  hemorrhage,  15 
Parkes,  C.  T.,  incision,  631 

intestinal  anastomosis,  414 

mishaps  intestinal  suture,  418 
Parkhill,  clamp  fracture,  902 
Parotid  gland,  173 
Parrott,  fracture  jaw,  100 
Partsch,  excision  inferior  maxilla,  94 

temporal  resection  superior  maxilla,  91 
Passot,  wrinkles,  1255 
Paste,  Beck's,  951 

Mosetig's,  947 
Patella,  anchylosis,  1052 

arthrectomy,  1044 

dislocation,  1057 

fracture,  925 

tendon  transplantation,  11 98 

tuberculosis,  1046 
Paterson,  Peter,  ascites,  532 


I302 


INDEX 


Patrick,  H.,  injection  nerve,  63 
Pauchet,  exploratory  stomach,  356 
exposure  pancreas,  539 
gastrectomy,  404 
Paul,  colectomy.  432 

•  intestinal  obstruction,  445 
Payr,  arterial  suture,  815 
arthroplasty,  1052,  1055 
clamp,  398 

dislocation  shoulder,  1102 
hydrocephalus,  44 
plastic  ear,  81 

thyroid  transplantation,  266 
volvulus  stomach,  450 
Pean,  rectotomy,  488 
Pearse,  hyperpyrexia  skull  injury,  24 
Pearson,  Y.,  catgut,  1266 
Pearson's  calipers,  917 
Peck,  arthrotomy  knee,  1028 
Peck,  C.  H.,  cleft  palate,  158 
Peck,  C.  H.,  hemolytic  jaundice,  549 
Peckham,  dislocation  shoulder,  1098 
Pectoralis,  major,  transplant,  800 
Peet,  omental  grafts,  452 
Pegs,  bone,  898 
Pelvic  bones,  974 
Pelvis  kidney  anatomy,  640 
Penis,  amputation,  733 
Peptic  ulcer,  375 
Perforation  duodenum,  409 
intestine,  411 
stomach,  364 
Perforating  ulcer,  803 
Perforator,  Doyen's,  9 
Periarterial  sympathectomy,  220 
Pericaecal  fossa,  623 
Pericardiocentesis,  334 
Pericardiolysis,  337 
Pericardiotomy,  335 
Pericardium,  operations  on,  330 

wounds,  293 
Perier,  laryngectomy,  235 
Perineal,  cystotomy,  704 
excision  rectum,  491 
prostatectomy,  706 
section,  704 
Periosteal  sarcoma,  959 
Periostitis,  943 
pelvis,  974 
Peritoneal  fossae,  622 
Peritonitis,  475 

tuberculous,  480 
Perkins'  operation,  1056 
Pernicious  ansemia,  549 
Peroneal  nerve,  804 

longus  tendon  displacement,  1200 
Perreve,  ileocaecal  tuberculosis,  481 
Perthes,  dislocation  shoulder,  1102 

epilepsy,  51 
Peters,  G.  A.,  uretero-rectostomy,  678 
Petersen,  pericardiolysis,  337 
Peterson's  operation,  hammer  toe,  1074 
Petit,  wounds  vena  cava,  857 
Phalanges,  amputation,  11 53 
Pharyngotomy,  230 
transhyoid,  170 
Pharynx,  230 

Phelps,  dislocation  shoulder,  1098 
hernia,  619 
operation,  club  foot,  1230 


Phelps,  varicose  veins,  867 

Phimosis,  737 

Phlebitis,  865 

Phrenic  nerve  section,  319,  320 

Phthisis,  apical,  330 

Freund's  operation,  320 
pulmonary  operation,  311 
Pia  mater  infections,  36 
Picot,  gangrene  lung,  326 
Picqu6  sacro-iliac  disease,  977 
Pigmented  moles,  1261 
Pilcher,  prostatectomy,  688 
Piles,  519 
Pin,  Makkas',  6 
Pins,  Steinmann's,  917 

Wycth's,  1157,  1 182 
Pirogoff's  amputation,  11 76 
Pituitary  bodj',  52 
Pituitrin  in  ileus,  444 
Plantar  fascia,  division,  1223 
Plastic  operations,  anus,  484 
bladder,  674, 
bones,  907 
bone  cavities,  952 
check, 109 
common  duct,  583 
ear,  76 

facial  palsy,  795 
nose,  184 

obstetric  palsy,  800 
salivary  fistula,  1 76 
superior  maxilla,  87 
ureter,  666 
closure  bone  cavities,  952 
repair  bladder,  699 
repair  salivary  fistula,  178 
surgery  principles,  1241 
Plates  for  fractures,  902 

Lanes,  880 
Plating  fractures,  jaw,  96 
Plating,  ununited  fracture,  902 
Pleth,  sympathectomy,  221 

tic  douloureux,  75 
Pleura  tumors,  324 
wounds,  286  et  seq 
pulmonary  fistula,  306 
Pleurisy,  Blocqu<ies,  296 
Plexus  brachial  palsy,  795 
Plugs  bone,  947 
Plummer  cardiospasm,  357 
Pneumectomy,  329 
Pneumococcal  arthritis,  1143 
Pneumolysis,  314 

interpleural,  323 
Pneumopexy,  325 
Pneumothorax,  286,  287,  293,  626 

artificial,  311 
Pneumotomy,  326 

Poggi  congenital  dislocation  hip,  1015,  1021 
Poisoning  corrosive  sublimate  colostomy,  459 
Polya,  gastrectomy,  400 
Poncet,  transplantation,    tendon    insertion, 

1 198 
Ponfick,  excision  liver,  555 
Popliteal  nerve,  804 
Porter,  C.  B.,  abscess  pancreas,  546 
Porter,     Miles,     injections     boiling     water, 

goitre,  267 
Position,  Bogojawlensky's,  52 
Fowler's,  476 


INDEX 


1303 


Position,  Jones,  elbow,  935 

Rixford's,  563 

Robson's,  563 
Posterior  gastro-cnterostomy,  366 

mediastinum,  341 
Posture  bile  ducts,  562 

kidney  operations,  629 

patient,  rib  resection,  301 
Potel,  sarcoma  scapula,  1079 
Pott's  disease  spine,  779 

fracture  malunion,  920 
Precautions  against  losing  abdominal  pads, 

356 
Preliminary  colostomy,  501 

laryngotomy,  165 

tracheotomy,  165,  242 

treatment  aneurysm,  826 
cleft  palate,  157 
thyroidectomy,  252 
Preparation  catgut,  1265 

Dakin's  solution,  1269 

patient  gastrotomy,  355 

sutures  and  ligatures,  1263 
Preparatory  treatment,  operation  piles,  519 
Prevention,  adhesions,  intestinal,  452 
meninges,  10,  ir,  51 

amputation  neuromata,  1148 
Primrose,  bone  implantation,  915 

skull  defects,  13 
Principles,  hare-lip  operations,  135 

plastic  surgery,  1241 

tendon  transplantation,  1201 
Pringle,  J.  H.,  crucial  ligaments,  1036 

hemostasis  liver,  556 

open  fractures,  890 
Probe  telephone,  1271 

Thrailkill's,  526 
Proctoclysis,  476 
Prognathism,  102 
Prognosis,  congenital  dislocation,  hip,  1009 

excision  ankle,  1066 

nerve  suture,  782 
Prolapsus  recti,  483 
Prophylactic  treatment  fistula,  524 
Prophylaxis  epilepsy,  48 
Prostatotomy,  702 

infrapubic,  712 

suprapubic,  687 
Prostatectomy  perineal,  706 

suprapubic,  687 
Prosthesis,  excision  inferior  maxilla,  95 
Proust's,  excision  rectum,  497 
Pruritus  ani,  522 
Pseudarthrosis,  893 
Pseudopancreatic  cysts,  535 
Psoas  abscess,  1260 
Ptosis  breast,  272 

kidney,  633 

liver,  553 

stomach,  361 
Pubis,  excision  of,  976 
Pulmonary  artery,  ligation,  319 

tuberculosis  operation,  311 

wounds,  286 
Puncture  callosal,  33 

exploratory  empyema,  294 

knee,  1024 

lumbar,  19,  755 

thoracotomy,  299 
Purves  facial  paralysis,  799 


Pussep,  Gasserian  ganglion,  72 
Putti,  amputation  arm,  1169 
Pyarthros,  1140 

hip,  989 
Pyelotomy,  pyelolithotomy,  653 
Pylorectomy,  389,  395 
Pyloric  exclusion,  372 

obstruction  congenital,  377 
Pylorodiosis,  380 
Pyloroplasty,  380 
Pyonephrosis,  654,  658 

Qu6nu,  anatomy  bronchi,  244 
caecopexy,  437 
excision  scapula,  1079 
fracture  patella,  930 
rectectomy,  502 
rectopexy,  487 

and  Desmarest,  amputation  hip,  1187 
Duval,  iliac  arteries,  849 

Radial  nerve,  804 

paralysis.  121 7 
Radiographic.localization  foreign  bodies,  1275 
Radius,  separation  head,  941 
Rammstedt  operation  pj^loric  stenosis,  377 
Ransohoff  calipers,  892,  917 

empyema,  302,  309 

fracture  skull,  19 

hernia,  616 

ligations,  840 

renal  tuberculosis,  658 
Ranula,  216 

Ranzi  intestinal  obstruction,  445 
Rasumowsky,  anastomosis  vas  and  testicle, 

743 
Reactions  after  sympathectomy,  221 
Recess  duodeno-jejunal,  622 
Reconstructive  endoaneurysmorrhaphy,  830 
Rectal  stricture,  488 
Rectopexy,  485,  486 
Rectorrhaphy,  485 
Rectotomy,  488 
Rectum,  482 

excision,  489 

vascular  supply,  504 
Recurrent  dislocation  patella,  1058 
Regnier's  operation  lip,  117 

visor  flap,  117,  1244 
Regno ti  Billroth  operation,  162 
Rehn,  excision  rectum,  493 
Reich,  complicated  hare-lip,  143 

femoral  hernia,  602 
Reinhardt,  temporal  resection  superior  max- 
illa, 91 
Remarks,  amputation  foot,  11 75 
penis,  734 

appendicitis,  479 

arthrectomy  knee,  1044 

arthrotomy  knee,  1029 

ascites,  533 

bow  leg,  972 

castration,  vasectomy,  etc,  746 

club  foot,  1233 

Dufourmental's  operation,  1251 

enlarged  prostate,  703 

excision,  hip,  988 

exstrophy  bladder,  680 

incisions,  appendicitis,  470 

intestinal  anastomosis,  423 


1304 


INDEX 


Remarks,  joint  transplantalion,  1056 

liRation  arteries,  834 
common  carotid,  830 
external  carotid,  842 

operations,  ankle,  1067 
renal,  658 

Pott's  disease,  780 

retropharyngeal  abscess,  222 

tendon  transplantation,  1203 

varicocele,  754 

wry  neck,  207 
Removal  foreign  bodies,  chest,  291 

trachea,  243 
Renal  abscess,  650 

artery  and  ureter,  662 

calculus,  646,  651,  658 

decapsulation,  635,  651,  659 

operations,  629 

tuberculosis,  658 

tumors,  654 
Renton,  femoral  hernia,  597 
Repair  crucial  ligaments,  1036 

lateral  ligament,  knee,  1039 

nerves,  781 
Report,  British  Medical  Association  fracture. 

Resection,  alveolus,  inferior  maxillary,  92 

arteries,  819 

elbow,  1 1 08 

enucleation  goiter,  264 

goiter,  263 

inferior  maxillary,  92 

knee,  1040 

lung,  330 

osteoplastic  superior  maxillary,  91 

rib,  empyema,  300 

shoulder,  1085 

small  intestines,  424 

tongue,  158 

upper  jaw,  85 

wrist,  1 1 22 
Respiration  during  thoracic  operation,  287 
Results,  amputation  breast,  286 

congenital  dislocation  hip,  1020 

excision  rectum,  518 
tongue,  167 

gangrene,  lung,  326 

hypophysectomy,  56 

ileo-caecal  tuberculosis,  481 

injections,  tic,  63 

intussusception,  449 

ligation,  common  carotid,  839 

nephropexy,  639 

nerve  suture,  783 

omentopexy,  529 

operation,  cancer  lip,  125 
stomach,  408 
pyloric  stenosis,  377 

osteoma  in  muscle,  11 22 

pericardiolysis,  338 

renal  tuberculosis,  658 

sarcoma  bone,  959-960 

sacro-iliac  disease,  979 

stone,  common  duct,  577,  582,  588 

sympathectomy,  219 

treatment  fractures,  877,  891,  892 

tuberculous  peritonitis,  480 

varicose  veins,  871 

wounds,  heart,  336 
knee,  1030 


Retractors,  thoracic,  297 
Retroduodenal  exposure  common  duct,  576 
Retrograde  strangulation  hernia,  594 
Retroperitoneal  neoplasms,  534 
Retro-pharyngeal  abscess,  222 

tumors,  91 
Revenstorf,  longitudinal  sinus,  18 
Reverdin  skin  grafts,  1254 
Reversal  circulation   821 
Reynolds'  excision  shoulder,  1087 
Rheumatic  arthritis,  1143 
Rhinophyma,  182 
Rhinoplasty,  184 
Ribs,  cervical,  208 
first  excision,  322 
fracture  pneumothorax,  293 
osteomata,  325 
resection  empyema,  300 
spreaders,  retractors,  292 
tuberculous,  323 
Richardson,  E.  H.,  nephrotomy,  649 
M.  H.,  oesophagotomy,  225 
oesophagus,  stricture,  227 
tuberculous  peritonitis,  481 
W.  G.,  ulcer  stomach,  364 
Richter,  artificial  respiration,  operations  on 

thorax,  288 
Ridlon,  club  foot,  1227 
Riedel,  ligation  subclavian  artery,  847 
Riedel's  lobe,  553 
Rieder,  thyroidectomy,  252 
Riedl,  bunion,  1070 
flat  foot,  1 1 89 
Rixford,  cancer  thorax,  325 
operating  table,  343 
position,  363 
Robinson,  S.,  artificial  pneumothorax,  312 

intratracheal  insufflation,  290 
Robson,  Mayo,  crucial  ligaments,  1036 
duodenal  choledochotomy,  581 
gastrolysis,  364 
incision,  563 

indications,  operation  ulcer  stomach,  376 
jejunostomy,  452 
pancreas,  541 
position,  343,  563 
Rochet,  anchylosis  jaw,  107 

arthroplasty,  hip,  992 
Rodent  ulcer,  89,  1262 
Rodman,  gastric  ulcer,  364 
Roeder,  caecopexy,  438 
Roentgen  rays,  foreign  bodies,  1272 
Rolando,  fissure,  21 

S.,  osteomyelitis,  943 
Rolfe,  castration,  740 
Rolleston,  ascites,  528 
Roots,  nerve,  division,  768 
Ropke,  closure  defect  skull,  12 

laminectomy,  761 
Rose,  excision  Gasserian  ganglion,  72 
Rosenberger,  epispadias,  724 

hypospadias,  730 
Rotter,  excision  rectum,  518 

fracture  patella,  931 
Round,  fracture  jaw,  100 
Routte  ascites,  532 
Roux,  amputation,  11 74 
costal  cartilage,  324 
diet  after  stomach  operation,  356,  408 
empyema,  308 


INDEX 


13OS 


Roux,  femoral  hernia,  597 

gastro-enterostomy,  372 

asophagoplasty,  228 
Rovsing,  bone  transplantation,  913 

cystectomj',  701 

gastropexy,  362 

pyelotomy,  653 

ureterostomy,  651 

vaseline  injections,  980 
Rowlands  and  Turner,   Chopart's  amputa- 
tion, 1 1 74 
Royster,  Kondoleon  operation,  876 
Rubber  tissue  after  trephining,  11,  24 
Rubritius  osteomyelitis,  944 
Ruggi,  tumor  pancreas,  542 
Rupture  of  bladder,  680 

of  crucial  ligaments,  1036 

of  supraspinalus,  1106 

urethra,  721 
Russell,  external  urethrotomy,  720 
Ruth,  fracture,  neck  femur,  922 

pancreatic  stones,  546 
Rutkovvski,  exstrophy,  676 

gastro-enterostomy,  370 

repair  bladder,  699 
Rydygier,  splenopexy,  547 

Sabanejeff,  amputation,  1182 
Sabre-cut,  Codman's,  1107 
Sac,  hernia,  591,  592,  604,  611 
Sacral  operation  excision  rectum,  491 
Sacro-iliac  disease,  977 
Saddle  nose,  200 
Salivary  fistula,  177 
Salkindsohn  catgut,  1266 
Salmon,  fistula  in  ano,  524 
Salpingitis  tuberculous,  481 
Salt  packs.  Gray,  1145 

solution  into  duodenum,  580 
infusions,  858,  860 
Sarcoma  bone,  958 

chest  wall,  325 

clavicle,  1083 

hip  disarticulation,  11 87 

humerus,  913 

liver,  560 

melanotic,  1262 

pelvis,  975 

scapula,  1079 

superior  maxilla,  86 
Sargent  and  Green,  nerve  sutures,  786 
Sartorius  flap  hernia,  615 
Sauerbruch  bronchiectasis,  319 

differential  pressure,  290 

pneumolysis,  318 
Saul,  catgut,  1266 
Savariand,  saline  infusions,  1145 
Saws,  965 

Gigli,  9 
Sayre,  intertrochanteric  osteotomy,  997 
Scalone,  projectiles  in  heart,  333 
Scalp,  angioma,  i 

cysts,  I 

malignant  tumors,  5 
Scapula,  1075 

alata,  1075 

head  excision,  1091 

shoulder  after  excision  scapula,  11 04 

transplantation  into  skull,  12 
Schaack,  hemostasis  liver,  558 


Schafer,  artificial  respiration,  301 
Schede,  aseptic  blood  clot,  950 

operation  chest,  306 

suture  veins,  857 

varicose  veins,  871 
Schimmelbusch,  rhinoplasty,  195 
Schlange,  excision  alveolus  superior  maxilla, 

85 
rectum,  494 

dislocation  elbow,  11 16 
shoulder,  1099 

exstrophy,  675 
Schlosser,  neuralgia,  59 
Schmidt,  excision  acetabulum,  976 
Schmieden,  hypospadias,  730 
Schneliende  Hufte,  979 
Schreiber,  webbed  fingers,  11 28 
Schult^n,  bone  cavities,  952,  953 
Schulze-Berge,  dural  defects,  17 
Schumacher,  bronchiectasis,  319 
Schwartz,  bronchotomy,  233 

and  Kuss  radial  nerve,  805 
Sciatica,  803 

Sclerogenic  injections,  1025 
Scoop,  gall-stone,  568 
Scudder,  dislocation  shoulder,  1098 

pyloric  stenosis,  377 
Sebaceous  cysts,  i 
Secondary  suture,  1277 
Sedillot,  excision  tongue,  162 
Seelig,  femoral  hernia,  602 

rhinophyma,  182 
Segond  exstrophy,  676 
Segmental  gastrectomy,  388 
Segregation,  intestinal,  439 
Seibert,  diaphragm,  hernia,  628 
Selig,  R.,  division  obturator  nerve,  772 
Semilunar  cartilage  loose,  1033 
Seminal  vesicles,  713,  745 
Semon,  laryngectomy,  233 
Sencert,  ampulla  Vater,  582 
Senn,  amputation  hip,  11 85 

bone  chips,  950 
Separation  omentum  from  colon,  404 
Sequestrotomy,  948 
Serratus  paralysis,  1075 
Serre,  excision  lip,  129 
Seton,  salivary  fistula,  177 
Sharpe,  decompression,  26 
Shaw,  cholecystostomy,  570 

incision,  465 
Sheaths,  tendon,  1192 
Shepherd,  cystic  goitre,  266 
Sherman,  bone  plates,  887,  902 

Carrel-Dakin,  1270 

H.,  cleft  palate,  156,  157 
Sherrington,  motor  centers,  20 
Shoe,  club-foot,  1235 

crooked  heel  and  bar,  1074 
Shortening  after  fracture,  916 
Shoulder,  amputation  or  disarticulation,  11 57 

after  excision  scapula,  1104 

arthrodesis,  1099 

dislocation,  1092 

flail,  802 

joint,  1084 
Sigmoidectomy,  429 
Sigmoid  sinus,  36,  37,  40 
Sigmoidostomy,  454 
Silk  preparation,  1264 


i3o6 


INDEX 


Silk  tendon  grafts,  1197 

waxed,  1264 
Silkworm  gut,  1265 
Simon  hare-lip,  140 

incision,  630 

pericardiolysis,  337 
Sinclair,  direct  extension,  917 

open  fractures,  890 
Sinus,  frontal,  57 

longitudinal,  17 

sigmoid,  36,  37,  40 
Sistrunk,  Kondoleon's  operation,  876 
Site  drainage  empyema,  302 
Skin  grafts,  1242,  1251 

melanoma,  1262 

transplantation,  1242 
Skull,  cancer  scalp,  5 

defects,  10 

fractures,  17 

operations  on,  6 

steeple,  26 
Sleeve  resection  stomach,  388 
Sliding  hernia,  594 
Sloughs  in  cerebral  abscess,  37 
Smith,  clamp  piles,  520 

Greig,  intestinal  obstruction,  444 
splenectomy,  548 

Peterson,  incision,  hip,  1022 
Snapping  fingers,  11 28 

hip,  979 
Snow,  carbon  dioxide,  5,  133 
SokolofI,  rectal  stricture,  489 
Solution,  Dakin's,  1269 

Murphy's,  formalin  glycerine,  1024 
Sonnenburg,  exstrophy,  676 

plastic  cheek,  112 

rectal  stricture,  489 
Souchon,  dislocation  shoulder,  1097 
Spasmodic  tic  facial,  804 

torticollis,  205 
Spasticity,  768,  1223 
Speculum  in  gastrotomy,  356 
Spence,  amputation  shoulder,  11 59 
Spencer,  dislocation  hip,  1007 

lingual  thyroids,  216 
Sphincter  ani  repair,  484 

in  fistula,  523 
Spiller,  facial  palsy,  794 

Gasserian  ganglion,  71 

spasticity,  768 
Spina  bifida,  774 

Spinal  accessory  nerve  effects  of  division,  170 
wry  neck,  204,  205 

anesthesia,  757 

collections,  fluid,  764 

cord,  relations  to  bones,  755 

injuries.  765 

mening'tis,  757 

tumors,  764 
Spine,  755 

Pott's  disease,  779 
Spino-facial  anastomosis,  792 
Spischarny,  excision  tongue,  170 
Spleen,  547 
Splenectomy,  548 
Splenic  artery  ligation,  551,  552 
Splenopexy,  547 
Splint  abduction  hip,  looi 

buried,  inferior  maxillary,  94.  96 

club-foot,  1229 


Spint,  elbow,  in  ' 

facial  palsy,  793 

Ilodgen,  890 

Jones,  ankle,  1063 

Thomas,  fracture,  890,  891 

walking  caliper,  892 
Sprengel,  exposure  pelvic  bones,  974 

incision,  566 
Spur,  OS  calcis,  1069 
Squier-Heyd,  cj^stectomy,  693 
Stabb,  pericardiolysis,  338 
Stabs,  diaphragm,  625 

Stamm  and  Jacobson,  ligation  superior  pole 
thyroid,  844 

Kader,  gastrostomy,  359 
Staples,  Jacoels,  880,  898 
Starch,  iodoform,  951 
Stasis,  intestinal,  440 
Statistics,  amputation  breast,  286 

closure  skull,  17 

cranial  defects,  13 

excision  rectum,  518 
tongue,  167 

gangrene  lung,  326 

gastrectomy  cancer,  408 

goiter,  251 

ileo-caecal  tuberculosis,  481 

interscapulo-thoracic  amputation,  1162 

intussusception,  449 

ligation  common  carotid,  839 

myositis  ossificans,  11 22 

nephropexy,  639 

nerve  suture,  783 

omentopexy,  529 

operation,  cancer  lip,  125 
fractures,  877,  891,  892 
pyloric  stenosis,  377 

pericardiolysis,  338 

projectiles  in  heart,  333 

renal  tuberculosis,  658 

sacro-iliac  disease,  979 

sarcoma  bone,  959,  960 

stone,  common  duct,  577,  582,  588 

tuberculous  peritonitis,  480 

varicose  veins,  871 

wounds,  heart,  336 
Steam,  treatment  sarcoma,  961 
Steeple,  skull,  26 

Steiner,  middle  meningeal  artery,  16 
Steinmann,  direct  extension,  917 
Stenger,  mastoiditis,  42 
Steno's  duct  fistula,  177 
Stenosis,  congenital  pylorus,  377 

trachea,  247 
Sterilization,  catgut,  1265 
Stern,  pleurisy  Blocqu6s,  296 
Sterno-mastoid,  tenotomy,  204 

effects  of  removal,  170 
Stevens,  empyema,  299 
Stewart,  Clark,  operation  lip,  121 

embolism,  820 

F.,  amputation  breast,  281 

facial  palsy,  790 

resection  artery,  819 
stomach,  388 
Stich,  arterio-venous  aneurysm,  833 
Stieda,  closure  defects  skull,  12 
Stiles,  Sir  H.,  amputation  breast,  283 

epispadias,  725 
Stillman,  S.,  wiring  inferior  maxillary,  95 


INDEX 


1307 


Stimson,  dislocation  metacarpal  phalanges, 
1127 

fracture,  patella,  Q28 
Stoffel  nerve  suture.  783 

spasticity,  771 
Stomach,  hour-Klass,  376 

operations,  355 

ulcer,  363,  383,  380 

volvulus,  450 
Stone,  bladder,  681 

cystic  duct,  575 

gaU,  568 

kidney,  646,  651,  658 

pancreatic,  546 

ureter,  661 
Stone,  J.  S.,  bone  transplantation,  910 
Stoney,  osteomyelitis,  946 
Stoyanov,  posterior  mediastinum,  341 
Strangulated  hernia,  591,  594,  623 
Strauss,  pyloric  stenosis,  377 
Streissler,  cervical  ribs,  209 
Stricture,  oesophagus,  226 

rectum,  488 

urethra,  663,  715 
Struma,  247 
Strumectomy,  250 

Stubenrauch,  plastic  common  duct,  584 
Stuckey,  hemostasis,  liver,  560 
Stump,  amputation,  1147 

appendix,  470 
Subastragaloid  dislocation,  1068 
Subcaecal  colectomy,  436 
Subclavian  artery,  846 
Subcoracoid  dislocation,  1093 
Subcutaneous  tenotomy,  1221 
Subglenoid  dislocation,  1093 
Subhyoid  pharyngotomy,  230 
Subluxation  obstetric  palsy,  796 
Submental  phlegmon,  216 
Subphrenic  abscess,  562 
Subspinous  dislocation  shoulder,  1098 
Sub-temporal  decompression,  25 
Subtrochanteric,  osteotomy,  997 
Sucking  wounds,  chest,  291 
Sudeck,  vessels  rectum,  504 
Sullivan,  plastic  common  duct,  583 
Sulzenbacher,  common  iliac  artery,  852 
Summers,  cholecystostomy,  569 

gangrene  gut,  451 
Superior  maxilla  excision,  85 

nerve,  62 
Superior  thyroid  artery,  844 
Suppurations  ear,  34 
Supra-articular  osteotomy,  1056 
Supra-condyloid  osteotomy,  966 
Suprahyoid  excision  tongue,  170 

pharyngotomy,  231 
Suprameatal  triangle,  34 
Supraorbital  nerv'e,  65 
Suprapubic  cystotomy,  681 

lithotomy,  684 

prostatectomy,  687 
Supraspinus  tendon  rupture,  1 106 
Suprarenals,  552 

Supra-trochanteric  osteotomy,  990 
Supratrochlear  nerve,  66 
Surgical  kidney,  658 
Sutcliffe,  tuberculous  glands  neck,  209 
Suter,  tendon  suture,  11 94 
Sutherland,  G.  A.,  hydrocephalus.  44 


Sutton,  Sir  J.    Bland,  hydronephrosis,  662 
Sutton,  Walter  S.,  foreign  bodies,  1275 

operation  lower  lip,  119 
Sutures,  1263 

abdomen,  347 

arterial,  812 

bone,  880,  897 

cleft  palate,  157 

Connell's,  419,  420 

fascial  nerve,  789 

hare-lip,  138 

intestinal,  352 

material  for  nerves,  786 

Mitchell-Hunner,  417 

nerves,  781 

olecranon,  938 

patella,  925 

recurrent  laryngeal  nerve,  789 

secondary,  1271 

silk,  dangers,  375 

tendon, 1193 

veins,  856 

vena  cava,  657 
Sweet,  arterial  suture,  815 
Syhaan  fissure,  22 
Syme,  amputation,  11 71 

operation  aneurysm,  826 
Syme's  staff,  718 
Sympathectomy,  cervical,  217 

tic,  75 
Syms,  Parker,  prostatectomy.  706 
Synechia  ear,  77 
Syndactylism,  11 27 
Synovial  sheaths  hand,  113  2 
Synovialis  hip  excision,  985 

knee  excision,  1039 
Sjningomyelia,  767 

Table,  operating,  27,  563 
Tainter.  fractures  jaw,  100 
Talipes  calcaneus,  1237 

cavus,  1235 

equino-varus,  1226 

equinus  paralytic,  1 207 
Talma's  operation  ascites,  528 
Tansini,  amputation  breast,  282 

Banti's  disease,  549 
Tanton,  hj'pospadias,  730 

urethral  replacements,  730 
Tarsectomy,  club-foot,  1230 
Taj^or,  A.  S.,  obstetric  palsy,  797 

spasticity,  770 

W.  J.,  excision  wrist,  11 24 
Teale's  gorget,  705 
Telephone  probe,  1271 
Temporal  bone,  41 
Temporary  control  carotid,  214 

hemostasis  scalp,  6 

occlusion  carotid,  214 

resection  superior  maxilla,  91 
Temporo-maxiUary  anchylosis,  103 

sphenoidal  abscess,  36 
Tendon  as  suture,  1265 
Tendo  Achillis,  transplantation  club-foot,  12  29 

tenotomy,  1221 
Tendon  insertions  transplantation  of,  1198 

lengthening,  1222 

operations  on,  1092 

peroneus  longus,  displacement,  1200 

shortening,  1200 


i3o8 


INDEX 


Tendon,  supra-spinatus  rupture,  1106 

transplantation  fingers,  1130,  1201 
radial  f^alsy,  80O 
Tendons,  fingers,  11 28 
Tenorrliapiiy,  1193    ' 
Tenosynovitis  hand,  1132 
Tenotomes,  1221 
Tenotomy,  1221 

dislocation  shoulder,  1092 

spastic  paraplegia,  1223 

wry  neck,  204 
Tension,  relief  of,  136,  137,  1241 
Teratoma,  testis,  740 
Terrier,  gastrostomy,  357 

osteotomy,  998 
Testicles,  operations  on,  739 

undescended,  749 
Tetany,  250,  266 
Thane,  cranial  topography,  21 
Thermotaxic  centre,  24 
Thiersch,  epispadias,  723 

grafts,  1252 

hypospadias,  727 

neurectomy,  59 
Thiosinimin,  otsophagus  stricture,  226 
Thomas'  operation  breast,  271,  273 
Thomas,  H.  O.,  simulated  paralysis,  1201 

splints,  890,  891 

wrench,  1228 
Thomas,  Lynn,  amputation,  1144,  1163,  1182 

fracture  patella,  931 
Thomas,  Thelwell,  wry  neck,  205 

piles,  519 
Thomas,  Turner,  dislocation  shoulder,  iioi 

obstetric  palsy,  iioi 
Thompson,  J.  E.,  hare-lip,  135,  140 

approach  to  bones,  894 
Thoracectomy,  300 
Thoracentesis,  295 
Thoracic  duct,  210 

stenosis,  322 
Thoracoplasty,  306,  309 
Thoracotomy,  292,  296 
Thorax,  operations  on,  286 
Thornton,  nephrectomy,  657 
Thrailkill,  anal  fistula,  526 
Thrombo-phlebitis,  865 
Thrombosis,  operation  for,  820 

sigmoid  sinus,  38 
Thurm  schjidel,  26 
Thymectomy,  268 
Thymus,  252,  268 
Thyro-glossal  duct,  216 
Thyroid  artery  inferior,  845 
superior,  844 

ligation  superior  pole,  844 

lingual,  216 

operations  on,  247 

transplantation  of,  266 
Thyroidectomy.  256 
Tibia,  congenital  absence,  912 

and  fibula  club  foot,  1233 

open  fractures,  889 

osteotomy,  967 

replaced  by  fibula,  909 
Tibial  arteries,  854 

nerve,  804 

spine  fracture,  1037 

tubercle,  fracture  of,  932 
transplantation  of,  1198 


Tibialis  anticus  tenotomy,  1222 

posticus  tenotomy,  1223 
Tic  (loloiirc'ux,  59 

spasmodic  facial  nerve,  804 
Tillmanns,  pelvic  osteomyelitis,  974 
Toe,  hammer,  1074 

Toes,  amputation  and  disarticulation,  1169 
Tongue,  operation  on,  158 

tumors  base  of,  231 

neurectomy  cancer,  70 
Topography,  brain,  20 

meningeal  vessels,  16 

spine,  755 
Torek's  operation,  323 
Torticollis,  204 
Toupet,  tenotomy,  1222 
Tourneur's  point,  661 
Tourniquet,  amputation  hip,  1183 
Trachea,  foreign  bodies  in,  243 
Tracheal  stenosis,  247 
Tracheoscopy,  243 
Tracheotomy,  239 

operations  on  tongue,  165 

preliminary,  242 
Transduodenal  choledochotomy,  581 
Transfusion  blood.  858 
Transgastric  resection  ulcer  stomach,  389 
Transhyoid  excision  tongue,  170 

pharyngotomy,  231 
Transmaxillarv  excision  tumors  nose,  181 
Transplantation  bone,  900,  909,  912 
clavicle,  1084 
inferior  maxilla,  95,  97 
skull,  II 

bursa  bunion,  1072 

cartilage,  elbow,  1119 

elbow,  1 120 

epiphysis,  914 

fascia,  defects  skull,  13 
hernia,  614 

finger,  rhinoplasty,  191 

insertion  pectoralis  major,  800 

joints,  1055 

muscle,  facial  palsy,  794 
obstetric  palsy,  800 
serratus  paralysis,  1076 

skin,  1242 

tendons,  1201 
finger,  11 30 
radial  palsy,  806 

thyroids  and  parathyroids,  266 
Transvenous  aneurysmorrhaphy,  833 
Transversostomy,  459 
Trap-door  opening  skull,  10,  13,  23,  24 
Trapezius  paralysis,  1077 
Traumata  diaphragm,  625 

pancreas.  546 
Treatment,  abscess  acute,  1259 
psoas,  1260 

anchylosis  elbow,  1 1 1 7 
knee,  1049 
wrist,  1 1 25 

aneurysm,  825 

angioma  face,  133 

appendicitis,  464 

arterio-venous  aneurysm,  832 

arthritis  deformans  knee,  1045 

ascites,  528 

bladder,  rupture  of,  680 

bone,  tumors  of,  958 


INDEX 


1309 


Treatment,  bunion,  1070 
burns,  X-ray,  1255 
bursitis  subacromial,  1106 
cervical  rib,  208 
club-foot,  1226 
congenital  dislocation  hip,  1015 

fistula  neck,  215 

pyloric  stenosis,  377 
contractures,  1238 
dislocation  elbow,  11 15 

hip,  IOCS 

patella.  1057 

shoulder.  1092 

ulnar  nerve,  803 
diverticulitis,  438 
ecchinococcic  cysts,  589 
elephantiasis,  875 
empyema  thoracis,  294 
epispadias,  723 
facial  deformities,  1244 
fingers,  snapping,  11 28 

web,  1 1 27 
fistula,  anal,  523 

faecal,  461 

salivary,  177 
flat-foot,  1 189 

foreign  bodies  in  trachea,  243 
fractures,  877 

elbow,_935 

malunion,  915 

neck  femur,  922 

olecranon,  938 

skull,  17 

special,  920 
goitre,  250 
haemorrhoids,  519 
hemorrhage  middle  nerve,  15 
hand  infections,  1132 
hernia,  590 
hydrocele,  752 

of  neck,  215 
hypospadias,  727 
injuries  diaphragm,  625 

thoracic  duct,  210 
intestinal  adhesions,  452 

obstruction,  443 
intussusception,  446 
joints,  indications,  1140 

Willems,  924 
lingual  thyroid,  216 
lymphatic  obstruction,  873 
melanoma,  1262 
myositis  ossificans,  1122 
obstetric  palsy,  795 
odontomata,  108 
oesophageal,  diverticula,  225 

stricture,  226 
osteomyelitis,  941 
pancreatic  affections,  536 
pancreatitis,  acute,  545 
paralysis,  facial,  790 

muscle,  1202 
peritonitis,  475 

tuberculous,  480 
pneumothorax  from  fracture  rib,  293 
Pott's  disease,  779 
preliminary  cleft  palate,  157 

excision  rectum,  489 

piles,  519 
prostate,  enlarged,  703 


Treatment,  pruritus,  522 

pseudarthrosis,  893 

rectal  stricture,  488 

retro-peritoneal  tumors,  534 

rhinophyma,  182     . 

rodent  ulcer,  89 

salivary  fistula,  177 

seminal  vesicles,  713 

serratus  paralysis,  1075 

shoulder,  flail,  1099 

snapping  hip,  979 

spastic  paraplegia,  1223 

spasticity,  768 

spina  bifida,  774 

thrombosis  and  embolism,  820 

tic  douloureux,  59 

toe,  hammer,  1074 

tuberculosis,  ribs,  323 
tendon  sheaths,  1192 

tumors  of  neck,  209 

undescended  testis,  749 

urethra,  rupture  of,  721 
stricture  of,  715 

varicocele,  753 

varicose  veins,  866 

wounds,  1268 
chest,  291 
hand, 1137 

wrinkles,  1255 

wry  neck,  204 
Treitz,  hernia,  623 
Trelat,  excision  lip,  129 
Trendelenburg,  cannula,  241 

excision  lip,  127 

exstrophy,  675 

pin,  1182 

position,  343 

varicose  veins,  866 
Trephines,  6 
Trephining,  7 

hemorrhage  meningeal  vessels,  15 
Treutlein,  excision  aneurysm,  826 
Treves,  pseudarthrosis,  893 

psoas  abscess,  1260 
Triangle,  suprameatal,  Macewens,  34 
Trigeminal  neuralgia,  59 
Trzebicky,  amputation,  11 77 
Tubby,  obstetric  palsy,  800 
Tubed  pedicles,  1244 
Tuberculosis,  adrenal,  553 

chondritis,  324 

epididymis,  746 

glands  neck,  209 

hip,  979,  et  sfq. 

intestinal  caecostomy,  460 

joints,  1 141 

knee,  1025,  1044 

lung,  311 

paraplegic,  763 

patella,  1046 

pelvic  bones,  974 

peritonitis,  480 

renal,  658 

ribs,  323 

tendon  sheaths,  11 92 

vesical,  651 

wrist,  1 1 25 
Tubes,  decalcified  bone,  1258 

drainage  bladder,  705 

Mixter's,  458 


I3IO 


INDEX 


Tubes,  Pauls,  458 

Wetherill's,  1257 
TuflBer,  aortic  aneurysm,  832 

complete  cystectomy,  700 

lipotamf>onade,  319 

nephrectomy,  654 

operations  on  heart,  330  el  seq. 

resection  lung,  330 

urethral  replacement,  730 

volvulus  stomach,  450 
Tuholske,  femoral  hernia,  602 
Tumors,  adrenal,  553 

bladder,  651,  681,  685,  689,  699 

bone,  958 

brain.  20,  24 

breast,  272 

cervical,  209 

cheek,  109 

chest  wall,  324 

kidney,  654 

lar>-nx,  233 

liver,  555 

lower  jaw,  92 

malignant  scalp,  5 

nervus  acusticus,  28 

nose,  iSi 

oesophagus,  224,  227 

operations  on,  1261 

orbit,  84 

pancreas,  542 

parotid,  173 

pelvic  bones,  974 

retro-  and  naso-pharyngeal,  91 

retro- peritoneal,  534 

retro  pharjTigeal,  222 

scalp,  5 

scapula,  1078 

spinal,  764 

spleen,  548 

tongue,  158 
base,  231 

upper  jaw,  85 
lip,  129 
Turner,  ascites,  528 
Tuttle,  excision  rectum,  515 
Tympanic  cavity,  infections,  35 
Typhlo-sigmoidostomy,  441 
Typhoid,  arthritis,  1143 

chondritis,  324 

coxitis,  989 

Ulcer,  duodenum,  363,  386 

jejunum,  375 

peptic,  375 

perforating  foot,  803 

rodent,  89,  1262 

stomach,  363,  383,  386  et  seq. 
Ulna,  fractures,  940 
Ulnar,  nerve  dislocation,  803 

paralysis,  1219 
Umbilical  hernia,  590,  619 
Undescended  testicle,  749 
Ununited  fracture,  893 
Upper  lip,  129 
Uranoplasty,  146 
Urban,  laminectomy,  760 
Uremia  v.  intestinal  obstruction,  443 
Ureter,  operations  on,  661 

anastomosis,  670 

stones  in,  661 


Ureter,  lithotomy,  665 
Ureterectomy,  669 
Ureterotomy,  665 
Ureterostomy,  651 
Uretero-cajcostomy,  677 
Urctero-colostomy,  677,  725 
Uretero-cystostomy,  671 
Urethra,  implantion  of  vein,  721 

operations  on,  715 

replacement  of,  730 

rupture,  721 
Urethral  fever,  717 
Urethrectomy,  719 
Urethrotomy,  external,  717 

internal,  715 
Urinary  bladder,  operations  on,  673 

calculus,  681 

infiltration,  722 

Vaginal,  excision  rectum,  490 
Vagus,  injuries,  214 
VaUas,  excision  tongue,  170 

fracture  patella,  928 

pharyngotomy,  231 
Valves  of  heart,  operations  on,  332 
Van  Hook,  hyTJospadias,  732 

ureteral  anastomosis,  670 

uretero-cystostomy,  672 
Van  Lair,  nerve  repair,  781 
Vanghetti,  amputations,  1165 
Varicocele,  753 
Varicose  veins,  866 
Varnish,  Whitehead's,  162 
Vas  deferens,  anastomosis  to  testicle,  743 

suture,  743 
Vasectomy,  703,  744 
Vaseline  injections  hip,  980 
Vasostomy,  748 
Vater,  ampulla  of,  582 
Vaughan,  T.,  wounds  heart,  336 
V'autrin,  common  bile  duct,  576 

exposure  pancreas,  539 

intestinal  exclusion,  443 
Veau,  thymectomy,  269 
Veins,  drainage  into,  in  ascites,  532 

internal  jugular  ligation,  38,  840 

operations  on,  856 
Vein,  popliteal  ligation,  832 

substitute  for  urethra,  721,  730 

varicose,  866 
Velpeau,  incision,  85 
Vena  cava,  injuries  in  nephrectomy,  655,  65; 

suture,  657 
Ventral  Hernia,  590,  620 

dangers  of  injury,  24 
Ventricles,  lateral  puncture,  33 

lateral  hydrocephalus,  45 
Venous  implantation,  819 

urethra,  721,  730 
Vercesco,  operation  piles,  521 
Verhoogen,  excision  bladder,  702 
Vermiform  appendix,  464 
Vemeuil,  rectal  prolapse,  485 
Vertebrae,  operations  on,  759 

tuberculosis,  763 
Vesical  calculus,  681 

diverticula,  712 

tumors  and  tuberculosis,  651 
Vesiculectomy,  713,  74Si 
Vesiculotomy,  713 


INDEX 


131I 


Vessels,  ligation  angioma,  133 

meningeal,  15 

rectal,  504 
Vicious  circle,  372,  375 
Vidal,  Eck's  fistula,  530 
Voelcker,  nephrotomy,  650 

renal  tuberculosis,  658 

snapping  hip,  979 
Vogt,  meningeal  vessels,  15 
Volkmann,  contracture,  1240 

excision  knee,  1042 

hydrocele,  752 
Volume  blood,  estimation,  858 
Volvulus,  440 
Vn5d6ne,  amputation,  1166 
Vulpius  flat  foot,  1 192 

nerve  suture,  783 

Wallace,  Cuthbert,  bone  bolts,  900 

Walsham,  club  foot,  1232 

Walther,  sclerogenic  injections,  1025 

Walton,  plastic  common  duct,  584 

Ward,   Barrington,   Hirschsprung's    disease, 

439 
Wardrop's  operation,  825 
War  Wounds,  1268 
Warren,  amputation  breast,  281 

osteomyelitis,  945 
Water,  boiling  injections,  goitre,  267 
Waterhouse,  appendicitis,  477 
Watson's  amputation,  11 73 
Watson,  C.  H.,  catgut,  1266 
Watson, F.  S.,  nephrostomy,  651 

perineal  drain,  705 
Wax,  iodoform,  Mosetig's,  947 

Horsley's,  7 
Waxed  thread,  1264 
Webbed  fingers,  11 27 
Weber's  incision,  85 
Weglowski,  anchylosis  elbow,  11 19 
Weil,  pericarditis,  334 
Weinhold,  dislocation  shoulder,  1092 
Weir,  appendicostomy,  461 

bunion,  1071 

excision  rectum,  507 

snapping  finger,  1130 
Wengloski  sarcoma  bone,  961 
Wens,  I 

Werndorff,  anchylosis,  knee,  1049 
West,  M.,  pituitary,  54 
Wetherill,  after  treatment,  350 

drain,  1257 

epispadias,  725 
White,  J.  W.,  epilepsy,  48 

interscapulo-thoracic  amputation,  1162 
White,  Sinclair,  excision  inferior  maxilla,  94 

gastro-enterostomy,  368 
Whitehead,  excision  tongue,  161 

operation  piles,  521 
Whitehouse,  liquid  air,  4 
Whitelocke,  dislocation  patella,  1059 
Whiting,  mastoid  operation,  39 

semilunar  cartilage,  1033 
Whitman,  osteotomy,  969,  1002 

tendon  transplantation,  12 10 
Wieting,   Pasha,  arteriovenous  anastomosis, 
821 


Wildey,  A.  G.,  ununited  fracture,  893 
Willems,  arthrotomy,  1108,  1141 
ankle,  io6i 

immediate  mobilization  joints,  924 

treatment  purulent  arthritis,  1031 
Wilms,  caecopexy,  437 

pneumolysis,  318 

plastic  common  duct,  583 

ureterostomy,  651 
Winslow,  foramen  hernia,  622 
Wire,  mesh,  hernia,  619 

splint,  lower  jaw,  95 
Wiring  bones,  897 

fractures  jaw,  96 
Witzel,  gastrostomy,  358 

uretero  cystostomy,  671 
Wohlgemuth,  pancreatic  fistula,  542 
Wolf's  grafts,  1244,  1251 
Wolff,  implantation  tendon  in  bone,  1197 
Wolfler's  operation,  365 
Wood,  exstrophy,  674 

hypospadias,  730 
Woodcock,  artificial  pneumothorax,  311 
Wounds,  diaphragm,  625 

hand,  1137 

heart,  333,  336 

joints,  1030 

longitudinal  sinus,  18 

lung  and  pleura,  286 

meninges,  17 

nerves,  781 

pancreas,  546 

spine,  765 

thoracic  duct,  210 

treatment  of,  1268 

veins,  856 

vena  cava,  657 
Wreden's  operation,  1057 
Wrench,  Thomas',  1228 
Wrinkles,  1255 
Wrist,  1 1 22 

amputation  or  disarticulation,  1155 

anchylosis,  11 25 

arthritis  deformans,  11 24 

drop,  tendon  transplantation,  121 7 
Wry  neck,  204 
Wullstein,  hernia,  621 

dislocation  patella,  1060 
Wyeth,  amputation  hip,  1185 

colostomy,  455 

pins,  1157,  1182 
Wynter,  ascites,  533 

X-ray,  burns,  1255 

diaphragm,  hernia,  624 
localization  foreign  bodies,  1272 
osteomyelitis,  944 

Yeomans,  caeco-sigmoidostomy,  440 
Young,  J.  K.,  bunion,  1070 

Hugh  prostatectomy,  707,  709 
prostatotomy,  702 
vesiculectomy,  745 

Zarraga,  excision  parotid,  176 
Zondek,  nephrotomy,  649 
Zuckerkandl,  incision,  631 
prostatectomy,  708 


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